Memorial Hospital of Gardena

“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: 42937 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1.A. The nurse failed to ensure one of33 sampled patients (Patient 13), who was identified a high fall risk (an individual with a significant, documented likelihood of falling,), have a fall prevention plan be instituted and documented every shift in accordance with the facility ’ s “Fall Prevention Program” policy and procedure. This deficient practice resulted in Patient ’ s 13 ’ s fall, for which can potentially cause severe harm/injuries (hip fractures, head trauma), increased risk of repeat falls, increased hospital stays, reduced quality of life, and inadequate care continuity. (Refer to A-0395). B. The nurse failed to ensure one of 33 sampled patients (Patient 13), Glasgow Coma Scale (GCS, is a neurological tool used to assess consciousness) assessment was completed and documented every 4 hours and after a fall incident, in accordance with the facility ’ s “Assessment/ Reassessment of Patients” and “Fall Reduction Program” policy and procedure. This deficient practice has the potential to lead to serious patient harm, including missed diagnosis of brain injuries, permanent impairment, or death. Without timely neuro checks, rapid, life-threatening changes in a patient’s status may go unnoticed. (Refer to A-395). 2. The facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), hypertension (HTN, high blood pressure), cerebral vascular accident (CVA - stroke, loss of blood flow to a part of the brain) and cardiac dysrhythmia (an irregular, too fast, or too slow heartbeat) needs for three of 33 sampled patients (Patient 3,Patient 4, and Patient 6). This deficient practice had the potential to result in Patient 3, Patient 4, and Patient 6 not receiving the right level of care and not meeting the needs for the identified patient concerns. (Refer to A-0396). 3.A. The facility failed to ensure for one of 33 sampled patients (Patient 4), nursing care was provided when Patient 4 ’ s pain was not adequately managed to a desired comfort goal or thoroughly reassessed, in accordance with the facility ’ s policy and procedure regarding pain management and pain assessment/reassessment. This deficient practice had the potential to result in Patient 4 ’ s ineffective treatment plan, worsening pain, and distrust in the facility ’ s ability to manage care. (Refer to A-398) B. The facility failedto adhere to the admission policy for one of 33 sampled patients (Patient 1), when staff failed to assess Patient 1 ’ s vital signs within four hours of direct admission from another facility. This deficient practice had the potential to delay necessary treatment by failure to establish a baseline (starting point, standard, or initial measurement used as a foundation for comparison) needed in order to detect changes in Patient 1 ’ s condition. (Refer to A-398). The facility failed to ensure that one of 33 sample patients (Patient 19) was administered a medication appropriately, as ordered by the physician. This deficient practice resulted in Patient 19 ’ s medication for nor-epinephrine (Levophed - a critical neurotransmitter and hormone that increases alertness, focus, and blood pressure, as part of the body ’ s “fight-or-flight” stress response) drip rapidly increased unsafely. (Refer to A-405). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“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: 42937 Based on interview and record review, the facility failed to ensure one of 33 sampled patients (Patient 7) had a signed informed consent for surgical procedures to place a gastrostomy tube (g-tube, a tube fitted into the stomach to allow feedings to be administered directly into the stomach, common for people with swallowing problems) in accordance with the facility ’ s policy and procedure on informed consent. This deficient practice resulted in a procedure being done without documentation that Patient 7 ’ s representative were fully informed of the risks and benefits and the nature of the surgery and provided written consent for this procedure. Findings: During a review of Patient 7 ’ s face sheet (the front page of the chart that contains a summary of basic information about the resident), dated 7/24/2025, the face sheet indicated, Patient 7 was admitted to the Emergency Department (ED, a hospital facility providing immediate, unscheduled care for life-threatening or severe injury or illnesses) on 7/24/2025. The face sheet indicated Patient 7 ’ s emergency contact as his daughter and included a telephone number. During a review of Patient 7 ’ s “Emergency Department (ED) Physician Note,” dated 7/24/2025, the ED note indicated, on 7/24/2025 Patient 7 arrived via ambulance from a board and care facility (also known as a boarding care facility, a facility providing 24 hour care for non-medical care, including assistance with daily living, meals, and medication monitoring) for a dislodged (suddenly out of place) gastrostomy tube (g-tube, a tube fitted into the stomach to allow feedings to be administered directly into the stomach, common for people with swallowing problems). The ED Note indicated Patient 7 had a history of dementia (a progressive state of decline in mental abilities), hypertension (HTN- high blood pressure) and was nonverbal (unable to express spoken words). The ED Note indicated an attempt was made in the ED to replace Patient 7 ’ s g-tube and that the attempt was unsuccessful. The ED note indicated Patient 7 was admitted to the facility for another attempt at g-tube replacement and to prevent decompensation (a significant decline in a patient ’ s health). During a review of Patient 7 ’ s “History and Physical (H&P),” the H&P indicated, on 7/24/2025 Patient 7 ’ s daughter provided Patient 7 ’ s past medical history, including but not limited to, multiple past cerebral vascular accidents (CVA – stoke, loss of blood flow to a part of the brain), history of endocarditis (an inflammation of the lining around the heart), history of coronary artery bypass grafting (CABG, a heart procedure that treats blocked or narrowed arteries in the heart). The H&P further indicated Patient 7 previously resided at a nursing home (a facility staffed with 24 hour healthcare providers that provide medical care for patients recovering from illness or injury) and then was sent to a boarding care. During a concurrent interview and record review on 3/05/2026 at 5:24 p.m. with Registered Nurse (RN) 6, Patient 7 ’ s surgical consent for “Esophagogastroduodenoscopy [a safe, minimally invasive procedure using a flexible camera tube to examine and treat conditions of the esophagus (a tube in the throat area that transports foods and liquids to the stomach) and stomach] with Percutaneous (a procedure that occurs through or penetrates the skin, without opening a larger surgery incision) Endoscopic (a minimally evasive procedure using a thin, flexible camera) Gastrostomy Tube (g-tube, a tube fitted into the stomach to allow feedings to be administered directly into the stomach, common for people with swallowing problems) Placement,” was reviewed. Patient 7 ’ s surgery consent indicated two different witness signatures were in the lines indicated for Witness #1 and Witness #2. Patient 7 ’ s surgery consent form indicated Patient 7 ’ s daughter ’ s name was written in the line indicated for “Patient/Parent/Legal Guardian (if signed by other than patient, indicate relationship below)” line. RN 6 stated one of the witness signatures on Patient 7 ’ s surgery consent was hers and the second witness signature belonged to the unit ’ s charge nurse (CN) 4. RN 6 stated Patient 7 ’ s surgical consent was considered a telephone consent (an acceptable consent for surgery when a patient ’ s representative is unavailable in person to provide a consent, provided it is witnessed by a staff member and thoroughly documented in the medical record). RN 6 stated there was no indication on Patient 7 ’ s surgical consent identifying the surgery consent as a telephone consent. RN 6 stated there would be no other place in Patient 7 ’ s medical record where a reference would be noted Patient 7 ’ s surgical consent was a telephone consent. RN 6 stated there was no need to indicate in any part of patient 7 ’ s medical record the surgical consent was a telephone consent. RN 6 stated it was implied Patient 7 ’ s surgery consent was a telephone consent since Patient 7 ’ s daughter ’ s name and phone number were entered on the “Patient/Parent/Legal Guardian” line of the surgery consent. During a review of the facility ’ s policy and procedure (P&P) titled, “Informed Consent,” last revised 01/2025, indicated, “Telephone Consent. Telephone consent may be provided by a legally authorized representative when the representative is not local, or when the clinical situation is urgent. Telephone consent must be obtained in the hearing presence of two witnesses. Both witnesses are required to sign the consent form. The practitioner should document the date and time of the conversation, and the informed consent process in a progress note.””

“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: 42937 Based on observation and interview, the facility failed to ensure that a call bell device (a freestanding device which when touched, makes a bell sound; the device is commonly used in situations where one needs to press the call bell to get attention, such as the front desk of a hotel) was within reach to one of 33 sampled patients (Patient 33). The Emergency Department (ED, a hospital facility providing immediate, unscheduled care for life-threatening or severe injury or illnesses) currently does not have a call light system for individual Emergency Department (ED) beds. This deficient practice had the potential to place patients at risk of not being able to request assistance for necessary care and emergencies. Findings: During a review of Patient 33 ’ s “Face Sheet (the front page of the chart that contains a summary of basic information about the resident)” dated 3/05/2026, the Face Sheet indicated Resident 33 ’ s age was 74 years old. During a record review of Patient 33 ’ s “Emergency Department (ED, a hospital facility providing immediate, unscheduled care for life-threatening or severe injury or illnesses) Note,” dated 3/05/2026, the ED Note indicated, Patient 33 arrived at the ED for a complaint of shortness of breath (the uncomfortable sensation of being unable to get enough air into the lungs) and coughing for 5 days. Patient 33 ’ s ED Note indicated Patient 33 had a history of hypertension (HTN - high blood pressure), chronic kidney disease (CKD – a long-term and progressive loss of kidney function), congestive heart failure (CHF – a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and chronic obstructive pulmonary disease (COPD – a chronic lung disease causing difficulty in breathing). During an observation and interview on 3/05/2026 at 2:50 p.m. with the Director of Emergency Services (Dir ED Svc), Dir ED Svc stated, the Emergency Department did not have individual call lights assigned to each bed. Dir ED Svc stated each ED room had one, two, three, or four patient beds/gurneys. Dir ED Svc stated each ED room had an assigned registered nurse who would stay in their assigned room for the most part. Dir ED Svc stated each ED bed and patient had a designated free standing call bell, which is a free standing bell which when pressed will make a sound to alert the nurse a patient is calling. Dir ED Svc stated each ED room was equipped with one central call light which alerts visually and audibly in the ED nurse station. During a concurrent observation and interview on 3/05/2026 at 3:00 p.m. with Patient 33 in the Emergency Department, Patient 33 was observed in ED bed 1 on a gurney receiving oxygen (a gas needed for breathing). Patient 33 ’ s assigned call bell was situated on a night stand-type of table approximately 3 feet behind and to the right of the Patient 33 ’ s head. Patient 33 was asked if she knew what to do if she needed to ask for assistance. Patient 33 pointed to the nurse sitting at a computer station in the room, approximately six feet away. Patient 33 was asked if she had been instructed on the use of the call bell when she needed to call for assistance. Patient 33 replied, “Yes.” Patient 33 was asked if she knew where her assigned call bell was located. Patient stated, “No,” looked to her right and left, and repeated, “No.” During a concurrent observation and interview on 3/05/2026 at 3:05 p.m. with Registered Nurse (RN) 7 in Patient 33 ’ s ED room, Patient 33 ’ s call bell was on the night stand behind Patient 33 ’ s line of sight and out of Patient 33 ’ s reach. RN 7 stated the call bell should be within Patient ’ s 33 reach. RN 7 stated the call bells are necessary to Patient 33 ’ s need for assistance. RN 7 stated if she (RN 7) was with another patient in the same room as Patient 33, there was a possibility she could not hear Patient 33 ringing the call bell assistance if the call bell was not within Patient 33 ’ s reach. During a review of the facility ’ s policy and procedure (P&P) titled, “Age Specific Patient-Related Safety Hazards,” last revised 10/2024, the P&P indicated, “Elderly Patient Safety...In order to ensure a safe environment for patients of all ages the following procedures will be followed by the affected departments ...a call button will be within easy reach at all times.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42937 Based on interviews and record reviews, the nurse failed to: A. Ensure one of thirty-three sampled patient ’ s (Patient 13), who was identified a high fall risk (an individual with a significant, documented likelihood of falling,), have a fall prevention plan be instituted and documented every shift in accordance with the facility ’ s “Fall Prevention Program” policy and procedure. This deficient practice resulted in Patient ’ s 13 ’ s fall, for which can potentially cause severe harm/injuries (hip fractures, head trauma), increased risk of repeat falls, increased hospital stays, reduced quality of life, and inadequate care continuity. B. Ensure one of thirty-three sampled patient ’ s (Patient 13), Glasgow Coma Scale (GCS, is a neurological tool used to assess consciousness) assessment was completed and documented every 4 hours and after a fall incident, in accordance with the facility ’ s “Assessment/ Reassessment of Patients” and “Fall Reduction Program” policy and procedure. This deficient practice has the potential to lead to serious patient harm, including missed diagnosis of brain injuries, permanent impairment, or death. Without timely neuro checks, rapid, life-threatening changes in a patient’s status may go unnoticed. Findings: During a review of Patient 13’s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem),” dated 0/13/2025, the H&P indicated Patient 13 was brought in by ambulance to the emergency department (ED) with complaints of shortness of breath and lower extremity edema (swelling) for the past 3 days. During a concurrent interview and record review on 3/4/2026 at 1:47 PM, with Registered Nurse 5 (RN5), review of Patient 13’s “Daily Assessment Inquiry – Fall Risk Evaluation” dated 3/16/2026, indicated the patient fall risk assessment score (a screening tool that assesses patient fall risk) was noted at “High Risk” at 8:03 AM, 2:30 PM, and 14:45 PM , with no fall precaution initiated. The safety checks (a clinical tool used by staff to ensure universal safety precautions are met, making sure that ID band on and correct, Allergy band on and correct, Bed locked/ position low, less that 4 siderails up, call light within reach, bed alarm on, seizure precaution, and sitter) was also not completed for each time. RN5 stated that the nurse should have documented and initiated fall preventive measures, as well as completed a safety check on Patient 13, who was a high risk for fall. Per RN5, this expectation was standard in nursing practice and it helped reduce fall, patient injuries and improve patient safety. During a review of the facility ’ s policy & procedure (P&P) titled “Fall Reduction Program,” last revised 7/2024, the P&P indicated the following: 1.Fall risk assessment will be conducted, using the Morse Fall Scale, on each patient at time of admission by RN and will be re-evaluated each shift by RN or LVN. 2.If patient is found to be at risk for falls, the FALL PREVENTION PLAN shall be instituted. 3.Document as appropriate all assessments, interventions, evaluations and education. Fall Prevention Protocol (To be instituted at any point of hospitalization based on Fall Risk Assessment Score) [Each level is inclusive of the level before it) Risk Score Intervention NO RISK 1.Provide a safe environment. 2.Orient patient to surroundings. 3.Keep bed in lowest position and locked. 4.Secure the nurse call light within easy reach. 5.Answer the call light promptly. 6.Staff to be responsible for eliminating environmental hazards (spills, objects obstructing the walkway, unstable furniture, etc.) 7.Remove any malfunctioning/defective equipment immediately. 8.Offer patient assistance with toileting during care rounds. 9.Review medication list for medications that could cause changes in mental or functional status. 10.Reassess and observe closely after medication change or administration. LOW RISK Requires Falling Star (Visual Cue) on the head board and yellow Armband and normal treaded socks. Yellow socks are reserved for ‘High Risk’ fall patients only as a visible safety alert for all staff, Institute the above plans and include the following: 1.Evaluate patient’s environment and make modifications as appropriate. Place patient in room closest to Nurses’ Station for observation. Reorient patient to room and unit layout Keep personal items close to the patient Provide adequate lighting Use medical equipment (assistive devices) appropriate to patient. Patient to wear treaded socks 2.Educate patient and/or family of identifying risk and contributing factors. Provide fall prevention education ro patient/ family as appropriate 3.Instruct patient/family to ask for assistance for any patient activities. 4.Evaluate medications that patient is receiving; provide alternative to hypnotics when possible. 5.Consider use of bed alarm monitoring device; Umano beds have this function-built in. 6.,Update Care Plan. Communicate safety level and interventions taken in shift report. HIGH RISK Requires Falling Star (Visual Cue) on the head board, yellow armband, and yellow treaded socks Institute the above plans and include the following: 1.Evaluate environment for further modifications. 2.Consider need for additional night lighting. 3.Involve family in risk identification and plan of care. 4.Offer toileting as needed 5.Institute alternatives to restraint use; if restraints are indicated, follow policy. 6.Consider use of sitter if restraint use is not appropriate. 7.Update Care Plan. 8.Communicate safety level and interventions taken in shift report. 9.Activate bed alarm monitoring device on Umano bed or OQtain a bed alarm. 10.Recommend Physical Therapy Evaluation Ongoing Evaluation: The patient is to be re-evaluated whenever medical conditions or environment changes are identified, such as, after an actual fall. Post fall Guidelines: Assess for the report to the physician any of the following: 1. Visible signs of bleeding, 2. Alterations in neurological status, 3. Complaint of pain (new onset) and 4. Complaint of numbness, tingling, respiratory distress, body alignment abnormalities (new onset) During a concurrent interview and record review on 3/4/2026 at 1:55 PM, with the Registered Nurse 5 (RN5), review of Patient 13’s “Daily Assessment Inquiry – Neurological(rapid evaluation of the patient brian and nerve function)” dated 9/16/2026, indicated an incomplete neurological assessment of Patient 13 at 8:00 AM, 12:00 PM and 2:45 PM. There was no Glasgow Coma Scale (GCS, a neurological tool used to assess consciousness) assessment completed during these times there. It was also noted that at 2:45 p.m. Patient 13 was more confused, got up to pee and fell. RN5 stated that Patient 13 was in the telemetry unit when Patient 13 fell, and assessment and reassessment were not done at start of the shift and every 4 hours after. A complete neurological assessment would include completion of a GCS assessment. RN5 added that it was important for nursing to complete a GCS assessment because it assessed the patient ’ s consciousness, monitor possible neurological decline, and helps guide nursing correct care to patients, especially to someone like Patient 13 who was noted to being more confused and has had a fall incident. During a review of the facility ’ s policy & procedure (P&P) titled “Assessment/ Reassessment of Patients”, last revised 1/2026, the P&P indicated the following: Initial shift Assessments in Telemetry Unit shall be initiated within 4 hours from start of each shift and documented in the electronic medical record. Reassessments (focused) will be conducted at a minimum of every 4 hours.”

“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: 42937 Based on interview and record review, the facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), hypertension (HTN, high blood pressure), cerebral vascular accident (CVA - stroke, loss of blood flow to a part of the brain) and cardiac dysrhythmia (an irregular, too fast, or too slow heartbeat) needs for three of 33 sampled patients (Patient 3,Patient 4, and Patient 6). This deficient practice had the potential to result in Patient 3, Patient 4, and Patient 6 not receiving the right level of care and not meeting the needs for the identified patient concerns. Findings: 1. During a review of Patient 3 ’ s “Face Sheet” (a summary document that provides a quick, essential overview of a patient ’ s identity, insurance, and key health data), undated, the face sheet indicated that Patient 3 was admitted on 1/14/2026 at 9:45 pm for altered mental status (AMS, any change in a person ’ s awareness, alertness, or cognitive function). During a review of Patient 3 ’ s “History and Physical” (H&P, a formal and complete assessment of the patient and the problem),” dated 1/15/2026 at 7:59 am, the H&P indicated that Patient 3 arrived at the hospital for AMS with expressive aphasia (Broca ’ s aphasia, a language disorder where a person knows what they want to say but struggles to speak or write). Patient 3 was homeless, presented with a right below the knee amputation (BKA, a surgical procedure that removes the lower leg, including the foot) and an unknown medical history. A computed tomography (CT, a diagnostic test that uses an x-ray and computer technology to produce images of the inside of the body) scan of the head showed possible hemorrhagic conversion (a complication where a blocked blood vessel in the brain ruptures and causes bleeding into the damaged tissue). It also showed possible prior hemorrhagic contusion (a bruise on the brain that includes bleeding) due to traumatic brain injury (TBI, damage to the brain caused by an external physical force, such as bump, blow, or jolt to the head). A magnetic resonance imaging (MRI, a scan that uses a powerful magnet and radio waves to create highly detailed, 3D pictures of the body ’ s internal soft tissues [brain, muscles, organs, and nerves]) was performed and code stroke (an emergency protocol activated when a patient shows signs of a stroke) initiated. Patient 3 was admitted for possible acute cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain) with hemorrhagic conversion versus TBI, AMS, generalized weakness, expressive aphasia, and homelessness. Laboratory test resulted with elevated cholesterol levels, elevated glucose levels, elevated natriuretic peptide test (proBNP, a protein released into the blood by the heart when the heart is under stress, stretched or working too hard) along with other minor abnormalities. During a review of Patient 3 ’ s “Medication Administration Record” (MAR, a document that provides a list of all medications given to a patient by a healthcare professional), the MAR indicated that Patient 3 received and was receiving losartan (a prescribed medication used to treat high blood pressure [HTN], protect kidneys from damage caused by high sugar levels, and reduce the risk of stroke), carvedilol (a medication used to treat high blood pressure [HTN], heart failure, and to improve survival after a heart attack), amlodipine (a medication used to treat high blood pressure [HTN] and prevent chest pain [angina] or coronary artery disease [CAD, the buildup of fatty plaque inside the arteries that supply the heart]), atorvastatin (a medication used to lower “bad” cholesterol in the blood), and aspirin (a non-prescribed medication used to relieve mild pain, reduce fever, and decrease inflammation [swelling]. It is also used as a blood thinner to prevent blood clots, heart attacks, and strokes) daily or twice daily. The MAR indicated that Patient 3 had occasionally elevated BP readings outside of the routine BP medication administration times requiring as needed (prn) medications, clonidine (a medication used to lower high blood pressure by allowing blood to flow more easily) and labetalol (a medication used to treat high blood pressure [HTN]) for management of elevated BP readings. The MAR further indicated that Patient 3 received Plavix (a prescribed medication that acts as a blood thinner to prevent harmful blood clots) daily. During a concurrent interview and record review on 3/4/2026 at 9:50 am, with Registered Nurse 2 (RN 2), Patient 3 ’ s “Care Plans”, undated, were reviewed. There was no care plan addressing Patient 3 ’ s risk for bleeding associated with the use of Plavix, aspirin, and potential CVA with hemorrhagic conversion or TBI medical diagnosis. RN 2 stated that a care plan should have been initiated for bleeding, to monitor Patient 3 for risk and provide appropriate, preventative care. RN 2 further stated there was no care plan addressing Patient 3 ’ s HTN (nursing diagnosis: potential for decreased cardiac output) or CVA/TBI (nursing diagnosis: potential for ineffective cerebral tissue perfusion). RN 2 stated that a care plan should have been initiated for Patient 3 ’ s HTN and CVA needs. RN 2 stated care plans were important to identify problem areas/barriers, changes, treatment plans, knowledge of the condition(s), educational needs, and associated symptoms to monitor. RN 2 further stated lack of a required care plan could lead to missed opportunities, worsening symptoms including death, failed/undesired treatment, and lack of understanding. Per the facilities policy and procedure (P&P, a guideline that defines “why” or “what” a facility does, acting as a guide for decision-making), the purpose of a care plan was to establish guidelines for individualized patient care that was consistent, coordinated, high-quality, cost effective, and based on best practices. It also facilitate communication among multidisciplinary team members providing patient and family-centered care. 2. During a review of Patient 4 ’ s “Face Sheet (a summary page acting as a quick-reference guide, detailing a patient ’ s demographics [name, address, date of birth, etc.], insurance information, emergency contact, admission details, etc.)”, undated, the face sheet indicated that Patient 4 was admitted on 3/1/2026 at 4:57 pm, for tachycardia medical reaction via ambulance. During a review of Patient 4 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/2/2026 at 11:16 am, the H&P indicated that Patient 4 had a past medical history of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and hypertension (HTN-high blood pressure). Patient 4 presented to the emergency department (ED, a 24/7 facility specializing in immediate care of patients with severe, life-threatening injuries or illnesses who require urgent evaluation and stabilization) for seizure-like (events that physically resemble a seizure [shaking, loss of consciousness, or stiffening] but are not caused by abnormal electrical activity in the brain) activity and associated confusion (inability to think clearly, swiftly, or with coherence resulting in difficulty with decision-making). Patient 4 was started on a new outpatient medication (Seroquel, an antipsychotic medication primarily used to treat bipolar disorder) and since starting, reported feeling prodrome (early symptoms that occur before the main, characteristic signs of a disease or illness appear) like symptoms with “fogginess” (confusion) for one week. Patient 4 reported taking an extra dose of a routinely taken medication (Gabapentin, a medication used to treat seizures and nerve pain) with the new medication, Seroquel. Patient 4 ’ s laboratory test (lab test, blood test) was significant for lactic acidosis (a serious condition where too much lactic acid builds up in the bloodstream, making blood too acidic) with evidence of acute renal failure (ARF, sudden loss of kidney function). An assessment further revealed ARF, lactic acidosis, drug reaction with extrapyramidal syndrome (drug-induced movement disorders caused by medications, most commonly antipsychotics), possible new onset of seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and a history of diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). Patient 4 ’ s urine drug screen (a urine test to detect the presence of specific illegal drugs or prescription medications) was negative on 3/1/2026 at 6:26 pm. During a review of Patient 4 ’ s “Medication Administration Record” (MAR, a document that provides a list of all medications given to a patient by a healthcare professional), undated, the MAR indicated that Patient 4 received amlodipine (a medication used to treat high blood pressure [HTN], coronary artery disease [CAD], and angina [chest pain]) daily and heparin (an injectable “blood thinner” [anticoagulant] medication that prevents blood clots from forming or getting larger) every eight hours. Patient 4 received a one-time dose of hydralazine (a medication used to treat [HTN] high blood pressure) for elevated blood pressure (BP) reading(s). Patient 4 also received clonidine (a medication primarily used to treat high blood pressure) every three hours, as needed (prn) for elevated BP reading(s). Patient 4 also received intravenous (IV, directly into a vein) fluids for hypotension (low blood pressure). During a concurrent interview and record review, on 3/4/2026 at 10:55 am, with Registered Nurse 2 (RN 2), Patient 4 ’ s “Care Plans”, undated, were reviewed. RN 2 stated there was no care plan addressing Patient 4 ’ s HTN needs or Patient 4 ’ s risk for bleeding due to prescribed heparin. RN 2 stated that a care plan addressing Patient 4 ’ s HTN should have been initiated (started) due to Patient 4 having unstable BP readings throughout hospital stay, requiring fluids, routine medication, and prn medication(s) for stabilization. RN 2 further stated that this was important to continuously monitor Patient 4 ’ s BP, the effectiveness (to produce a desired result) of treatment options, and prevent further complications (something that makes a situation more difficult) associated with unstable BP readings. RN 2 also stated that it was extremely important to have a care plan addressing Patient 4 ’ s bleeding risk due to being on a blood thinner with seizure precautions (a set of safety measures taken to protect a person who is at risk of having a seizure from injury). RN 2 stated that this was important as seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) may lead to injury, which may cause hemorrhaging (rapid, uncontrolled loss of blood – heavy or severe bleeding) for patients on blood thinners. Per RN 2, a care plan was important to consistently identify symptoms of bleeding (internally and externally), monitor laboratory values (numerical or qualitative measurements taken from tests of bodily samples [blood, urine, tissue]), and for safety concerns. Per the facility ’ s P&P, the RN identifies those nursing diagnosis/problem(s) that relate to each patient and completes the information to individualize the plan of care. Nursing diagnosis/problem identified can be actual or potential problems and should be noted on the plan by checking the appropriate box next to the diagnosis/problem. 3. During a review of Patient 6 ’ s “Face Sheet (a summary page acting as a quick-reference guide, detailing a patient ’ s demographics [name, address, date of birth, etc.], insurance information, emergency contact, admission details, etc.)”, undated, the face sheet indicated that Patient 6 was admitted on 2/27/2026 at 6:00 pm for shortness of breath (SOB, feeling of difficult, labored, or uncomfortable breathing) via paramedic (a trained professional who provides advanced, life-saving emergency medical care at the scene of an injury or illness and during transport to a hospital). Patient 6 ’ s admitting diagnosis was sepsis (a life-threatening medical emergency caused by the body ’ s extreme response to an infection). During a review of Patient 6 ’ s “History and Physical” (H&P, a formal and complete assessment of the patient and the problem), dated 2/27/2026 at 8:11 pm, the H&P indicated that Patient 6 was sent to the emergency room (ER, a 24/7 facility specializing in the immediate care of patients with severe, life-threatening injuries or illnesses who require urgent evaluation and stabilization) from a nursing home (a residential facility providing 24-hour nursing care for people who cannot live independently) for hypoxia (a condition where the body ’ s tissues and organs do not receive enough oxygen to function properly) with oxygen levels in the 80th percentile (normal 94% and above). Patient 6 ’ s initial past medical history included hypertension (HTN, high blood pressure), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), atrial fibrillation (AFib, a heart condition causing an irregular, often rapid heart rate), aphagia (the inability or refusal to swallow), gastroesophageal reflux disorder (GERD, a condition where stomach acid frequently flows back [refluxes] into the esophagus [food pipe]), hypothyroidism (the thyroid gland is “underactive” and doesn ’ t produce enough thyroid hormone, the body ’ s energy regulator), and epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]). Patient 6 was not following commands, altered (different from the normal state), and lethargic (extreme tiredness, sluggishness, and lack of energy or motivation). Laboratory results (reports detailing the analysis of body samples) indicated an elevated troponin (measures a protein in the blood that is released when the heart muscle is damaged - result 0.076 ng/mL, normal range 0.000-0.034 ng/mL), elevated natriuretic peptide test (proBNP, a protein marker released into the blood when the heart is under high pressure or stress – result 1770 pg/mL, normal range 20-300 pg/mL), elevated prothrombin time (PT, a test that measures the speed of blood clotting to check for bleeding issues – result 15.1 Sec, normal range 9.7-12.2 Sec), elevated international normalized ratio (INR, a blood test that measures how long it takes for blood to clot – result 1.4 INR, normal range 0.0-1.3 INR), white blood cells (WBC, the body ’ s primary germ-fighting cells – result 24.3, normal range 4.5-11.0), low platelet count (the number of platelets [thrombocytes], cells that initiate blood clotting – results 148, normal range 150-440), and elevated glucose (sugar), blood urea nitrogen (BUN, the amount of nitrogen urea [waste product] in the blood), and creatinine levels (the amount of creatinine [a waste product from muscle metabolism] in the blood or urine, acting as an indicator of kidney function) with abnormal electrolyte levels (the amount of essential minerals [sodium, potassium, or calcium] carrying electric charges in the blood and bodily fluids). Patient 6 ’ s diagnoses included hypernatremia (the sodium [salt] concentration in the blood is too high), severe dehydration (a life-threatening emergency where the body has lost a dangerous amount of fluids, preventing organs from functioning properly), acute respiratory failure (a condition where the lungs cannot get enough oxygen into the blood), pneumonia (an infection that inflames the air sacs [alveoli] in one or both lungs, causing them to fill with fluid or pus), severe protein calorie malnutrition (a life-threatening, critical lack of protein in the diet, even if calorie intake is sufficient), and sepsis (a life-threatening medical emergency caused by the body ’ s extreme dysfunctional immune response to an infection). During a review of Patient 6 ’ s “Progress Note” (a daily medical record written by healthcare professionals to document a patient ’ s clinical status, treatment, and response to care), dated 3/4/2026 at 10:11 am, the progress note indicated that Patient 6 was noted to be in Atrial Fibrillation (AFib, a common heart condition where the heart quivers instead of beating effectively) and on a Cardizem drip (a continuous intravenous [IV] infusion of medication used in emergency settings to immediately slow down a rapid heart rate). Patient 6 ’ s diagnoses included hypokalemia (a low level of potassium in the blood, a vital electrolyte that enables heart function and muscle contractions, that can lead to weakness, cramps, and arrhythmias [abnormal, irregular, or malfunctioning heartbeat]). During a review of Patient 6 ’ s “Vitals Inquiry” (a medical document used to record a patient ’ s basic body measurements – temperature, pulse, respiration rate, and blood pressure), undated, the vital signs inquiry indicated that Patient 6 had consistent elevated heart rate (HR) readings above 100 beats per minute (normal resting HR 60-100 beats per minute), with one reading at 240 beats per minute on 3/3/2026 at 8:05 pm. During a review of Patient 6 ’ s “Medication Administration Record” (MAR), undated, the MAR indicated that Patient 6 received Cardizem drip, potassium (an electrolyte that helps the body maintain fluid balance, sends nerve signals, and regulates muscle contractions, including keeping the heart beating regularly), metoprolol (a medication used to treat high blood pressure, angina [chest pain], and heart failure), and digoxin (a drug used to treat irregular heartbeat and some types of heart failure) to treat cardiac arrhythmias. During a concurrent interview and record review, on 3/4/2026 at 12:15 pm, with Registered Nurse 2 (RN 2), Patient 6 ’ s “Care Plans,” undated, were reviewed. RN 2 stated there was no care plan addressing Patient 6 ’ s dysrhythmia (an abnormal, irregular, or improper heartbeat, where the heart beats too fast [tachycardia], too slow [bradycardia], or with an erratic rhythm). RN 2 stated that there should have been a care plan addressing Patient 6 ’ s dysrhythmia due to Patient 6 having sustained abnormal heart rates/beats (arrythmia, a heart rhythm disorder where the heart beats too fast, too slow, or irregularly for a prolonged period, longer than 30 seconds) requiring treatment with IV medication(s). RN 2 stated that a care plan was important to monitor symptoms, evaluate the effectiveness of the current treatment plan, educate the patient, and prevent potentially life-threatening complications (stroke, blood clots, weakened heart muscle, or heart failure). RN 2 further stated that having a plan of care was important to identify available treatment options, prior to complications, due to the results of complications associated with irregular heartbeats could be silent, rapid, and deadly. During a review of the facility ’ s policy and procedure (P&P), titled “Care Plan, Multidisciplinary”, dated 10/2025, the P&P indicated: PURPOSE: To establish guidelines for providing individualized patient care that is multidisciplinary, consistent, coordinated, high quality, and cost effective. To provide guidelines for initiating, customizing, and following a goal-directed plan of care based on best practices. To facilitate communication among multidisciplinary team members providing patient and family-centered care. POLICY: 1. The Multidisciplinary Care Plan is initiated by the Registered Nurse within 24 hours of admission and updated every shift and as necessary. Other healthcare team members will make entries on the care plan upon admission and continue throughout the patient’s hospital stay. 4. Each member of the care team contributes to a multidisciplinary plan of care based on assessed patient/family needs/goals that is guided by evidence and/or best practices. Care is initiated as clinically-indicated and documented accordingly. PROCEDURE: 2. Nursing Diagnosis/Problem A. After considering the patient plan of care, the current patient condition and patient’s stated goals, identify priority problems and expected outcomes (improve, stabilize, support decline) that will be addressed this shift as part of the multidisciplinary plan of care. C. The RN identifies those nursing diagnosis/problem that relate to each patient and completes the information to individualize the plan of care. Nursing diagnosis/problem identified can be actual or potential problems and should be noted on the plan by checking the appropriate box next to the diagnosis/problem”

“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: 42937 Based on interview and record review, the facility failed to: A.Ensure for one of 33 sampled patients (Patient 4), nursing care was provided when Patient 4 ’ s pain was not adequately managed to a desired comfort goal or thoroughly reassessed, in accordance with the facility ’ s policy and procedure regarding pain management and pain assessment/reassessment. This deficient practice had the potential to result in Patient 4 ’ s ineffective treatment plan, worsening pain, and distrust in the facility ’ s ability to manage care. B.Adhere to the admission policy for one of 33 sampled patients (Patient 1), when staff failed to assess Patient 1 ’ s vital signs within four hours of direct admission from the emergency department (ED, a specialized hospital facility operating 24/7 to provide immediate care for acute, life-threatening, or severe medical conditions) at another facility. This deficient practice had the potential to delay necessary treatment by failure to establish a baseline (starting point, standard, or initial measurement used as a foundation for comparison) needed in order to detect changes in Patient 1 ’ s condition. Findings: A. During a review of Patient 4 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/2/2026 at 11:16 am, the H&P indicated that Patient 4 had a past medical history of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and hypertension (HTN-high blood pressure). Patient 4 presented to the emergency department (ED, a 24/7 facility specializing in immediate care of patients with severe, life-threatening injuries or illnesses who require urgent evaluation and stabilization) for seizure-like (events that physically resemble a seizure [shaking, loss of consciousness, or stiffening] but are not caused by abnormal electrical activity in the brain) activity and associated confusion (inability to think clearly, swiftly, or with coherence resulting in difficulty with decision-making). Patient 4 was started on a new outpatient medication (Seroquel, an antipsychotic medication primarily used to treat bipolar disorder) and since starting, reported feeling prodrome (early symptoms that occur before the main, characteristic signs of a disease or illness appear) like symptoms with “fogginess” (confusion) for one week. Patient 4 reported taking an extra dose of a routinely taken medication (Gabapentin, a medication used to treat seizures and nerve pain) with the new medication, Seroquel. Patient 4 ’ s laboratory test (lab test, blood test) was significant for lactic acidosis (a serious condition where too much lactic acid builds up in the bloodstream, making blood too acidic) with evidence of acute renal failure (ARF, sudden loss of kidney function). An assessment further revealed ARF, lactic acidosis, drug reaction with extrapyramidal syndrome (drug-induced movement disorders caused by medications, most commonly antipsychotics), possible new onset of seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and a history of diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). Patient 4 ’ s urine drug screen (a urine test to detect the presence of specific illegal drugs or prescription medications) was negative on 3/1/2026 at 6:26 pm. During a review of Patient 4 ’ s “nursing assessment”, dated 3/1/2026, Patient 4 reported an acceptable level of pain at a score of 3 to 4 out of 10 (4/10) on a numeric pain scale (a 0 to 10 tool used to measure pain, where 0 means “no pain,” and 10 signifies “the worst imaginable pain”). During a concurrent interview and record review on 3/4/2026 at 11:04 am, with Registered Nurse 2 (RN 2), Patient 4 ’ s “pain assessment,” dated 3/1/2026 through 3/3/2026 was reviewed. Patient 4 reported a pain score of 8/10 on 3/1/2026 at 5:03 pm. Patient 4 maintained generalized and back pain scores of seven to eight during the length of the hospitalization despite interventions (any action, treatment, or procedure to prevent, manage, or treat a disease, injury, or illness). RN 2 stated there was no documentation of communication with Patient 4 ’ s provider to discuss ineffective pain management, for pain scores above acceptable threshold (the specific point where something begins, changes, or triggers a reaction) following pharmaceutical interventions (the use of medicine to prevent, manage, or cure a medical condition) and without pharmaceutical interventions. RN 2 further stated the provider should have been notified of the reported pain scores to re-evaluate the treatment regimen (plan designed to manage a medical condition) and make potential changes or place additional orders to evaluate the cause. Per RN 2, untreated pain may lead to worsening symptoms and distrust of the healthcare team to effectively manage care. During a concurrent interview and record review on 3/4/2026 at 11:16 am, with RN 2, Patient 4 ’ s “Medication Administration Record (MAR, a legal log used to track all drugs given to a patient), undated, was reviewed. The MAR indicated that Patient 4 received: Oxycodone (a narcotic medication used to treat moderate to severe pain) on 3/1/2026 at 5:03 pm for a pain score of 8/10. At 6:08 pm, Patient 4 reported a pain reassessment of 6/10. There were no further interventions provided per RN 2 Norco (an opioid pain reliever medication used to treat moderate to severe pain) on 3/2/2026 at 8:30 am for a pain score of 8/10. Patient 4 ’ s pain reassessment at 9:30 am on 3/2/2026 indicated a pain score of 8/10. RN 2 stated there were no further interventions. Patient 4 ’ s pain remained at an 8/10 on 3/2/2026 at 12:00 pm with no further interventions administered for pain management. Norco on 3/3/2026 at 8:53 am for a pain score of 8/10. Patient 4 ’ s pain reassessment at 9:19 remained a reported pain score of 8/10. Patient 4 ’ s reported a pain score of 7/10 during a reassessment on 3/3/2026 at 9:50 am. At 12:00 pm, Patient 4 continued to report a pain score of 7/10 as the final documented score prior to discharge. RN 2 stated there was no further interventions administered for the reported pain scores above Patient 4 ’ s acceptable threshold and no documented communication with Patient 4 ’ s provider to discuss the potential ineffective treatment regimen. During a review of Patient 4 ’ s “Discharge Summary (a document created when a patient leaves the hospital, outlining their diagnosis, treatment, and hospital course)”, dated 3/3/2026 at 11:03 am, the discharge summary indicated that Patient 4 was discharged home with Norco 5 milligrams (mg) every six hours as needed (prn) for pain and Norco 10 mg every four hours as needed for pain. During a review of the facility ’ s policy and procedure (P&P) titled, “Pain Management”, dated 10/2024, the P&P indicated: POLICY Patients have the right to pain management. It is the policy of Memorial Hospital of Gardena (hereinafter referred to as the “organization”) to do the following: 1.Conduct an appropriate assessment and/or reassessment of a patient’s pain consistent with the scope of care, treatment, and service provided in the specific care setting in which the patient is being managed. 2.Require that methods used to assess a patient’s pain are consistent with the patient’s age, condition, and ability to understand 3.Assess the patient’s response to care, treatment, and service implemented to address pain. 4.Treat the patient’s pain or refer the patient for treatment. Treatment of Pain In general, inpatients shall receive treatment for any active pain issue (acute or chronic), when intensity exceeds their acceptable level. Reassessment Following Treatment for Pain If a treatment intervention for pain is provided, the response to that intervention should be assessed to include progress toward pain goal and side effects. Reassessment is recommended to occur within 15 - 60 minutes following treatment (depending on the type of intervention). However, by policy, this reassessment must occur at least at the next scheduled routine reassessment. During a review of the facility ’ s P&P titled, “Pain Assessment and Reassessment Management”, dated 10/2024, the P&P indicated: POLICY: 1. Pain is whatever the experiencing patient/resident says it is and exists whenever the patient/ resident says it does. 4. Patient/Resident will be assessed for pain upon admission, at least every shift, during routine vitals, and will be assessed and reassessed after each intervention, procedure and treatment. Causes of pain should be evaluated. A RN will perform the initial assessment. 7. Unrelieved pain has negative physical and psychological consequences. All unrelieved or unsatisfactorily relieved pain is to be reported to the physician and alternative methods/ agents/plans are to be considered. 8. Pharmacological and non-pharmacological treatments should be considered. Non¿ pharmacological treatments may include relaxation, distraction, heat, cold, massage, movement or immobility. PROCEDURE: 6. Any pain control mechanism that has been implemented will have re-assessment within 30 minutes for IV intervention and 60 minutes for oral (PO) intervention to determine the amount of pain control or relief obtained. DOCUMENTATION: 1. If pain is identified as a problem, it must be addressed during reassessment in nursing charting. 2. Pain assessment, reassessment and intervention should be documented on the nursing flowsheet. 3. Pain management interventions will be documented on the medication administration record. B. During a review of Patient 1 ’ s “Face Sheet” (a summary document that provides a quick, essential overview of a patient ’ s identity, insurance, and key health data)”, undated, the face sheet indicated that Patient 1 was admitted on 1/22/2026 at 11:15 am via ambulance for complaints of muscular fasciculation (a small, involuntary, and often visible twitching of a muscle), low back pain, and urinary tract infection (UTI, an infection in the bladder/urinary tract). The admitting diagnosis was unspecified dorsalgia (back pain). Patient 1 was discharged on 1/22/2026 at 9:48 pm with a discharge status, “expired” (death). During a review of Patient 1 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/22/2026 at 1:03 pm, the H&P indicated that Patient 1 had a past medical history of endometriosis (a painful condition where tissue similar to the lining of the uterus [endometrium] grows outside the uterus) status post (s/p) hysterectomy (surgical removal of the uterus [womb]), Ehlers Danlos Syndromes (EDS, a group of rare inherited conditions that affect connective tissue [body tissue that supports, binds, protects, and cushions organs and structures]), and functional neurological disorder (FND, a condition where the brain has difficulty sending and receiving signals properly, causing real physical symptoms). Patient 1 was transferred from another facility for intractable back pain (severe, constant, and relentless back pain that does not improve with standard medical treatments). During a review of Patient 1 ’ s “Progress Note”, dated 1/23/2026 at 1:16 pm, the progress note indicated that the physician was made aware of Patient 1 ’ s presence in the hospital by nursing staff on 1/22/2026 at 11:00 am – 1:00 pm. Per documentation, the physician performed rounding for Patient 1 with the assigned registered nurse (RN) on 1/22/2026 between 11:00 a.m. and 1:00 p.m. During a concurrent interview and record review, on 3/2/2026 at 4:06 pm, with Clinical Analyst (CA RN) and Lead Electronic Health Record Specialist (EHRS), Patient 1 ’ s “Progress Notes Report”, dated 1/22/2026 at 11:29 pm was reviewed. The progress notes report indicated that Patient 1 was admitted on 1/22/2026 at 10:55 for UTI. Upon arrival, vital signs (measurable indicators of body function-blood pressure, heart rate, breathing rate, temperature, oxygen level, and pain) were within normal limits, according to documentation. CA RN stated and confirmed that there were no documented vital signs during the time of the entry. During an interview on 3/2/2026 at 4:12 pm, with Director of Intensive Care Unit and Telemetry (Dir ICU/Tele), Dir ICU/Tele stated that the expectations for staff to assess (the process of gathering, analyzing, and interpreting information to understand a patient ’ s health condition) vital signs for a patient arriving from another facility would be to perform them on admission. Dir ICU/Tele stated that if the vital signs were not obtainable on admission, they should be completed within 4 hours of admission. Per Dir ICU/Tele, Patient 1 ’ s vital signs should have been done within the shift of arrival. Dir ICU/Tele further stated that obtaining vital signs was an important part of an assessment to establish an individual baseline (starting point, standard, or initial measurement used as a foundation for comparison) for the patient. Dir ICU/Tele stated a baseline was important to recognize changes that may be significant for a change in the patient ’ s condition. During a concurrent interview and record review on 3/2/2026 at 4:10 pm, with CA RN and EHRS, Patient 1 ’ s “Admission Assessment Report”, dated 1/22/2026 at 1:21 pm was reviewed. The assessment report indicated a height of 68.4 inches (5.7 feet) and weight of 168 pounds. The temperature (T or Temp, how hot or cold a person/object is), pulse (P or HR, heart beating), respiration (R or RR, breathing), blood pressure (BP), and oxygen saturation (O2 %, percentage of hemoglobin carrying oxygen in the body) were left blank. CA RN stated there were no documented vital signs noted during this nursing assessment. On 1/22/2026 at 3:05 pm a RR of 18 breaths per minute was entered. Per CA RN, no other vital signs were documented. During a review of Patient 1 ’ s “Vital Sign Report”, dated 1/22/2026 at 10:55 am through 1/24/2026 3:00 am, the vital sign report indicated one entry for vital signs on 1/22/2026 at 8:00 pm, approximately nine hours after admission, for Patient 1. Patient 1 ’ s BP was 129/89, P 110, R 18, T 99.1, and O2 % 97.0%. During a concurrent interview and record review on 3/2/2026 at 4:57 pm, with CA RN and EHRS, Patient 1 ’ s “Medication Administration Record” (MAR, a legal log used to track all drugs given to a patient), undated, was reviewed. The MAR indicated that Patient 1 received lorazepam (Ativan, a potent medication used to treat anxiety disorders, seizures, sleeping problems, and agitation) on 1/22/2026 at 2:19 pm and hydromorphone (Dilaudid, a very strong opioid medication used to treat moderate to severe pain) on 1/22/2026 at 7:33 p.m. Per CA RN there were no vital signs recorded prior to administration of both medications noted. CA RN stated that vital signs should have been assessed prior to administration of both medications as the medication may cause lowering of the BP. CA RN further stated that monitoring a patient ’ s vital signs prior to administration of certain medications was important to prevent causing a patient to become hypotensive (low BP) and/or slow respirations (breathing), as this may cause a change of condition. During an interview on 3/5/2026 at 4:28 pm, with the Manager of Regulatory Affairs (Reg Mgr), Reg Mgr stated that the facility does not have a vital signs policy. Reg Mgr further stated that in discussion with the ICU Nursing Director, it was reported that the facility ’ s “assessment and reassessment” policy noted the monitoring frequency, “example: telemetry reassessment every four hours. Head to toe including vitals”, per Reg Mgr. Reg Mgr also stated that during discussion with the facility ’ s Chief Nursing Officer (CNO), the CNO “identified an opportunity to improve the facility ’ s current policy with plans to review and adopt a policy from one of the facility ’ s sister hospitals and implement it, which outlines the assessment requirements”. Reg Mgr stated the assessment/reassessment policy was “all we have” that mentioned rounding/assessment/reassessment. During a review of the facility ’ s policy and procedure (P&P, a written rule defining what must be done to meet safety, clinical, or legal standards and how to carry out that policy, ensuring consistent actions), titled “Assessment / Reassessment of Patients”, dated 10/2025, the P&P indicated: POLICY: Patient care shall be based on a documented assessment upon admission to the department of the patient’s needs and includes consideration of the following factors: biophysical, psychosocial, environmental, self-care, educational, discharge planning needs and input from legally authorized representative, when appropriate. The initial admission assessment of the patient is the responsibility of the registered nurse. The RN also screens for the need for further assessment by members of the Multidisciplinary Team (MDT). Licensed Vocational Nurses may assist in the collection of data through auscultation, palpation, percussion and inspection after completing the physical assessment and competency validation. When appropriate, data from the patient’s legally authorized representative are included in the assessment. Initial shift Assessments shall be initiated at start of each shift and documented in the electronic medical record. Reassessments (focused) will be conducted at a minimum as follows below: DEPARTMENT INITIAL REASSESSMENT (FOCUSED) ER Promptly Per assessment Recovery Room Within 15 minutes Continuous Same Day Surgery Within 1 hour Prior to discharge G.I. Lab Prior to start of procedure Continuous - pre, intra, post procedure Operating Room On admission Continuous through surgical procedure Telemetry Within 4 hours Every 4 hours ICU Within 1 hour Every 2 hours; more frequently if condition changes Medical-Surgical Within 4 hours Every shift Cardiopulmonary 2 hours after receiving order from physician Every shift; more frequently if condition changes SPECIFIC SCREENING Suicide On arrival as part of triage process and/or part of admission process. Dependent of level of lethality, each shift check for high levels of lethality. Nursing will document a minimum of 1 progress note per shift that includes (as appropriate), physician/ family, significant other interactions, patient concerns, team interactions and applicable outcomes. Nursing will also document an “End of Shift Summary” statement in the progress notes giving an overview of care rendered during the shift.”

“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: 42937 Based on interview and record review, the facility failed to ensure that one of 33 sample patients (Patient 19) was administered a medication appropriately, as ordered by the physician when nor-epinephrine (Levophed - a critical neurotransmitter and hormone that increases alertness, focus, and blood pressure, as part of the body ’ s “fight-or-flight” stress response) drip was started at a maximum dose. This deficient practice has the potential to result in Patient 19 ’ s developing a dangerous hypertension (high blood pressure) and heart and blood vessels issue which can lead to death. Findings: A review of Patient 19 ’ s face sheet (a concise document providing a summary of key information to display a patient ’ s demographic, insurance, and medical date for quick reference) dated 1/25/2025, indicated the date of admission – 1/25/2025, complaint – small bowel obstruction (complete or partial blockage of the small intestine), and service – intensive care unit (special department for patients with life-threatening conditions). On 3/3/2026, at 3:30 PM, during concurrent interview with charge nurse (Chg Nse) 1 and record review of Patient 19 ’ s medication order, dated 1/26/2025, Chg Nse 1 stated the following: The patient had an order for norepinephrine (chemical that increase blood pressure and heart rate) 5 micrograms (small unit of weight) per minute (mcg/min) by way of the vein (IV – into the vein). Initial rate 5 mcg/min IV Titrate (to gradually adjust a medication ’ s dose (up or down) over time to find the optimal level for a patient, balancing maximum effectiveness with minimal side effects, often guided by specific responses like blood pressure changes, rather than starting at a full dose) by 5 mcg/min every 5 minutes until a goal of mean arterial pressure (MAP) of 65 millimeters of mercury (mmHg – a manometric unit used to measure blood pressure) is achieved. Maximum rate 50 mcg/min. Medication had a black box warning (the most stringent safety notice required by the US Food and Drug Administration for prescription drugs, alerting healthcare providers and patients to serious, life-threatening, or potentially disabling side effects) Concurrently, during review of Patient 19 ’ s medication administration record (MAR – a document used by healthcare professionals to track, verify, and record all medications administered to a patient, including dosage, time, and route), dated 1/26/2025, Chg Nse 1 stated, at 5:00 AM, the nurse documented norepinephrine was titrated and started at the patient ’ s maximum dose of 50 mcg/min. The nurse did not follow the physician orders to start norepinephrine at 5 mcg/min and to titrate by 5 mcg/min every 5 minutes. Instead, the nurse started the norepinephrine at the maximum rate of 50 mcg/min. A review of the facility ’ s Administration of Medications – General policy, dated 10/2024, indicated the following: All aspects of medication management shall include incorporation of the ten rights of medication administration – right patient, right medication, right dose, right route, right time, right documentation, right patient education, right to decline, right assessment, right evaluation. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Monitor the effects of the medication to ensure effective patient response, i.e. blood pressure monitoring.”

“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: 36329 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to provide care as evidence by failing to reposition every two (2) hours for two (2) of 36 sampled patients (Patient 1 and Patient 4) according to facility’s policy and procedure for wound care . This deficient practice resulted in Patient 1 and Patient 4 had acquired pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) while in the hospital. (Refer to A - 0395). 2. The facility failed to assess (initial assessment) and/or reevaluate (after medication administration) for patient’s pain for five (5) of 36 sampled patients (Patient 10,16, 20, 22, and 23). This deficient practice had the potential for Patients 10,16, 20, 22, and 23’s pain not being proper identified for proper treatment and relief for the pain. (Refer to A - 395). 3. The facility failed to provide an individualized care plan for two (2) of 36 sampled patients (Patient 4 and Patient 10) as evidence by: a. Patient 4 had no care plan for pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time). This deficient practice had the potential for delayed provision of necessary care and services for prevention on the development of a pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) on Patient 4. (Refer to A - 396). b. Patient 10 has no care plan for pain management. This deficient practice had the potential for delayed provision of necessary care and services for pain management for Patient 10. (Refer to A - 396). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36329 Based on interview and record review the facility failed to provide care as evidence by failing to: 1. Reposition every two (2) hours for two (2) of 36 sampled patients (Patient 1 and Patient 4). This deficient practice resulted in Patient 1 and Patient 4 had acquired pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) while in the hospital. 2. Assess (initial assessment) and/or reevaluate (after medication administration) a patient pain five (5) of 36 sampled patients (Patient 10,16, 20, 22, and 23). This deficient practice had the potential for Patient 10,16, 20, 22, and 23)’s pain not properly identified for proper treatment and relief for the pain. Findings: 1a. A record review of Patient 1’s Daily Focus Assessment Report (record of assessment and intervention provided to patient) from 4/26/23 at 00:00 (12 a.m.) through 5/2/23 at 23:59 (11:59 p.m.) , indicated Patient 1 was admitted to the facility on 4/26/23 at 21:31 (9:21 p.m.) with acute respiratory distress (a life-threatening lung injury that allows fluid to leak into the lungs). The record indicated an assessment at 8 a.m. indicating Patient 1’s mobility was, “Bedrest.” The record indicated at 4/27/23 at 9:25 a.m., Patient 1’s Braden score was 13 (assessment for risk factors for pressure injury and score scale: very high risk for 9 or less, high risk for score 10 - 12, and moderate risk for score 13 - 14). A record review of Patient 1’s Photographic Documentation - Nursing, dated 4/27/23 indicated Patient 1 had a Stage 1 pressure wound (skin that presents redness with no indication of underlying skin damage) to the sacrum (tailbone, triangular and lowest part of the spine situated between the hips). During an interview, on 1/25/24 at 10:10 AM, the Wound Care Nurse stated the initial evaluation of this Patient 1’s skin indicated Patient 1 had no pressure injury on admission. The Wound Care nurse stated Patient 1 was assessed a low Braden Score (assessment for risk factors for pressure injury, score scale: very high risk for 9 or less, high risk for score 10 - 12, and moderate risk for score 13 - 14) on admission. The Wound Care Nurse asserted that wound evaluations were generally performed based upon the severity of the wound, physical condition, as well as the Braden Score. A record review of Patient 1’s MD orders indicated Patient 1 has a wound care evaluation ordered by Medical Doctor 1 (MD 1), on 4/29/23. The record indicated the wound care evaluation was not implemented until 5/3/23 (four days after the doctor’s order was made). During an interview, on 1/25/24 at 11:25 AM, the Wound Care Nurse stated Patient 1 was assessed as having a Braden Score of 13 (moderate risk for score 13 - 14 for pressure injury), upon admission on 4/27/23, and the minimum practice for preventing pressure injury was to reposition the patient off bony parts of the body every 2 hours and apply foam dressing (dressing with silicone [rubber-like substances] provide barrier and a moist wound environment) to affected body parts. The Wound Care Nurse stated wound evaluation order was received on 4/29/23 (Monday) and had multiple visits on Monday and prioritize visits (wound care evaluation) by ED note acuity, wound staging, and patient’s status. A record review of Patient 1’s Daily Assessment Inquiry, from 4/28/23 to 4/29/23, indicated under “Activity” Patient 1 should be repositioned every 2 hours. The record indicated Patient 1 had been repositioned from/to his left, right, or face up position every 4 hours for more. The record indicated Patient 1 was turned on the following date and time: i. On 4/28/23 at 12 PM, Patient 1 was on right side, at 4 PM, Patient 1 on supine (back), and at 8 PM, Patient 1 was on right side. (turned every four hours). ii. On 4/29/23 at 4 AM, Patient 1 was on right side, and at 8 AM, Patient 1 was on the left side. (8 hours after being last turned/repositioned on 4/28/24 at 8 PM). iii. On 4/29/23 at 8 PM, Patient 1 was on the right side. (12 hours after being turned/repositioned at 4/28/2024 at 8 AM). A record review of Patient 1’s Chemistry (laboratory, blood test) report indicated Patient 1’s albumin level was 3.7 g/dL(gram/deciliter, unit of measurement) on 4/27/23, on 5/1/23 the albumin level was 2.7 g/dL, and on 5/5/23, the albumin level dropped to 1.6 g/dL (normal level range 3.4 to 5.4 g/dL, low level may indicate malnutrition [the body doesn’t get enough nutrients and cause wasting, stunting, underweight, and deficiencies in vitamins and minerals]). A record review of Patient 1’s Photographic Documentation - Nursing, dated 5/3/23, indicated Patient 1’s sacrum wound had advanced to a Deep Tissue Pressure Injury (DTPI, a form of pressure wound that remains invisible for up to 48 hours and then progresses rapidly to upper and lower levels of skin loss. DTPI is usually purple colored) (Pressure wound was Stage 1 on 4/27/23, initial wound assessment). A record review of Patient 1’s Progress Note Inquiry, dated 5/5/23, indicated Patient 1 had a DTPI to the sacrum. The record indicated the pressure injury as being deep red, maroon, or purple in coloration. The DPTI had a dark wound bed or blood-filled blister. The record indicated the interventions to promote healing included: turning and repositioning, support surfaces, padding, pillows, elevation (of body part), skin care barrier ointments, incontinence (loss of bladder or bowel control) management. The record indicated some of the contributing factors delaying healing: poor nutrition status, abnormal laboratory, worsening of medical condition. During an interview, on 1/25/24 at 12:07 PM, the Medical Surgical Telemetry (MST, unit for patient requiring medical, surgical, and [Telemetry, care in a hospital where patients undergo continuous heart monitoring]) ) Director stated it (turning/repositioning) was a common practice to reposition patient at risk of pressure injury every 2 hours. MST Director stated she didn’t know why nurses would reposition such Patient 1 every 4 hours instead of every 2 hours. A record review of facility’s policy and procedure, titled, Wound Care Policy and Procedure,” revised 10/2021, indicated all patients will have a skin integrity assessment during admission and during each shift during the patient’s stay at the hospital. The Braden Risk Assessment Scale Tool will be used to assess. The policy and procedure specified a Braden Score of 13 indicates a moderate risk for pressure ulcer. The policy and procedure objectives were to determine risk of developing pressure ulcer and develop plan of care for prevention of pressure ulcers (pressure injury) to patients determined to be at risk and provide guidelines for individualized treatment. The policy and procedure indicated repositioning included for patient unable to turn or reposition related to current health status were to, “Turn every 2 hours ...This will apply to all bedbound patient that require maximum assist every 2 hours turning and all other patients while in bed. 1b. A record review of Patient 4’s Progress Note Inquiry, indicated Patient 4 was admitted on 1/19/24. The record indicated the following pressure injuries during admission: i. A stage 4 pressure ulcer (injury displaying severe skin tissue damage, possibly exposing muscle, bone, or tendon) on the right hip. The record indicated the wound size/measurement was 5 centimeters (cm) by 6 cm (width and length), and depth of 3.5 cm, “Full thickness tissue loss with exposure of bone. Tendon, and/or muscle.” The record indicated treatment orders that included: cleansing right hip wound with normal saline (mixture of sodium chloride and water), patting wound dry, applying Medihoney (dressing used to provide a moist healing environment), applying moist normal saline (NS, saltwater solution) gauze dressing and foam dressing daily and as needed. ii. A unstageable wound (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin), on the right ankle/foot. The record indicated the wound size/measurement was 1 cm by 1 cm. The record indicated treatment order to cleanse the right foot/ankle with NS, pat dry, apply betadine (a topical solution with used as disinfectant), and leave open to air daily and prn (as needed). iii. A stage 3 wound (pressure injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on the left heel. The record indicated the wound size/measurement was 3.5 cm by 5.5 cm, and depth 0.5 cm. The wound had, “Full thickness tissue (damage extends all layers of the skin) loss involving damage or necrosis of subcutaneous (fatty) tissue, may extend down but not through underlying fascia (sheath of connective tissue).” The record indicated treatment order to cleanse heel wound with NS, pat dry, apply Medihoney, cover with dry dressing, wrap with Kerlix (a gauze roll) daily and prn when soiled. iv. A stage 3 wound on the left ankle. The record indicated wound size/measurement was 3.5 cm by 3.5 cm and depth 0.7 cm. The record indicated the wound had, “Full thickness tissue loss involving damage or necrosis of subcutaneous, may extend down to but not through underlying fascia ...obscured by granulation tissue (new connective tissue). The record indicated treatment order to cleanse left ankle wound with NS, pat dry, apply Medihoney, cover with dry dressing, wrap with Kerlix. v. A diabetic ulcer (open wound due to diabetes [condition of having high blood sugar[) on the left lateral (side) foot. The record indicated the wound size/measurement was 9 cm by 6 cm, and depth 0.9 cm. The wound had “Full thickness tissue loss involving damage or necrosis of subcutaneous tissue, may extend down to but not though underlying fascia ...obscured by granulation. A record review of Patient 4’s Daily Assessment Inquiry, indicated Patient 4 was bedbound (someone who has become very weak and is no longer able to move easily) and should be repositioned every 2 hours. The record indicated Patient 4 was not repositioned every 2 hours. The record indicated Patient 4’s position between 1/20/24 and 01/21/24: i. On 1/20/24 at 8 a.m. and 8 p.m., Patient 4 was supine (not repositioned for 12 hours). ii. On 1/21/24 at 00:00 (12 a.m.), Patient 4 was on the right side, at 4 a.m., Patient 4 was supine, at 8 a.m. Patient 4 was supine, at 19:47 (7:47 p.m., Patient 4 was on supine. Patient 4 was not repositioned every 4 hours and was on the same position for more than 4 hours. During an interview on 1/25/24 at 12:07 PM, the ICU (Intensive Care Unit, unit for the critical and acutely ill and injured patients)/Telemetry Director acknowledged repositioning was common practice to reposition patient at risk of pressure injury to be turned every 2 hours. ICU/Telemetry Director stated she didn’t know why nurses would reposition such patients every 4 hours instead of every 2 hours. A record review of facility’s policy and procedure, titled, Wound Care Policy and Procedure,” revised 10/2021, indicated all patients will have a skin integrity assessment during admission and during each shift during the patient’s stay at the hospital. The Braden Risk Assessment Scale Tool will be used to assess. The policy and procedure specified a Braden Score of 13 indicates a moderate risk for pressure ulcer. The policy and procedure objectives were to determine risk of developing pressure ulcer and develop plan of care for prevention of pressure ulcers (pressure injury) to patients determined to be at risk and provide guidelines for individualized treatment. The policy and procedure indicated repositioning included for patient unable to turn or reposition related to current health status were to, “Turn every 2 hours ...This will apply to all bedbound patient that require maximum assist every 2 hours turning and all other patients while in bed. 2a. A record review of Patient 10’s History and Physical Note, dated 1/24/224, indicated Patient 10 was admitted with complaints of fever, vomiting, and elevated heart rate (heart beating fast). Patient 10 had a history of multiple abdominal surgeries and left hip dislocation (event where thighbone is forced out of its socket in the hip bone) related to a gunshot wound. During an interview on 1/22/24 at 4:15 PM, Patient 10 stated he had an open wound to the abdomen and his right leg was broken. Patient 10 stated he received pain medication every 4 hours as needed. Patient 10 stated he was unable to not recall if the nurse ever came back to ask if the pain had been relieved. A record review of Patient 10’s Medication Administration History Report, ] indicated Patient 10 was prescribed 1 milligram (mg, unit of measurement) of Diluadid (medication for severe pain relief) to be given every 3 hours as needed. This record indicated Patient 10 was given Diluadid on the following dates and times: i. On 1/23/24 at 2:56 AM, for pain level 9 (Pain scale using numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain). ii. On 1/23/24 at 6:02 AM, for pain level 10. iii. On 1/23/24 at 9:11 AM, for pain level 10. iv. On 1/23/24 at 12:52 PM for pain level 10. A review of Patient 10’s Vitals Inquiry, for indicated no reassessment of pain level after the medication (Diluadid) was given for pain on 1/23/24 at 2:56 AM; on 1/23/24 at 6:02 AM; on 1/23/2024 at 9:11 AM; and on 1/23/24 at 12:52 PM. b. A review of Patient 16’s emergency department (ED) physician note, dated 1/20/24, indicated Patient 16 came from home with complaint of chest pain for 30 minutes and received medications in the ambulance for chest pain, on the way to the facility. A review of Patient 16’s History and Physical (H&P - a physician’s examination of a patient which includes a thorough medical history, a physical examination and complete assessment of the patient’s problems) note, dated 1/21/24, indicated Patient 16’s chief complaint was chest pain. Patient 16 had history of stroke (a brain attack, occurs when something blocks blood supply to part of the brain) with right-sided weakness, high blood pressure, and diabetes (a serious condition where your blood glucose level is too high). On 1/23/24, at 1:27 PM, during concurrent interview with IT Nurse 1 (Informatic Nurse, nurse that facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers) and record review of Patient 16’s Triage Notes (a note by an RN in the emergency department who is responsible for assessing patients and determining their level of need for medical assistance), dated 1/20/24, at 10:20 PM, IT Nurse 1 stated Patient 16, who came to the facility with chest pain. IT Nurse 1 stated Patient 16 was assessed on 1/20/24, at 11:06 PM, with a pain score of 7 out of 10 (severe pain). IT Nurse stated Patient 16 record had no documentation of nursing interventions done to relieve Patient 16’s pain including pain medication. On 1/23/24, at 2:20 PM, during concurrent interview with ICU/Tele Director, ICU/Tele director stated pain assessment should be done every four hours with vital signs. ICU/Telemetry Director stated a pain of 7 out of 10, or greater, was severe pain. ICU/Telemetry Director stated, if pain medicine was given through a vein, the patient’s pain should be re-assessed after 30 minutes of giving pain medicine. A record review of the facility’s policy and procedure, titled, Assessment/Reassessment of Patient,’ revised 10/2023, indicated the “Patient’s condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results.” The policy and procedure indicated, “A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration.” c. A record review of Patient 20’s ED Triage note, admit date 1/28/24, indicated Patient 20 was brought to the ED for abdominal (stomach) pain for 3 months with history of diabetes (condition of having high blood sugar) and hypertension (high blood pressure). On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20’s ED Triage note, dated 1/18/24, from 10:06 PM, IT Nurse 2 stated Patient arrived by ambulance from home, complained of abdominal pain. IT Nurse stated Patient 2 was not assessed for pain during triage assessment with vital signs. A record review of Patient 20’s CPOE (computer provider order entry) Order, dated 1/18/24, indicated a physician order for Morphine 4 milligram (mg, unit of measurement) IV (medication given into the vein) one time dose (x 1 only). On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20’s ED medication administration records (MAR), dated 1/18/24, IT Nurse 2 stated on 1/18/24, at 11:03 PM, Patient 20 had a pain score of 10 out of 10. IT Nurse 2 stated on 1/18/2024 at 11:05 PM, Patient 20 was given Morphine 4 mg IV. On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20’s vital signs report, dated 1/18/24 to 1/19/24, IT Nurse 2 stated, on 1/18/24, at 11:17 PM, patient was re-evaluated for pain and had a pain score of 10 out of 10, after having received pain medicine, at 11:05 PM. A record review of Patient 20’s CPOE Order, dated 1/18/24, indicated a physician order Tylenol (pain medication) 1000 mg by mouth (oral) x1 only. On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20’s ED MAR, IT Nurse 2 stated, on 1/18/24, at 11:18 PM, Patient 20 received Tylenol (pain medication) 1000 milligrams by mouth. IT Nurse 2 stated, on 1/18/24, at 11:31 PM, patient’s vital signs were done without pain re-assessment. Patient 20 was not re-assessed for effectiveness of pain medicine given. A record review of the facility’s policy and procedure, titled, Assessment/Reassessment of Patient,’ revised 10/2023, indicated the “Patient’s condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results.” The policy and procedure indicated, “A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration.” d. A review of Patient 22’s Face Sheet, dated 12/1/2023, indicated patient was admitted with abdominal pain. On 1/26/24, at 10:13 AM, during concurrent interview with IT Nurse 2 and record review of Patient 22’s ED records and Triage Notes, dated 12/1/23, IT Nurse 2 stated Patient 22’s paramedics records indicated Patient 22 was picked up from home and complained of having abdominal pain for three days. IT Nurse 2 stated Patient 22’s triage notes, patient complained of abdominal pain and vomiting blood. On 1/26/24, at 10:13 AM, during concurrent interview with IT Nurse 2 and record review of Patient 22’s Patient 22’s pain assessment in ED, dated 12/1/2023 to 12/2/2023, IT Nurse 2 stated, on 12/1/2023, at 10:11 AM, patient had pain score of 0/10 pain, during triage. IT Nurse 2 stated, on 12/1/2023At 4:26 PM, patient had a pain score of 10 of 10. There was no pain assessment for six hours since triage (for 10:11 a.m. to 4:26 p.m., 6 hours and 15 minutes). IT Nurse 2 stated, on 12/2/2023, at 2:00 AM, pain had no pain with a pain score of 0/10 pain (No pain assessment for 9 hours and 34 minutes, since 12/1/23, at 4:26 PM). A record review of the facility’s policy and procedure, titled, Assessment/Reassessment of Patient,’ revised 10/2023, indicated the “Patient’s condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results.” The policy and procedure indicated, “A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration.” e. A review of Patient 23’s Face Sheet, dated 1/5/2024, indicated patient was admitted for generalized weakness after multiple falls. On 1/26/24, at 1:26 PM, during interview with IT Nurse 2 and record review of Patient 23’s Triage and ED notes, dated 1/5/24, IT Nurse 2 stated Patient was brought to facility by paramedics from home for evaluation regarding generalize weakness and after having missed two days of hemodialysis treatments. IT Nurse 2 stated Patient lived at home alone and has been having multiple falls at home. IT Nurse 2 stated on 1/5/2024 at 7:03 AM, Patient 23 was triaged and was not assessed for pain. IT Nurse stated on 1/5/2024 at 12:44 PM, Patient 23 was assessed for pain level at 8/10 (pain scale using numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain). No pain assessment for more five [5] hours and 41 minutes after arrival to the ED at 7:03 AM. On 1/26/24, at 1:26 PM, during interview with IT Nurse 2 and record review of Patient 23’s Triage and ED notes, dated 1/5/24, On 1/5/2024 at 12:44 PM, Patient 23 was given Morphine 2 milligrams by vein. IT Nurse 2 stated, there was no re-assessment for the effectiveness of pain medicine given on 1/5/2024 at 12:44 PM. A record review of the facility’s policy and procedure, titled, Assessment/Reassessment of Patient,’ revised 10/2023, indicated the “Patient’s condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results.” The policy and procedure indicated, “A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration.””

“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: 36329 Based on record interview and record review the facility failed to complete an individualized care plan for two (2) of 36 sampled patients (Patient 4 and Patient 10) as evidence by: 1. Patient 4 had no care plan for pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) This deficient practice had the potential for delayed provision of necessary care and services for prevention of the development of a pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) on Patient 4. 2. Patient 10 has no care plan for pain management. This deficient practice had the potential for delayed provision of necessary care and services for pain management for Patient 10. This deficient practice had the potential for delayed provision of necessary care and services for chest pain. Findings: 1. A record review of Patient 4’s History and Physical (H&P, physician examination record), dated 1/19/2024, indicated Patient 4 was admitted with a history of cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), history of seizure (uncontrolled electrical activity in the brain which can affect a person’s movement and level of consciousness). The record indicated Patient 4 was admitted with chronic feet ulceration (formation of a break on the skin or on the surface of an organ) and Patient has multiple bruises on the patient’s body. A record review of Patient 4’s Daily Assessment Inquiry, indicated Patient 4 was bedbound (someone who has become very weak and is no longer able to move easily) and should be repositioned every 2 hours. The record indicated Patient 4 was not repositioned every 2 hours. The record indicated the following between 1/20/24 and 01/21/2024: a. On 1/20/2024 at 8 a.m. and 8 p.m. Patient 4 was supine (not repositioned for 12 hours). b. On 1/21/2024 at 00:00 (12 a.m.) Patient 4 was on the right side, at 4 a.m., Patient 4 was supine, at 8 a.m. Patient 4 was supine, at 19:47 (7:47 p.m., Patient 4 was on supine (not repositioned for 4 hours and on the same position on the same position). A record review of Patient 4’s Patient Care Plan Report,” printed 1/23/2024, indicate there were care plans for “Resp - Pulmonary Changes (Potential),” “Safety - Risk for Injury (Potential),” “Infection - Risk for (Potential),””Fall Risk/Potential for Falls (Potential),”, “Seizure Disorder (Actual),”and “Functional - Impaired Physical Mobility (Actual).” There was no care plan for pressure injury for Patient 4. During an interview, on 1/25/2024 at 12:19 PM, the ICU (Intensive Care Unit, area that provide treatment and monitoring for patients, who are very ill)/ Telemetry (area that provide treatment and monitoring for patients with heart conditions) Director stated all patients should have a nurse care plan so that nursing recognizes patient needs and can act upon those needs. A record review of the facility’s policy and procedure (P&P), titled, “Care Plan, Multidisciplinary,” effective 10/2019, indicated purpose for the P&P were the following: a. To establish guidelines to provide personalized and high-quality care. b. To provide best practice care; to facilitate communication among all care givers. c. Within 24 hours of patient admission to the hospital, and updated every shift, d. The care plan will include the provider’s plan of care along with orders. e. The nursing plan of care will include the specific patient problems addressing short term goals and measurable outcomes, interventions to meet the goals, nursing summary of responses to these care interventions, and any nursing care plan changes or recommendations. . 2. A record review of Patient 10’s History and Physical Note, dated 1/24/2024, indicated Patient 10 had complaints of fever, vomiting, and elevated heart rate. The record indicated Patient 10 had a history of multiple abdominal surgeries and left hip dislocation (event where thighbone is forced out of its socket in the hip bone) related to a gunshot wound. A record review of Patient 10’s Medication Administration History Report, ] indicated Patient 10 was prescribed 1 milligram (mg, unit of measurement) of Diluadid (medication for severe pain relief) to be given every 3 hours as needed. This record indicated Patient 10 was given Diluadid on the following: a. On 1/23/2024 at 2:56 AM, for pain level 9 (Pain scale using numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain). b. On 1/23/2024 at 6:02 AM, for pain level 10. c. On 1/23/2024 at 9:11 AM, for pain level 10. d. On 1/23/2024 at 12:52 PM for pain level 10. A review of Patient 4’s Vitals Inquiry, for indicated no reassessment of pain level after the medication (Diluadid) was given for pain on 1/23/2024 at 2:56 AM; on 1/23/2024 at 6:02 AM; on 1/23/2024 at 9:11 AM; and on 1/23/2024 at 12:52 PM. A record review of Patient 10’s Patient Care Plan Report, dated 1/23/2024, indicate Patient 10’s care plans included, “Resp. (respiratory) - Ineffective Breathing Pattern (Actual),”Knowledge Deficit; Hospitalization (Potential),” ‘Impaired Skin Integrity: Moderate Risk (13-14) (Actual)’, ‘Safety - Risk for Injury (Potential),” “Infection (Actual),” and “Functional - Impaired Physical Mobility (Actual).” Patient 10 had no nursing care plan for pain. During an interview, on 1/25/2024 at 12:19 PM, the ICU (Intensive Care Unit, area that provide treatment and monitoring for patients, who are very ill)/ Telemetry (area that provide treatment and monitoring for patients with heart conditions) Director stated all patients should have a nurse care plan so that nursing recognizes patient needs and can act upon those needs. A record review of the facility’s policy and procedure (P&P), titled, “Care Plan, Multidisciplinary,” effective 10/2019, indicated purpose for the P&P were the following: a. To establish guidelines to provide personalized and high-quality care. b. To provide best practice care; to facilitate communication among all care givers. c. Within 24 hours of patient admission to the hospital, and updated every shift, d. The care plan will include the provider’s plan of care along with orders. e. The nursing plan of care will include the specific patient problems addressing short term goals and measurable outcomes, interventions to meet the goals, nursing summary of responses to these care interventions, and any nursing care plan changes or recommendations.”