UCLA West Valley Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to perform a Medical Screening Examination (MSE - screening used to determine whether a patient has an emergency medical condition) in the emergency department (ED) for one of 20 sampled patients (Patient 1). This deficient practice had the potential to result in the failure to treat Patient 1 for an emergency medical condition, including life-threatening conditions, and placing Patient 1 at risk of serious harm and poor outcomes. Findings: During a review of the local city Police Department (PD) report titled “MEU [Mental Examination Unit] Incident,” dated 12/2/2024, the report indicated two police officers were dispatched to the facility on 12/1/2024 at 9:49 p.m. The report further indicated, “[Officers] responded to a radio call regarding a battery (the willful, unlawful, and harmful or offensive physical contact of another person) investigation at [Facility Name] in the lobby. Victim was a security guard who had already left the location prior to PD arrival ... While the subject [Patient 1] was being advised to leave the area, [Patient 1] made suicidal statements that [Patient 1] wanted to kill herself by going into oncoming traffic ... [Officers] advised hospital staff that they were placing [Patient 1] on a 5150 Hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])-DTS (danger to self) and attempted to submit an application for a mental evaluation hold. The charge nurse at the facility refused to accept the application expressing their frustration that [Patient 1] has been placed on hold several times at the hospital and returns upon being released. ... [Officers] then transported [Patient 1] to [Hospital B] where they submitted the Mental Evaluation application.” The report further indicated, “[Patient 1] refused to leave the [hospital A], [Patient 1] stated she wants to kill herself, we attempted to place her on hold at [Hospital A], they refused to accept the hold ... We [transported Patient 1] to [Hospital B] and placed her on hold.” During a concurrent interview and record review on 9/16/2025 at 10:15 a.m. with RN 2, the facility ’ s “ Emergency Department (ED) Central Log,” dated 12/1/2024, was reviewed. RN 2 confirmed there was one entry on the ED Central Log for Patient 1 on 12/1/2024 at 11:36 a.m. During a concurrent interview and record review on 9/16/2025 at 10:15 a.m. with Registered Nurse (RN) 2, Patient 1’s “Emergency Provider Report,” dated 12/1/2024 at 12:16 p.m., was reviewed. The “Report” indicated Patient 1 arrived on 12/1/2024 at 11:36 a.m. by ambulance with a chief complaint of “wound.” Patient 1 had a history of cerebral palsy (a lifelong neurological disorder caused by brain damage or improper development, resulting in problems with movement, muscle tone, balance, and posture), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania [high energy and euphoria] and depression), schizophrenia (a serious mental health condition that affects a person ’ s ability to think, feel, and behave clearly), and was wheelchair-bound (a person unable to walk and reliant on a wheelchair for mobility due to injury, illness, or disability). Patient 1 was treated for a wound and discharged at 5:25 p.m. on 12/1/2024. RN 2 confirmed there were no further Emergency Department (ED) Central Log entries or medical record entries for Patient 1 on 12/1/2024. During an interview on 9/16/2025 at 2:10 p.m. with the Director of Emergency Department (DED), the DED confirmed there were no incident reports filed on 12/1/2024. The DED further stated if there was a disruptive patient in Emergency Department (ED), the situation would be escalated to the charge nurse and the charge nurse would then further escalate it, and it should be documented in the patient’s chart and the facility ’ s incident report system. The DED further stated if there was a call to the police, it should also be documented in the patient’s chart and in the event reporting system. The DED further stated all patients presenting to the ED were signed in and could get assistance signing in the ED lobby. During an interview on 9/16/2025 at 2:15 p.m. with the Director of Emergency Department (DED), the DED stated all patients that come to the ED sign in electronically. If the patient needed assistance, the vital signs technician (clinical staff responsible for monitoring and recording patients’ essential health indicators, such as heart rate, blood pressure, temperature, and respiratory rate) in the ED lobby would assist the patient in signing in to the ED. During an interview on 9/16/2025 at 2:20 p.m. with the Chief Nursing Officer (CNO), the CNO stated the facility reviewed their event reporting systems and there was no ED incident report for 12/1/2024 that was escalated up to the incident reporting system. The CNO further stated the facility changed to a new contracted security provider on 3/12/2025, and the CNO and Chief Operating Officer (COO) were trying to obtain ED security incident reports on 12/1/2024 from the previous security provider. During an interview on 9/17/2025 at 11:35 a.m. with the DED, the DED stated if the police department placed a patient on a 5150 hold, the ED would medically clear the patient and hold the patient for psychiatric placement elsewhere. During an interview on 9/17/2025 at 4:29 pm with the ED Charge Nurse (CRN), the CRN stated he could not recall anything that happened on 12/1/2024. The CRN stated if a patient walked into the ED and was physically aggressive or combative, the facility ’ s staff would call security and deescalate (reducing the intensity of a conflict). If a patient presented to the ED on a 5150 hold, that patient has to be put in a room and medically cleared. The CRN further stated they would have to hold the patient until transferred to a psychiatric facility that was available to take the patient. During an interview on 9/17/2025 at 11:45 a.m. with the Security Operations Manager (SOM), the SOM stated there was an assault incident that was reported by the facility on 12/1/2024 between 9:45 p.m. and 10:26 p.m. The CNO stated the facility was attempting to get the police report as well as the incident report from the previous contracted security provider. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Department Management of Potential Safety Risks of Persons with Emergency Mental Health and/or Substance Abuse Presentations,” last revised 6/2025, the P&P indicated, “The purpose of this policy is to specify the responsibilities of emergency department (ED) staff and providing a safe environment for the initial treatment and stabilization of patients who present with emergency mental health and or substance abuse presentations ... 72 hour hold: written order by a peace officer ... for the involuntary detention of a patient who was suffering from a mental illness and as a result of that illness is a danger to himself or herself, or others, or gravely disabled (California Welfare and Institution Code 5150). This order is valid for up to seventy-two hours of involuntary detention for the purpose of evaluation and treatment within [Facility Name] ... Communication between the clinical and security teams is critical in order to provide a safe environment for appropriate intake and stabilization of patients presenting with emergency psychiatric conditions ... All patients will be triaged by emergency department personnel and provided initial medical intake.” During a review of the facility ’ s policy and procedure (P&P) titled “EMTALA (Screening, Stabilization, and Management of Emergency Transfers),” last revised 4/2025, the P&P indicated, “It is the policy of [Facility Name] to provide an appropriate Medical Screening Exam to: ... Individuals presenting at the dedicated emergency department ( ’ DED ’ s) requesting examination or treatment of a medical condition.””

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to document on the “Emergency Department (ED) Central Log” that one of 20 sampled patients (Patient 1) presenting to the ED did not receive a Medical Screening Examination (MSE – screening used to determine whether a patient has an emergent medical condition). This deficient practice had the potential to result in other patients presenting to the ED not being accounted for, not receiving an appropriate medical screening examination or stabilization, and placing them at risk for delayed care and adverse outcomes. Findings: During a review of the local city Police Department (PD) report titled “MEU [Mental Examination Unit] Incident,” dated 12/2/2024, the report indicated two police officers were dispatched to the facility on 12/1/2024 at 9:49 p.m. The report further indicated, “[Officers] responded to a radio call regarding a battery (the willful, unlawful, and harmful or offensive physical contact of another person) investigation at [Facility Name] in the lobby. Victim was a security guard who had already left the location prior to PD arrival ... While the subject [Patient 1] was being advised to leave the area, [Patient 1] made suicidal statements that [Patient 1] wanted to kill herself by going into oncoming traffic ... [Officers] advised hospital staff that they were placing [Patient 1] on a 5150 Hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])-DTS (danger to self) and attempted to submit an application for a mental evaluation hold. The charge nurse at [Hospital A] refused to accept the application expressing their frustration that [Patient 1] has been placed on hold several times at the hospital and returns upon being released. ... [Officers] then transported [Patient 1] to [Hospital B] where they submitted the Mental Evaluation application.” The report further indicated, “[Patient 1] refused to leave the [hospital], [Patient 1] stated she wants to kill herself, we attempted to place her on hold at [Hospital A], they refused to accept the hold ... We [transported Patient 1] to [Hospital B] and placed her on hold.” During a concurrent interview and record review on 9/16/2025 at 10:15 a.m. with Register Nurse 2 (RN 2), the facility ’ s “Emergency Department (ED) Central Log,” dated 12/1/2024, was reviewed. RN 2 confirmed there was one entry on the ED Central Log for Patient 1 on 12/1/2024 at 11:36 a.m. During a concurrent interview and record review on 9/16/2025 at 10:15 a.m. with Registered Nurse (RN) 2, Patient 1’s “Emergency Provider Report,” dated 12/1/2024 at 12:16 p.m., was reviewed. The “Report” indicated Patient 1 arrived on 12/1/2024 at 11:36 a.m. by ambulance with a chief complaint of “wound.” Patient 1 had a history of cerebral palsy (a lifelong neurological disorder caused by brain damage or improper development, resulting in problems with movement, muscle tone, balance, and posture), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania [high energy and euphoria] and depression), schizophrenia (a serious mental health condition that affects a person ’ s ability to think, feel, and behave clearly), and was wheelchair-bound (unable to walk and reliant on a wheelchair for mobility due to injury, illness, or disability). Patient 1 was treated for a wound and discharged at 5:25 p.m. on 12/1/2024. RN 2 confirmed there were no further ED Central Log entries or medical record entries for Patient 1 on 12/1/2024. During an interview on 9/16/2025 at 2:10 p.m. with the Director of Emergency Department (DED), the DED confirmed there were no incident reports filed on 12/1/2024. The DED further stated if there was a disruptive patient in ED, the situation would be escalated to the charge nurse and the charge nurse would then further escalate it, and it should be documented in the patient’s chart and the facility ’ s incident report system. The DED further stated if there was a call to the police, it should also be documented in the patient’s chart and in the event reporting system. The DED further stated all patients presenting to the ED were signed in and could get assistance signing in the Emergency Department (ED) lobby. During an interview on 9/16/2025 at 2:15 p.m. with the Director of Emergency Department (DED), the DED stated all patients that come to the Emergency Department (ED) sign in electronically. If the patient needed assistance, the vital signs technician (clinical staff responsible for monitoring and recording patients’ essential health indicators, such as heart rate, blood pressure, temperature, and respiratory rate) in the ED lobby would assist the patient in signing in to the ED. During an interview on 9/16/2025 at 2:20 p.m. with the Chief Nursing Officer (CNO), the CNO stated the facility reviewed their event reporting systems and there was no ED incident report for 12/1/2024 that was escalated up to the incident reporting system. The CNO further stated the facility changed to a new contracted security provider on 3/12/2025, and the CNO and Chief Operating Officer (COO) were trying to obtain ED security incident reports on 12/1/2024 from the previous security provider. During an interview on 9/17/2025 at 11:35 a.m. with the DED, the DED stated if the police department placed a patient on a 5150 hold, the ED would medically clear the patient and hold the patient for psychiatric placement elsewhere. During an interview on 9/17/2025 at 3:15 p.m. with Emergency Department Registered Nurse (ED RN), ED RN stated the police were called for various reasons in the ED, including if a patient refused to leave. If a patient was aggressive, they would document that in the patient ’ s chart if the patient had a chart. ED RN stated if the facility ’ s security officers called the police, if the patient was registered in the ED and triaged, then the nursing staff would document that in the patient’s chart; if the patient was not registered and did not have a medical record number, the nursing staff would write the incident on the patient assignment sheet and share it with the charge nurse and ED Director. ED RN stated they did not deny care and they saw all patients in the ED. ED RN further stated she did not recall any incidents occurring on 12/1/24. During a review of the facility ’ s policy and procedure (P&P) titled “EMTALA (Screening, Stabilization, and Management of Emergency Transfers),” last revised 4/2025, the P&P indicated, “It is the policy of [Facility Name] to provide an appropriate Medical Screening Exam to: ... Individuals presenting at the dedicated emergency department ( ’ DED ’ s) requesting examination or treatment of a medical condition ... EMTALA Central Logs must identify the patients presenting for emergency services ... The Central Log shall include the patient’s name and outcome and indicate whether the patient refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45774 Based on interview and record review, the facility failed to perform a Medical Screening Examination (MSE - screening used to determine whether a patient has an emergency medical condition) in the emergency department (ED) for one of 20 sampled patients (Patient 1). This deficient practice had the potential to result in the failure to treat Patient 1 for an emergency medical condition, including life-threatening conditions, and placing Patient 1 at risk of serious harm and poor outcomes. Findings: During a review of the city Police Department (PD) report titled “MEU [Mental Examination Unit] Incident,” dated 12/2/2024, the report indicated two police officers were dispatched to the facility on 12/1/2024 at 9:49 p.m. The report further indicated, “[Officers] responded to a radio call regarding a battery (the willful, unlawful, and harmful or offensive physical contact of another person) investigation at [Facility Name] in the lobby. Victim was a security guard who had already left the location prior to PD arrival ... While the subject [Patient 1] was being advised to leave the area, [Patient 1] made suicidal statements that [Patient 1] wanted to kill herself by going into oncoming traffic ... [Officers] advised hospital staff that they were placing [Patient 1] on a 5150 Hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])-DTS (danger to self) and attempted to submit an application for a mental evaluation hold. The charge nurse at [Hospital A] refused to accept the application expressing their frustration that [Patient 1] has been placed on hold several times at the hospital and returns upon being released. ... [Officers] then transported [Patient 1] to [Hospital B] where they submitted the Mental Evaluation application.” The report further indicated, “[Patient 1] refused to leave the [hospital], [Patient 1] stated she wants to kill herself, we attempted to place her on hold at [Hospital A], they refused to accept the hold ... We [transported Patient 1] to [Hospital B] and placed her on hold.” During a concurrent interview and record review on 9/16/2025 at 10:15 a.m. with Register Nurse 2 (RN 2), the facility ’ s “Emergency Department (ED) Central Log,” dated 12/1/2024, was reviewed. RN 2 confirmed there was one entry on the ED Central Log for Patient 1 on 12/1/2024 at 11:36 a.m. During a concurrent interview and record review on 9/16/2025 at 10:15 a.m. with Registered Nurse (RN) 2, Patient 1’s “Emergency Provider Report,” dated 12/1/2024 at 12:16 p.m., was reviewed. Indicated Patient 1 arrived on 12/1/2024 at 11:36 a.m. by ambulance with a chief complaint of “wound.” Patient 1 had a history of cerebral palsy (a lifelong neurological disorder caused by brain damage or improper development, resulting in problems with movement, muscle tone, balance, and posture), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between mania [high energy and euphoria] and depression), schizophrenia (a serious mental health condition that affects a person ’ s ability to think, feel, and behave clearly), and was wheelchair-bound (a person unable to walk and reliant on a wheelchair for mobility due to injury, illness, or disability). Patient 1 was treated for a wound and discharged at 5:25 p.m. on 12/1/2024. RN 2 confirmed there were no further ED Central Log entries or medical record entries for Patient 1 on 12/1/2024. During an interview on 9/16/2025 at 2:10 p.m. with the Director of Emergency Department (DED), the DED confirmed there were no incident reports filed on 12/1/2024. The DED further stated if there was a disruptive patient in Emergency Department (ED), the situation would be escalated to the charge nurse and the charge nurse would then further escalate it, and it should be documented in the patient’s chart and the facility ’ s incident report system. The DED further stated if there was a call to the police, it should also be documented in the patient’s chart and in the event reporting system. The DED further stated all patients presenting to the ED were signed in and could get assistance signing in the ED lobby. During an interview on 9/16/2025 at 2:15 p.m. with the Director of Emergency Department (DED), the DED stated all patients that come to the Emergency Department (ED) sign in electronically. If the patient needed assistance, the vital signs technician (clinical staff responsible for monitoring and recording patients’ essential health indicators, such as heart rate, blood pressure, temperature, and respiratory rate) in the ED lobby would assist the patient in signing in to the ED. During an interview on 9/16/2025 at 2:20 p.m. with the Chief Nursing Officer (CNO), the CNO stated the facility reviewed their event reporting systems and there was no Emergency Department (ED) incident report for 12/1/2024 that was escalated up to the incident reporting system. The CNO further stated the facility changed to a new contracted security provider on 3/12/2025, and the CNO and Chief Operating Officer (COO) were trying to obtain ED security incident reports on 12/1/2024 from the previous security provider. During an interview on 9/17/2025 at 11:35 a.m. with the Director of Emergency Department (DED), the DED stated if the police department placed a patient on a 5150 hold, the ED would medically clear the patient and hold the patient for psychiatric placement elsewhere. During an interview on 9/17/2025 at 4:29 pm with the ED Charge Nurse (CRN), the CRN stated he could not recall anything that happened on 12/1/2024. The CRN stated if a patient walked into the ED and was physically aggressive or combative, the facility ’ s staff would call security and deescalate (reducing the intensity of a conflict). If a patient presented to the ED on a 5150 hold, that patient has to be put in a room and medically cleared. The CRN further stated they would have to hold the patient until transferred to a psychiatric facility that was available to take the patient. During an interview on 9/17/2025 at 11:45 a.m. with the Security Operations Manager (SOM) and CNO, the SOM stated there was an assault incident that was reported by the facility on 12/1/2024 between 9:45 p.m. and 10:26 p.m. The CNO stated the facility was attempting to get the police report as well as the incident report from the previous contracted security provider. During a review of the facility ’ s policy and procedure (P&P) titled, “Emergency Department Management of Potential Safety Risks of Persons with Emergency Mental Health and/or Substance Abuse Presentations,” last revised 6/2025, the P&P indicated, “The purpose of this policy is to specify the responsibilities of emergency department (ED) staff and providing a safe environment for the initial treatment and stabilization of patients who present with emergency mental health and/or substance abuse presentations ... 72 hour hold: written order by a peace officer ... for the involuntary detention of a patient who was suffering from a mental illness and as a result of that illness is a danger to himself or herself, or others, or gravely disabled (California Welfare and Institution Code 5150). This order is valid for up to seventy-two hours of involuntary detention for the purpose of evaluation and treatment within [Facility Name] ... Communication between the clinical and security teams is critical in order to provide a safe environment for appropriate intake and stabilization of patients presenting with emergency psychiatric conditions ... All patients will be triaged by emergency department personnel and provided initial medical intake.” During a review of the facility ’ s policy and procedure (P&P) titled “EMTALA (Screening, Stabilization, and Management of Emergency Transfers),” last revised 4/2025, the P&P indicated, “It is the policy of [Facility Name] to provide an appropriate Medical Screening Exam to: ... Individuals presenting at the dedicated emergency department ( ’ DED ’ s) requesting examination or treatment of a medical condition.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by: 1. The facility failed to ensure three of 31 sampled patients (Patient 16, Patient 17, and Patient 22), the Conditions of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) were provided by facility staff per policy & (and) procedure. This deficient practice resulted in violation of Patient 16, Patient 17, and Patient 22 ’ s patient rights by failing to establish an agreement of admission, consent to treatment, clear and precise explanation of services provided, and ensuring a clear understanding of the patient ’ s financial obligation was achieved. (Refer to A-0117) 2. The facility failed to ensure: A. The safety precautions of cold therapy were in place for one of 31 sampled patients (Patient 24), when BREG Polar Care (a cold therapy system designed for pain and swelling relief, often used post-surgery or for managing chronic pain) was used without a physician order and not following manufacturer’s instructions, for Patient 24 while on the Surgical recovery unit (a hospital unit where patients recover after a surgical procedure ). These deficient practices had the potential for Patients 24 to suffer bodily injury, including but not limited to serious cold-induced injury (damage to the body caused by exposure to cold temperatures), including full thickness necrosis (the death of tissue that extends through all layers of the skin, potentially involving muscle, fat, or even bone. (Refer to A-0144). B. One of 31 sampled patients (Patient 24) who was at risk for fall, was not provided with a safe environment to minimize the risk of falls in accordance with the facility ’ s policy and procedure. This deficient practice had the potential to result in an unsafe care that may lead to Patient 24 suffering from a fall that could cause injury and/or death to the patient. (Refer to A-0144). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by: 1. The facility failed to ensure for one of 31 sampled patients (Patients 27), Patient 27 who was assessed to be at moderate risk for suicide (a mental state in which it is likely that a person will try to end their own life or feeling that people would be better off without them) the continuous sitter (provides direct, one on one observation and supervision for patients who may be at risk of harming themselves or others) monitored and documented Patient 27 ’ s whereabouts for suicidal ideation in accordance with the facility ’ s policy and procedure (P&P). This deficient practice had the potential for Patient 27 with suicide risk to result in injury to Patient 27 or even death due to lack of monitoring. (Refer to A-0395). 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) for four of 31 sampled patients (Patient 12, Patient 13, Patient 17 and Patients 26). The facility did not develop a nursing care plan addressing diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD [kidney failure], a condition in which the kidneys lose the ability to remove waste and balance fluids) on hemodialysis (HD, medical procedure that filters a person ’ s blood to remove waste and fluid, acting as a kidney for those with kidney failure) and bleeding (loss of blood) for Patient 12, Patient 13, Patient 17. For Patient 26, no nursing care plan was developed to address Hemodialysis (a medical procedure used to remove waste products and excess fluid from the blood usually due to kidney disease) was not initiated in accordance with facility ’ s policy and procedure (P&P). This deficient practice had the potential to result in Patient 12, Patient 13, and Patient 17, and Patient 26 not receiving the right level of care and not meeting the needs for the identified patient ’ s concerns. (Refer to A-0396). 3. One of 31 sampled patients (Patient 24), who was at risk for fall, was not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall), water was observed on the floor and bed alarm (sound alarm that will alert hospital staff when patient get out of bed unassisted) was not on. These deficient practices had the potential to result in an unsafe care that may lead to Patient 24 suffering from a fall injury. (Refer to A-398). 4. One of 31 sampled patients (Patient 23) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) was not labeled to include the date and time of insertion, and the respective staff member’s initials by the staff to identify who inserted the respective IV catheter in the patient. This deficient practice had the potential to result in increasing the risks for intravascular catheter related infections for Patient 23. (Refer to A-0398). 5. One of 31 sampled patients (Patient 23) Lactated Ringers (a solution used to restore fluids and electrolytes in the body) intravenous (IV-in the vein) solution bag was not labeled to include identification number, the date and time, the ordered rate and duration of infusion, and the respective staff member ’ s initials by the staff to identify who hanged the IV bag for patient administration. This deficient practice may have resulted in Patient 23, increase risk for receiving IV solution bag not intended for Patient 23. (Refer to A-0398). 6. One of 31 sampled patients (Patients 29), who was experiencing pain, was not assessed and documented for pain level (pain assessment includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain) according to the facility ’ s policies and procedures prior medication administration. This deficient practice had the potential to result in a delay and provide appropriate amount of pain management necessary to address Patient 29 ’ s pain. (Refer to A-0398). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50521 Based on interview and record review the facility failed to ensure three of 31 sampled patients (Patient 16, Patient 17, and Patient 22), the Conditions of Admission (COA - a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) were provided by facility staff per policy & (and) procedure. This deficient practice resulted in violation of Patient 16, Patient 17, and Patient 22 ’ s patient rights by failing to establish an agreement of admission, consent to treatment, clear and precise explanation of services provided, and ensuring a clear understanding of the patient ’ s financial obligation was achieved. Findings: 1. During a review of Patient 16 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/23/24, with the Hospital Informaticist Manager (HIM), Patient 16 ’ s H&P indicated a past medical history of Parkinson ’ s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) who presented to the hospital on 12/23/24 with generalized weakness (a feeling of reduced strength and energy throughout the body, making it difficult to perform everyday tasks), flu-like symptoms (a set of symptoms that resembles the flu), and poor oral intake (low intake of food and beverages to meet a person ’ s nutritional needs). During a review of Patient 16 ’ s “Condition of Admission (COA, admission agreement defining the rights and responsibilities of both the patient and the facility, outlining the terms and conditions of a patient ’ s entry into a facility),” there was no COA document found. During a concurrent interview and record review on 8/5/25 at 1:15 p.m., with HIM, HIM confirmed there was no COA for Patient 16. During a concurrent interview and record review on 8/6/25 at 3:32 p.m., with Nurse Informaticist 2 (NI 2), NI 2 stated there was no COA document available for Patient 16. NI 2 stated the COA is important as it acknowledges a patient ’ s consent to admission and treatment. NI 2 further stated that the COA notifies patients of their rights and responsibilities, among other things. During an interview on 8/7/25 at 12:26 p.m., with Director of Admissions (DOA), DOA stated that if a patient ’ s COA was not completed prior to discharge, a follow-up is attempted. If the patient was reached, the patient could complete the COA via “My Chart” (a patient portal offered by healthcare providers, allowing patients to access their medica information online). DOA stated if the patient does not have “My Chart”, staff may obtain verbal consent (giving consent for something to happen through spoken words). DOA further stated that a patient rights notice is in the COA. During a review of the facility ’ s Condition of Admission (COA, admission agreement defining the rights and responsibilities of both the patient and the facility, outlining the terms and conditions of a patient ’ s entry into a facility) indicated the following items are topics provided in the COA. An explanation of each item is provided on the form: “Admission and Medical Services Agreement – Read Carefully Before Signing” 1. UCLAH: UCLA Health (UCLAH) is part of the University of California and is comprised of its hospital(s), medical center(s), its hospital-based clinics, its Primary Care Network clinics, the UCLA Medical Group; and the David Geffen School of Medicine. 2. Medical Consent 3. Teaching, Research, and Healthcare Institution: UCLAH is a teaching, research, and healthcare institution. The section explains information about the use of residents, interns, etc. 4. Use of Medica Information and Specimens 5. Personal Valuables 6. Release of Medical Information 7. Financial Agreement 8. Open Payments Database: is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. 9. Assignment of Benefits (including Medicare benefits): authorization and direct payment to UCLAH of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on behalf for UCLH services, including emergency services, at a rate not to exceed UCLAH actual charges. 10. Texting Consent 11. E-mail Consent 12. Video Visits Consent 13.Nurse Practitioners: a nurse practitioner is not a physician and surgeon. Patients have the right to see a physician and surgeon under the following circumstances: the circumstances are listed. 14. Patient Rights Notice: (applies to inpatient admissions only) Would you like your durable power of attorney (DPOA) or next of kin to receive a copy of the Patient Rights and Responsibilities Notice? If so, please contact the Patient Affairs Department at (310) 267-9113. 15.Advanced Directives During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Rights and Responsibilities, HS 1354,” dated 04/2025, indicated the following: 1.Purpose - The purpose of this policy is to address patient rights specified by the Medicare Conditions of Participation, California law and The Joint Commission standards and to set forth the responsibilities of medical and administrative staff associated with the recognition of these rights at the UCLA Hospital System. 2. Procedure I.Provide the Patient with a Notice of Rights and Responsibilities: UCLA Hospital System will inform the patient, or when appropriate the patient’s representative, of its patient rights policy in advance of furnishing or discontinuing patient care whenever possible. It may inform the patient using the following methods, as appropriate: B. Providing a patient and visitor information brochure “Whenever possible, whether at the time of admission, or prior to receiving treatment, each patient will receive information regarding his or her responsibilities as a patient in the hospital system. Each patient may be given a copy of the patient and visitor information brochure. Upon admission, the hospital shall ask the patient if he or she would like the hospital to provide the patient’s next of kin or agent under a durable power of attorney for health care with materials regarding patient’s rights and responsibilities. If the patient states that he or she would like these materials to be provided, the hospital shall do so. Upon the request of the patient, or of the patient’s representative, an explanation of the materials will be provided ...examine and receive an explanation of the hospital’s bill, regardless of the source of payment ...” 2. During a review of Patient 17 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/19/24, with the Hospital Informaticist Manager (HIM), Patient 17 ’ s H&P indicated Patient 17 was brought to the hospital for a left foot infection. Patient 17 had a history of an above-the-knee amputation (AKA, the surgical removal of a leg above the knee joint) of the right leg due to infection. Patient 17 had a past medical history of diabetes mellitus (DM, a disease that result in too much sugar in the blood). During a review of Patient 17 ’ s “Condition of Admission (COA, admission agreement defining the rights and responsibilities of both the patient and the facility, outlining the terms and conditions of a patient ’ s entry into a facility),” There was no COA document found. During a concurrent interview and record review on 8/5/25 at 2:25 p.m., with HIM, HIM confirmed there was no COA for Patient 17 on file. During a concurrent interview and record review on 8/6/25 at 3:09 p.m. with Nurse Informaticist 2 (NI 2), NI 2 stated that there was no COA for Patient 17. NI 2 stated that the COA is needed for a patient ’ s consent (agreement to do something) to admission (being allowed to enter a place) and treatment (actions taken to manage, ease, or cure a health condition or disease). During a review of the facility ’ s Condition of Admission (COA, admission agreement defining the rights and responsibilities of both the patient and the facility, outlining the terms and conditions of a patient ’ s entry into a facility) indicated the following items are topics provided in the COA. An explanation of each item is provided on the form: “Admission and Medical Services Agreement – Read Carefully Before Signing” 2.UCLAH: UCLA Health (UCLAH) is part of the University of California and is comprised of its hospital(s), medical center(s), its hospital-based clinics, its Primary Care Network clinics, the UCLA Medical Group; and the David Geffen School of Medicine. 3.Medical Consent 4.Teaching, Research, and Healthcare Institution: UCLAH is a teaching, research, and healthcare institution. The section explains information about the use of residents, interns, etc. 5. Use of Medica Information and Specimens 6. Personal Valuables 7. Release of Medical Information 8. Financial Agreement 9. Open Payments Database: is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. 10. Assignment of Benefits (including Medicare benefits): authorization and direct payment to UCLAH of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on behalf for UCLH services, including emergency services, at a rate not to exceed UCLAH actual charges. 11. Texting Consent 12. E-mail Consent 13. Video Visits Consent 14. Nurse Practitioners: a nurse practitioner is not a physician and surgeon. Patients have the right to see a physician and surgeon under the following circumstances: the circumstances are listed. 15. Patient Rights Notice: (applies to inpatient admissions only) Would you like your durable power of attorney (DPOA) or next of kin to receive a copy of the Patient Rights and Responsibilities Notice? If so, please contact the Patient Affairs Department at (310) 267-9113. 16. Advanced Directives During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Rights and Responsibilities, HS 1354,” dated 04/2025, indicated the following: 2. Purpose - The purpose of this policy is to address patient rights specified by the Medicare Conditions of Participation, California law and The Joint Commission standards and to set forth the responsibilities of medical and administrative staff associated with the recognition of these rights at the UCLA Hospital System. 3. Procedure II. Provide the Patient with a Notice of Rights and Responsibilities: UCLA Hospital System will inform the patient, or when appropriate the patient’s representative, of its patient rights policy in advance of furnishing or discontinuing patient care whenever possible. It may inform the patient using the following methods, as appropriate: C. Providing a patient and visitor information brochure “Whenever possible, whether at the time of admission, or prior to receiving treatment, each patient will receive information regarding his or her responsibilities as a patient in the hospital system. Each patient may be given a copy of the patient and visitor information brochure. Upon admission, the hospital shall ask the patient if he or she would like the hospital to provide the patient’s next of kin or agent under a durable power of attorney for health care with materials regarding patient’s rights and responsibilities. If the patient states that he or she would like these materials to be provided, the hospital shall do so. Upon the request of the patient, or of the patient’s representative, an explanation of the materials will be provided ...examine and receive an explanation of the hospital’s bill, regardless of the source of payment ...” 3. During a review of Patient 22’s “History and Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 11/23/2024, indicated Patient 22 was admitted to the facility with a chief complainant of right hip pain. During a concurrent interview and record review with Patient Access Director (PAD), on 8/7/2025, at 2:58 p.m., the PAD confirmed that Patient 22 ’ s “Collection Summary” (a form in an electronic medical record that collects patient information) was missing a COA (a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.) form for the date of 11/24/2024 at 2:19 am. During a review of the facility ’ s Condition of Admission (COA, admission agreement defining the rights and responsibilities of both the patient and the facility, outlining the terms and conditions of a patient ’ s entry into a facility) indicated the following items are topics provided in the COA. An explanation of each item is provided on the form: “Admission and Medical Services Agreement – Read Carefully Before Signing” 3.UCLAH: UCLA Health (UCLAH) is part of the University of California and is comprised of its hospital(s), medical center(s), its hospital-based clinics, its Primary Care Network clinics, the UCLA Medical Group; and the David Geffen School of Medicine. 4.Medical Consent 5. Teaching, Research, and Healthcare Institution: UCLAH is a teaching, research, and healthcare institution. The section explains information about the use of residents, interns, etc. 6. Use of Medica Information and Specimens 7. Personal Valuables 8. Release of Medical Information 9. Financial Agreement 10. Open Payments Database: is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. 11. Assignment of Benefits (including Medicare benefits): authorization and direct payment to UCLAH of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on behalf for UCLH services, including emergency services, at a rate not to exceed UCLAH actual charges. 12. Texting Consent 13. E-mail Consent 14. Video Visits Consent 15. Nurse Practitioners: a nurse practitioner is not a physician and surgeon. Patients have the right to see a physician and surgeon under the following circumstances: the circumstances are listed. 16. Patient Rights Notice: (applies to inpatient admissions only) Would you like your durable power of attorney (DPOA) or next of kin to receive a copy of the Patient Rights and Responsibilities Notice? If so, please contact the Patient Affairs Department at (310) 267-9113. 17. Advanced Directives During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Rights and Responsibilities, HS 1354,” dated 04/2025, indicated the following: 3. Purpose - The purpose of this policy is to address patient rights specified by the Medicare Conditions of Participation, California law and The Joint Commission standards and to set forth the responsibilities of medical and administrative staff associated with the recognition of these rights at the UCLA Hospital System. 4. Procedure III. Provide the Patient with a Notice of Rights and Responsibilities: UCLA Hospital System will inform the patient, or when appropriate the patient’s representative, of its patient rights policy in advance of furnishing or discontinuing patient care whenever possible. It may inform the patient using the following methods, as appropriate: D. Providing a patient and visitor information brochure “Whenever possible, whether at the time of admission, or prior to receiving treatment, each patient will receive information regarding his or her responsibilities as a patient in the hospital system. Each patient may be given a copy of the patient and visitor information brochure. Upon admission, the hospital shall ask the patient if he or she would like the hospital to provide the patient’s next of kin or agent under a durable power of attorney for health care with materials regarding patient’s rights and responsibilities. If the patient states that he or she would like these materials to be provided, the hospital shall do so. Upon the request of the patient, or of the patient’s representative, an explanation of the materials will be provided ...examine and receive an explanation of the hospital’s bill, regardless of the source of payment ...””

“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: 50521 Based on observation, interview and record review, the facility failed to ensure: A. The safety precautions of cold therapy were in place for one of 31 sampled patients (Patient 24), when BREG Polar Care (a cold therapy system designed for pain and swelling relief, often used post-surgery or for managing chronic pain) was used without a physician order and not following manufacturer’s instructions, for Patient 24 while on the Surgical recovery unit (a hospital unit where patients recover after a surgical procedure ). These deficient practices had the potential for Patients 24 to suffer bodily injury, including but not limited to serious cold-induced injury (damage to the body caused by exposure to cold temperatures), including full thickness necrosis (the death of tissue that extends through all layers of the skin, potentially involving muscle, fat, or even bone). B. One of 31 sampled patients (Patient 24), who was at risk for fall, was not provided with a safe environment to minimize the risk of falls in accordance with the facility ’ s policy and procedure. This deficient practice had the potential to result in an unsafe care that may lead to Patient 24 suffering from a fall that could cause injury and/or death to the patient. Findings: A. During a concurrent observation and interview, on 8/4/2025 at 3:14 p.m., with Patient Care Technician (PCT) 1, Patient 24 was observed in bed with the BREG Polar Care cold therapy (a cold therapy system designed for pain and swelling relief, often used post-surgery or for managing chronic pain) unit detachable cold therapy pad applied to the Patient 24 ’ s right knee. PCT 1 stated the Registered Nurse (RN) 1 instructed him (PCT 1) to set up the unit (add water to fill line, then ice to line, replace lid and lock with handle in upright position) every four hours. During a concurrent observation and interview, on 8/4/2025 at 3:18 p.m., with Registered Nurse (RN) 1, Patient 24 was observed with the BREG Polar Care cold therapy unit detachable cold therapy pad applied to the Patient 24 ’ s right knee. RN 1 stated he had instructed PCT 1 to set up the unit every four hours. RN 1 stated he would perform skin checks every four hours. During a review of Patient 24’s “History and Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 7/2/2025, indicated Patient 24 was admitted to the facility with a chief complainant of Pain of the Right knee. During a review of Patient 24’s “Physical Therapy Evaluation and Treatment” dated 7/29/2025, indicated Patient 24 had Right Total Knee Arthroplasty (TKA- surgical procedure to replace a damaged knee joint with an artificial one). During a concurrent interview and record review of Patient 24 “Physician Orders” on 8/6/2025 at 10:48 a.m., with Nurse Informaticist (NI) 4, NI 4 verified Patient 24 did not have any order for the use of BREG Polar Care (cold therapy system). During a concurrent interview and record review on 8/6/2025 at 10:48 a.m., with Nurse Informaticist (NI) 4, NI 4 verified Patient 24 ’ s “Cold Therapy” flowsheet (a form in an electronic medical record that collects all the necessary information and displays it for easier review), dated 8/2/2025, from 04:00 p.m. to 07:45 pm, the flowsheet indicated Patient 24 ’ s cold therapy was “in place.” NI 4 verified there was no documentation that indicated Patient 24 ’ s cold therapy pad was removed and skin assessed was performed on 8/2/2025 from 04:00 p.m. to 07:45 p.m. During a concurrent interview on 8/6/2025 at 2:16 p.m., with Chief Nursing Officer (CNO), CNO stated the duration and indication of BREG Polar Care cold application for Patient 24 would depend on the physician orders. During a review of the document (instructions for BREG Polar Care cold therapy user manual) title, “BREG Polar Care,” dated 2024, provided by the facility indicated “Use only as prescribed- Use only according to your practitioner ’ s( a person who actively engage in the an art, profession especially medicine) instructions regarding the frequency and duration of cold application and length of breaks between uses, how and when to inspect the skin, and total length of treatment. Do not use this device if you did not receive or do not understand the instructions ....to take a break between uses simply disconnect the power from the unit or remove the pad from our body for a minimum of 30 minutes ...Inspect Skin Regularly-inspect the skin under the cold therapy pad (by lifting the edge) as prescribed, typically every 1 to 2 hours ...Do not use the Polar Care unit if dressing, wrapping, bracing, or casting over the Cold Therapy pad prevents skin checks ...” During a review of the document title, “Cold Application,” dated 5/18/2025, provided by the facility indicated “Place the cold device on the treatment site and begin timing the application. Inspect the treatment site frequently for signs of tissue intolerance, such as blanching (whitish appearance as blood flow to the region is prevented), mottling (causes patterned areas to appear on the skin), cyanosis (bluish or purplish discoloration of the skin), maceration (skin breakdown resulting from prolonged exposure to moisture), and blisters. Also be alert for shivering and complaints of burning or numbness. If these signs or symptoms develop, discontinue treatment and notify the practitioner ...Remove the device after the prescribed treatment period ....Documentation associated with cold application includes: date and time of cold application, duration of cold application, type of device (ice bag or collar, cold therapy system, or chemical cold pack), application site ...appearance of skin at treatment site and neurovascular (the condition of both the nerves and blood vessels in a specific are of the body) status before, during, and after application ...” During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Rights and Responsibilities, HS 1354,” dated 04/2025, the P&P indicated the following: “Appendix 1 Patient Rights and Responsibilities A. As a patient of the hospital, you have the right to: ... receive care in a safe setting ...” B. During an observation on 8/4/2025 at 3:12 p.m., with Nursing Professional Development Practitioner (NPDP) and Chief Medical Officer (CMO), Patient 24 ’ s room was observed to have a “falling star” (indicated the patient was at risk for fall) signage by the door. Patient 24 was observed in bed, alert and oriented. During a concurrent observation and interview, on 8/4/2025 at 3:14 p.m., with Patient Care Technician (PCT) 1, Patient 24 ’ s room was observed with water on the floor (about 200 milliliters [ml- a unit of volume]). PCT 1 stated the water on the floor was unsafe for Patient 24 and he would clean it immediately to prevent patient (Patient 24) from falling. During a concurrent observation and interview, on 8/4/2025 at 3:18 p.m., with Registered Nurse (RN) 1, RN 1 stated Patient 24 was legally blind (a person eyesight is decrease), and she was at a high risk for fall. RN 1 stated Patient 24 required a safe environment (dry floor) to ambulate and to minimize (reduce) the risk of falls. During a review of Patient 24’s “History and Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 7/2/2025, indicated Patient 24 was admitted to the facility with a chief complainant of Pain of the Right knee. During a review of Patient 24’s “Physical Therapy Evaluation and Treatment” dated 7/29/2025, the document indicated Patient 24 presented with dementia and visual impairment and uses a straight cane to ambulates from room to room. The document indicated Patient 24 had Right Total Knee Arthroplasty (TKA- surgical procedure to replace a damaged knee joint with an artificial one). During a review of the facility ’ s policy and procedure (P&P) titled, “Patient Rights and Responsibilities, HS 1354,” dated 04/2025, the P&P indicated the following: “Appendix 1 Patient Rights and Responsibilities A. As a patient of [Name of the Facility] Hospital System, you have the right to: ... receive care in a safe setting ...” During a review of the facility’s policy and procedure (P&P), titled “Safety of the Patient-Adult Fall Prevention, Nur-HS G1004,” last reviewed 6/2025, the P&P indicated, “Patient Goals/Outcomes The patient will: ...3. Be provided with a safe environment to minimize the risk of falls.”

“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: 50521 Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled patients (Patients 27), who was assessed to be at moderate risk for suicide (a mental state in which it is likely that a person will try to end their own life or feeling that people would be better off without them) a continuous sitter (provides direct, one on one observation and supervision for patients who may be at risk of harming themselves or others) monitored and documented Patient 27 ’ s whereabouts for suicidal ideation in accordance with the facility ’ s policy and procedure (P&P). This deficient practice had the potential for Patient 27 with suicide risk to result in injury to Patient 27 or even death due to lack of monitoring. Findings: During a review of Patient 27 ’ s “History and Physical Exam (H&P, a full, complete assessment of a patient ’ s medical history and current condition),” dated 7/29/2025, the H&P indicated Patient 27 was admitted to the facility for burns to the right hand and digits. The H&P further indicated Patient 27 ’ s active hospital problem list included anxiety (a feeling of intense, excessive and persistent worry and fear about everyday situations) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation and interview on 8/4/2025 at 3:42 p.m., with Director of Burn Services (DBS), DBS stated Patient 27 was being observed for suicidal ideation (thinking about or planning to commit suicide) by Sitter 1 (S 1). Patient 27 was observed resting in bed with Sitter 1 sitting outside by the door. During a concurrent interview on 8/4/2025 at 3:42 p.m., with Sitter 1 (S 1), S 1 stated that she had missed to monitor and document Patient 27 ’ s whereabouts on the “Patient Safety Observer Documentation Form,” (documentation regarding suicidal ideation monitoring) on 8/4/25 at 11:00 am to 3:42 p.m. S1 stated it was important to document the Patient 27 ’ s whereabouts for suicidal ideation monitoring (to assess environment codes [1 indicates patient in room, 2 indicates in bed with head uncovered, 3 indicates in chair, 4 indicates in bathroom, 5 indicates in hallway, 6 indicates visitor present, 7 indicates off unit accompanied] and behavior codes [S indicates sleeping, Q indicates quiet/calm, A indicates awake, E indicates eating, CF indicates confused, AL indicates active/loud, R indicates restless, agitated, irritable, hostile, VT indicates verbally threatening, PT indicates physically threatening, BA indicates bathroom accompanied, AA indicates accompanied ambulation, O indicates other]) at least every 15 minutes for patient safety. During a concurrent interview on 8/4/2025 at 3:42 p.m., with Sitter 1 (S 1), S 1 stated that she had missed Patient 27 ’ s whereabout documentation regarding suicidal ideation because she did not receive the “Patient Safety Observer Documentation form.” S 1 stated it was important to complete the 15-minute monitoring environment codes and behavior codes to monitor Patient 27 ’ s suicidal ideation. S 1 stated “I am supposed to be closer to patient (Patient 27) to observe closely for safety.” During a review of Patient 27 ’ s “Columbia-Suicide Severity Rating Scale (CSSRS, a suicidal ideation and behavior rating scale),” dated 8/3/2025 at 09:00 a.m., Patient 27 ’ s CSSRS indicated Patient 27 had a moderate suicidal risk. During a review of Patient 27 ’ s “Columbia-Suicide Severity Rating Scale (CSSRS, a suicidal ideation and behavior rating scale),” dated 8/4/2025 at 12:00 p.m., Patient 27 ’ s CSSRS indicated Patient 27 had a moderate suicidal risk. During an interview and record review on 8/6/2025 at 4:18 p.m., with Nurse Informaticist (NI) 4, NI 4 stated Patient 27 was assessed with moderate suicidal risk and the sitter was required to complete the “Patient Safety Observer Documentation Form,” for patient (Patient 27) safety. NI 4 stated Patient 27 had no record of whereabouts and behavior on the “Patient Safety Observer Documentation Form.” During a review of the facility ’ s policy and procedure (P&P) titled, “Inpatient Suicide Risk Screening and Patient Safety Plan HS 3036,” dated 4/2025, the P&P indicated the following: “C. Patients identified to be “Moderate Risk” ... 2. 1:1 COA (sitter) until assessments are completed and the interdisciplinary team where applicable, determines that constant observation is no longer needed. During a review of the document title, “Patient Sitter Competency,” dated 1/2018, provided by the facility indicated sitter “Documents patient behavior as instructed””

“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: 50521 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) for four of 31 sampled patients (Patient 12, Patient 13, Patient 17 and Patients 26). The facility did not develop a nursing care plan addressing diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD [kidney failure], a condition in which the kidneys lose the ability to remove waste and balance fluids) on hemodialysis (HD, medical procedure that filters a person ’ s blood to remove waste and fluid, acting as a kidney for those with kidney failure) and bleeding (loss of blood) for Patient 12, Patient 13, and Patient 17. For Patient 26, no nursing care plan was initiated to address Hemodialysis (a medical procedure used to remove waste products and excess fluid from the blood usually due to kidney disease) in accordance with facility ’ s policy and procedure (P&P). This deficient practice had the potential to result in Patient 12, Patient 13, Patient 17, and Patient 26 not receiving the right level of care and not meeting the needs for the identified patient ’ s concerns. Findings: 1. During a review of Patient 12 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/2/25, with Nurse Informaticist 3 (Nse Infor 3), H&P indicated Patient 12 had a history of end stage renal disease (ESRD [kidney failure], a condition in which the kidneys lose the ability to remove waste and balance fluids) on Hemodialysis (HD-a medical procedure used to remove waste products and excess fluid from the blood usually due to kidney disease),cerebrovascular accident (CVA; stroke, loss of blood flow to the brain). hydronephrosis (high levels of fluid in a kidney due to a backup of urine), Patient 12 was consulted by Nephrology (a specialist that studies, diagnose, and treat patients with kidney diseases) and received HD in the emergency room (ER). During a review of Patient12 ’ s “Facesheet (a summary document containing key patient information, to provide a quick overview of a patient ’ s details)”, with Nse Infor 3, indicated that Patient 12 was admitted for hypercalcemia (too much calcium in the blood) on 8/2/25 at 8:58 a.m. During a review of Patient 12 ’ s “Nursing Care Plans” (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care), with Nse Infor 3, there was no care plan addressing Patient 12 ’ s risk for bleeding, associated with Patient 12 ’ s use of an anticoagulant (a medication that prevent blood from clotting or prevent existing clots from getting larger). There was also no care plan addressing Patient 12 ’ s ESRD (kidney failure) or HD (dialysis) needs. During a review of Patient 12 ’ s “Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)”, with Nse Infor 3, Patient 12 ’ s MAR indicated Patient 12 received Heparin (a medication that prevents blood clots from forming) 1000 unit per milliliter (mL, measurement) as needed to pack the HD catheter (a medical tube used to access a patient ’ s blood for HD treatment). Patient 12 ’ s MAR indicated that Patient 12 received a dose of heparin on 8/2/25 at 4:26 p.m. During a concurrent interview and record review on 8/6/25 at 10:00 a.m., with Nse Infor 3, Nse Infor 3 stated there was no care plan addressing Patient 12 ’ s risk for bleeding due to use of Heparin. Nse Infor 3 stated that a care plan was important for safety reasons, to prevent Patient 12 from bleeding out. Nse Infor 3 further stated that without a plan, Patient 12 may bleed out or have hemorrhage which can lead to a critical condition or death. During a review of Patient 12 ’ s “Hospitalist Discharge Summary (D/C Summary, a document that provides an overview of a patient ’ s hospitalization)”, with Nse Infor 3, Patient 12 ’ s D/C Summary indicated Patient 12 ’ s hemoglobin (a protein in red blood cells that carries oxygen from the lungs to the rest of the body) and Patient 12 ’ s creatinine (a waste product that is filtered from the blood by the kidneys and removed in urine) was 5.0 (normal 0.6 to 1.1 in females). Patient 12 were required to continue HD for outpatient ESRD (medical treatment without being admitted to a hospital) needs. Patient 12 ’ s hypercalcemia in the setting of ESRD (result of ESRD) was improved and Patient 12 was required to follow up with Nephrology. During a concurrent interview and record review on 8/6/25 at 9:55 a.m., with Nse Infor 3, Nse Infor 3 stated there was no care plan addressing Patient 12 ’ s ESRD, HD needs, or decreased ability/inability to produce urine as a result of Patient 12 ’ s ESRD. Nse Infor 3 further stated it was important to have a plan due to Patient 12 ’ s long list of medical conditions that may become worse from the excess fluid and/or complications of HD. A care plan may also assist in the acknowledgement and treatment of Patient 12 ’ s abnormal laboratory results, which may result from ESRD and HD. During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment of Patients, HS 1310,” revised on 5/2025, indicated, “Inpatient requirement- The registered nurse (RN) is responsible for performing all nursing assessment/reassessment processes. The RN may delegate aspects of data collection to the License Vocational Nurse (LVN), Psychiatric Tech., Trauma Tech., or Clinical Care Partner. The RN must then analyze the data and set care priorities, formulating, the plan of care, health education and initiate referrals ...” During a review of the facility ’ s policy and procedure (P&P), titled “Documentation of Patient Care, Nur-HS 250”, effective 07/1982, revised 06/2025, page one of six, the “Policy” section indicated information related to the patient’s initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient’s electronic health record (EHR). 5. Documentation Responsibilities C. RNs - All clinical care partners (CCP) and licensed vocational nurses (LVN) documentation responsibilities in addition to the following: d. Plan of care development: Nursing department guidelines for care provide one of the structures and basis for the Plan of Care. Guidelines define assessment parameters, interventions, and criteria/ goals. Individualized patient goals are documented in the EHR plan of care and reviewed each shift. 2. During a review of Patient 13 ’ s “H&P”, dated 7/26/25, with Nse Infor 3, Patient 13 ’ s H&P indicated Patient 13 had a history of chronic kidney disease (CKD, a long term condition where the kidneys do not work as well as they should) stage three (kidney function classified into five stages, one represents normal, three is moderately decreased, and five kidney failure), chronic hypotension (consistently low blood pressure), anemia (lack of blood), diabetes mellitus (DM, a disease that result in too much sugar in the blood) with renal (kidney) During a review of Patient 13 ’ s “Nursing Care Plans”, with Nse Infor 3, there was no care plan addressing Patient 13 ’ s DM needs, including a risk for unstable blood glucose (a fluctuation in blood sugar levels that fall outside the normal range) or addressing Patient 13 ’ s endocrinology (the branch of medicine that focuses on the glands that produce and release hormones that regulate various bodily functions), including insulin (a hormone produced by the pancreas [a gland located in the abdomen that plays a role in digestion and blood sugar regulation] that regulates blood sugar levels) . During a review of Patient 13 ’ s “Facesheet (a summary document containing key patient information, to provide a quick overview of a patient ’ s details)”, with Nse Infor 3, indicated that Patient 13 was admitted on 7/26/25 at 4:07 a.m. for hypokalemia (low level of potassium (mineral helps muscle and heart function) blood). During a concurrent interview and record review on 8/6/25 at 10:13 a.m., with Nse Infor 3, Nse Infor 3 stated there was no care plan addressing Patient 13 ’ s DM needs. Nse Infor 3 stated there should have been a care plan at least addressing Patient 13 ’ s blood sugar with the current electrolyte imbalance (when the body ’ s levels of certain minerals become too high or too low). Nse Infor 3 further stated that Patient 13 had a history of hormone imbalance (too high or not enough levels of hormones in the body) problems and kidney problems; therefore, it is important to make sure that Patient 13 ’ s sugar level is stable to prevent further complications that may trigger Patient 13 ’ s current medical symptoms and result in serious, life-threatening complications. During a review of Patient 13 ’ s “Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)”, with Nse Infor 3, Patient 13 ’ s MAR indicated that Patient 13 received Novolog (a rapid-acting insulin used to control high blood sugar) insulin three times daily before meal and at bedtime as needed, on a sliding scale (a method for determining insulin dosage based on blood glucose levels), with multiple doses administered. Patient 13 also received Lantus (a long-acting insulin used to manage blood sugar levels) every night, at bedtime, with multiple doses given and Levothyroxine (a synthetic form of the thyroid hormone) daily. During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment of Patients, HS 1310,” revised on 5/2025, indicated, “Inpatient requirement- The registered nurse (RN) is responsible for performing all nursing assessment/reassessment processes. The RN may delegate aspects of data collection to the License Vocational Nurse (LVN), Psychiatric Tech., Trauma Tech., or Clinical Care Partner. The RN must then analyze the data and set care priorities, formulating, the plan of care, health education and initiate referrals ...” During a review of the facility ’ s policy and procedure (P&P), titled “Documentation of Patient Care, Nur-HS 250”, effective 07/1982, revised 06/2025, page one of six, the “Policy” section indicated information related to the patient’s initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient’s electronic health record (EHR). 6. Documentation Responsibilities C. RNs - All clinical care partners (CCP) and licensed vocational nurses (LVN) documentation responsibilities in addition to the following: di. Plan of care development: Nursing department guidelines for care provide one of the structures and basis for the Plan of Care. Guidelines define assessment parameters, interventions, and criteria/ goals. Individualized patient goals are documented in the EHR plan of care and reviewed each shift. 3. During a review of Patient 17 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/10/24, with the Hospital Informaticist Manager (HIM), indicated Patient 17 was brought to the hospital for a left foot infection. Patient 17 had a history of an above-the-knee amputation (AKA, the surgical removal of a leg above the knee joint) of the right leg due to infection. Patient 17 had a past medical history of diabetes mellitus (DM, a disease that result in too much sugar in the blood), cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), and hysterectomy (surgical procedure to remove the uterus). Patient 17 was hospitalized and treated for hyperglycemia (high blood sugar levels), severe peripheral artery (vascular) disease ((PVD – severe narrowing of the blood flow to the arms and legs) sepsis (a life-threatening blood infection). During a review of Patient 17 ’ s “Nursing Care Plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care)”, with HIM, there was no care plan addressing Patient 17 ’ s risk for bleeding, associated with Patient 17 ’ s treatment with Heparin (anticoagulant, a medication that prevents blood clots from forming). During a concurrent interview and record review on 8/5/25, at 2:50 p.m., with HIM, HIM stated there was no care plan addressing Patient 17 ’ s risk for bleeding. HIM stated a care plan should be in Patient 17 ’ s chart. During a concurrent interview and record review on 8/6/25, at 3:55 p.m., with Nurse Informaticist 2 (NI 2), NI 2 stated there was no care plan addressing Patient 17 ’ s risk for bleeding. NI 2 stated a care plan should be started for all patients receiving anticoagulants (a medication that prevents blood from clotting) due to the risk of hemorrhaging (excessive or uncontrolled bleeding). NI 2 further stated the importance of having a care plan, in this situation, would be to understand the complications associated with the use of anticoagulants and what to do if Patient 17 experienced complications. During a review of Patient 17 ’ s “Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)”, with HIM, Patient 17 received intravenous (IV, fluids given directly into the blood stream) drip Heparin 25,000 units every 16 hours. 4. During a review of Patient 26 ’ s “History and Physical (H&P),” (H&P, a full, complete assessment of a patient ’ s medical history and current condition) dated 8/3/2025, indicated Patient 26 was admitted to the facility for missing hemodialysis (a medical procedure used to remove waste products and excess fluid from the blood usually due to kidney disease). The H&P further indicated, Patient 26 ’ s active hospital problem list included Renal Failure (the condition in which the kidneys lose the ability to remove waste and balance fluids). During a concurrent interview and record review on 8/6/2025 at 2:57 p.m., with Nurse Informaticist (NI) 4, NI 4 verified Patient 26 ’ s Nephrologist (a medical doctor who specializes in kidney care and treating diseases of the kidneys) consult, dated 8/4/2025, indicated “reason for consultation: evaluation and management of End Stage Renal Disease (ESRD- irreversible kidney failure) and dialysis (treatment use to remove waste and excessive fluid from the blood when the kidney can not to this function).” During a concurrent interview and record review on 8/6/2025 at 3:15 p.m., with NI 4, NI 4 stated Patient 26 ’ s nursing care plan list was missing a plan of care for Hemodialysis. NI 4 stated Patient 26 ’ s hemodialysis nursing care plan should have been initiated (started) on admission because it was the main reason the patient was admitted to the facility. NI 4 stated when a hemodialysis nursing care plan is initiated, the nurses can monitor Patient 26 ’ s progress, and the nurses would communicate to care for the patient. During a review of the facility ’ s policy and procedure (P&P) titled, “Assessment of Patients, HS 1310,” revised on 5/2025, indicated, “Inpatient requirement- The registered nurse (RN) is responsible for performing all nursing assessment/reassessment processes. The RN may delegate aspects of data collection to the License Vocational Nurse (LVN), Psychiatric Tech., Trauma Tech., or Clinical Care Partner. The RN must then analyze the data and set care priorities, formulating, the plan of care, health education and initiate referrals ...” During a review of the facility ’ s policy and procedure (P&P), titled “Documentation of Patient Care, Nur-HS 250”, effective 07/1982, revised 06/2025, page one of six, the “Policy” section indicated information related to the patient’s initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient’s electronic health record (EHR). 7. Documentation Responsibilities C. RNs - All clinical care partners (CCP) and licensed vocational nurses (LVN) documentation responsibilities in addition to the following: dii. Plan of care development: Nursing department guidelines for care provide one of the structures and basis for the Plan of Care. Guidelines define assessment parameters, interventions, and criteria/ goals. Individualized patient goals are documented in the EHR plan of care and reviewed each shift.”

“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: 50521 Based on observation, interview, and record review, the facility failed to ensure: A. One of 31 sampled patients (Patient 24), who was at risk for fall, was not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall), water was observed on the floor and bed alarm (sound alarm that will alert hospital staff when patient get out of bed unassisted) was not on. These deficient practices had the potential to result in an unsafe care that may lead to Patient 24 suffering from a fall injury. B. One of 31 sampled patients (Patient 23) intravenous (IV - in the vein) access sites (A point of access to the bloodstream, to move fluids and medications into the body) was not labeled to include the date and time of insertion, and the staff member’s initials by the staff to identify who inserted the IV catheter (thin, flexible tube inserted into vein to deliver medication or fluids) into the patient. This deficient practice may have resulted in negative consequences for Patient 23, increasing their risks for intravascular catheter related infections. C. One of 31 sampled patients (Patient 23) Lactated Ringers (a solution used to restore fluids and electrolytes in the body) intravenous (IV-in the vein) solution bag was not labeled to include identification number, the date and time, the ordered rate and duration of infusion, and the respective staff member ’ s initials by the staff to identify who hanged the IV bag for patient administration. This deficient practice may have resulted in Patient 23, increase risk for receiving IV solution bag not intended for Patient 23. D. One of 31 sampled patients (Patients 29), Patients 29 ’ s the policies and procedures were implemented when Patient 29, who was in pain, the pain assessment (pain assessment includes a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible, location of pain, character of pain, and duration of pain) was incomplete prior medication administration. This deficient practice had the potential to result in a delay in providing necessary treatment to address Patient 29 ’ s pain. Findings: A. During an observation on 8/4/2025 at 3:12 p.m., with Nursing Professional Development Practitioner (NPDP) and Chief Medical Officer (CMO), Patient 24 ’ s room was observed to have a “falling star” (indicated the patient was at risk for fall) signage by the door. Patient 24 was observed in bed, alert and oriented. During a concurrent observation and interview, on 8/4/2025 at 3:14 p.m., with Patient Care Technician (PCT) 1, Patient 24 ’ s room was observed with water on the floor (about 200 milliliters [ml- a unit of volume]). PCT 1 stated the water on the floor was unsafe for Patient 24 and he would clean it immediately to prevent patient (Patient 24) from falling. During a concurrent observation and interview, on 8/4/2025 at 3:18 p.m., with Registered Nurse (RN) 1, RN 1 stated the falling star signage indicated the patient was at risk for fall. RN 1 stated fall risk intervention included a yellow armband, yellow socks, signage on the patient ’ s room, and bed alarm on. Subsequently, Patient 24 was observed not wearing a yellow fall risk armband and bed alarm was off. RN 1 stated the importance of the fall risk armband is so that anyone that comes in Patient ’ s 24 room would monitor the patient closely to prevent a fall. RN 1 stated the bed alarm should be on for Patient 24 to alert staff when patient get out of bed unassisted. During a review of Patient 24’s “History and Physical” (H&P - a formal and complete assessment of the patient and the problem), dated 7/2/2025, the H&P indicated Patient 24 was admitted to the facility with a chief complainant of Pain of the Right knee. During a review of Patient 24’s “Physical Therapy Evaluation and Treatment” dated 7/29/2025, indicated Patient 24 had Right Total Knee Arthroplasty (TKA- surgical procedure to replace a damaged knee joint with an artificial one). During a review of Patient 24 ’ s “Morse Fall Risk Assessment” flowsheet (a form in an electronic medical record that collects all the necessary information and displays it for easier review), dated 8/4/2025, at 7:31 a.m., indicated Patient 24 score of a 75 on the Morse Fall Risk Score (a tool used to assess a patient ’ s risk of falling in a healthcare setting 0-26 indicates low fall risk, no interventions (planned actions), 25-45 indicate moderate (common) fall risk and 45 and above indicate high fall risk implement (start) high risk fall preventions). During a concurrent interview and record review on 8/6/2025 at 10:48 a.m., with Nurse Informaticist (NI) 4, NI 4 verified Patient 24 ’ s “High Fall Risk Precautions” flowsheet (a form in an electronic medical record that collects all the necessary information and displays it for easier review), dated 8/4/2025, at 7:31 a.m. to 6:00 pm, the flowsheet indicated Patient 24 did not have any fall precautions documented. During a review of the facility’s policy and procedure (P&P), titled “Safety of the Patient-Adult Fall Prevention, Nur-HS G1004,” last reviewed 6/2025, indicated, “Implement an individualized fall plan of care for patients with a risk score of = (equal or greater than) 45, targeting interventions to address patient-specific risk factors. In addition to the basic safety requirements above, the following interventions should be implemented: a. Place color-coded (yellow Fall Risk) armband on patient’s extremity ...d. Use bed alarm system and chair alarm system as adjuncts for patients who tend to get out of bed unassisted ...” B. During an observation and interview, on 8/4/2025 at 2:14 p.m., with Registered Nurse (RN) 2, inside Patient 23 ’ s room, RN 2 stated the Patient 23 ’ s IV (in the vein) site was missing a label with date, time, and initials when the IV access site was inserted into the patient. RN 2 further stated, “To start an IV access site, I assess the vein, open supplies in kit, then I label time, date, and initial.” During a review of Patient 23 ’ s “History and Physical (H&P),” dated 7/31/2025, indicated Patient 23 was admitted to the facility for abdominal pain. During a review of the facility ’ s policy and procedure (P&P) titled, “IV dressing change,” revised in 8/18/ 2024, indicated, “Label the dressing with the date you changed the dressing or the date when the dressing is next due to be changed ...” C. During a concurrent observation and interview, on 8/4/2025 at 2:14 p.m., with Registered Nurse (RN) 2, inside Patient 23 ’ s room, Patient 23 ’ s Lactated Ringers (a solution used to restore fluids and electrolytes in the body) IV solution bag was observed not labeled to include patient (Patient 23) identification number, the date and time, the ordered rate and duration of infusion, and the staff member ’ s initials by the staff to identify who hanged the IV bag for patient administration. RN 2 stated the importance of labeling the IV solution bag was to inform other staff regarding the ordered rate and duration of infusion. RN 2 stated the order was to discontinue the Lactated Ringers IV solution this morning, but she forgot to discard the IV bag. RN 2 stated she would remove the Lactated Ringers IV solution bag to prevent reuse. During a review of Patient 23 ’ s “History and Physical (H&P),” dated 7/31/2025, indicated Patient 23 was admitted to the facility for abdominal pain. During a review of the facility ’ s policy and procedure (P&P) titled, “ IV bag Preparation,” revised in 8/18/ 2024, indicated, “Label the IV bag with the patient’s name and identification number, the date and time, the bag number (if applicable), the ordered rate and duration of infusion, and your initials.” D. During a review of Patient 29 ’ s “History and Physical (H&P),” dated 7/31/2025, indicated Patient 29 was admitted to the facility with a diagnosis of Back pain. During a review of Patient 29 ’ s “Medication Administration Report (MAR-document medication taken by individuals)” dated 8/7/2025, the MAR indicated a physician ’ s order for Patient 29 to receive the following: - Ketorolac (pain medication) 30 mg (mg-a unit of measurement) intravenous (IV-in the vein) push every 6 hour as needed (PRN) for moderate pain (pain score of 4-6 is moderate pain) with a start day of 8/2/25; and, - Hydromorphone (narcotic pain medication) 3 mg intramuscular (IM-in the muscle) every 2 hours PRN for severe pain (pain score of 7-10 is severe pain), with a start day of 8/1/25. During a concurrent interview and record review, on 8/7/2025 at 11:10 a.m., with Nurse Informaticist (NI) 2, NI 2 verified Patient 29 ’ s corresponding pain assessment in the medical record (MR) titled, “Flowsheets -Pain Assessment,” was incomplete. NI 2 verified Patient 29 ’ s MAR indicated the following medication administration: -On 8/1/2025 at 08:09 a.m. Patient 29 was administered Hydromorphone 3 mg IM (into the muscle), the pain score was 8. The corresponding pain assessment was incomplete, it did not indicate the location of pain, pain descriptors, and duration of pain. -On 8/1/2025 at 11:23 a.m. Patient 29 was administered Hydromorphone 3 mg IM, the pain score was 8. The corresponding pain assessment was incomplete, it did not indicate the location of pain, pain descriptors, and duration of pain. -On 8/1/2025 at 3:58 p.m. Patient 29 was administered Hydromorphone 3 mg IM, the pain score was not documented. -On 8/4/2025 at 12:20 a.m. Patient 29 was administered Hydromorphone 3 mg IM, the pain score was 8. The corresponding pain assessment was incomplete, it did not indicate the location of pain, pain descriptors, and duration of pain. -On 8/4/2025 at 11:31 a.m. Patient 29 was administered Hydromorphone 3 mg IM, the pain score was 7. The corresponding pain assessment was incomplete, it did not indicate the location of pain, pain descriptors, and duration of pain. -On 8/4/2025 at 1:41 p.m. Patient 29 was administered Hydromorphone 3 mg IM, the pain score was 9. The corresponding pain assessment was incomplete, it did not indicate the location of pain, pain descriptors, and duration of pain. During a concurrent interview and record review on 8/7/2025 at 12:08 p.m., with Nurse Informaticist (NI) 2, NI 2 stated a complete pain assessment includes the pain score, location of pain, pain descriptors, and duration of pain. NI 2 stated a complete pain assessment was not performed by nursing care and the expectation is to document the full pain assessment prior to medication administration for Patient 29. During a review of the facility ’ s policy and procedure (P&P) titled, “Pain Management, Nur-HS G1006,” dated 6/2025, the P&P indicated, “Pain assessment will include: a. Intensity, duration, quality, location, precipitating and alleviating factors and associated impact of pain on function ...””