Clovis Community 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: 40644 Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA when stabilizing measures were not provided within the capacity and capability of the hospital for one of 20 patients, Patient (Pt) 1. The ED Physician (EDP 1) determined through ultrasound (US picture inside body) that Pt 1 had no definite intrauterine (in womb) pregnancy and had a “left adnexal mass with peripheral vascularity concerning for ectopic pregnancy, potentially ruptured”. EDP 1 made several unsuccessful efforts to contact the on-call Obstetrician (OB- Specializes in care of women during pregnancy, delivery and after delivery) specialist to address the emergency medical condition (EMC) of Pt 1’s ectopic pregnancy (when the fertilized egg implants somewhere other than the womb) and was unable to get a response. These failures resulted in Pt 1’s emergent OB specialist consultation being delayed by two hours and 3 minutes causing a delay in stabilizing care and surgical treatment for her internal hemorrhage (a rapid heavy loss of blood) caused by the ruptured ectopic pregnancy. These delays placed Pt 1 at risk for hemodynamic instability (insufficient blood flow, not enough blood carrying oxygen to body tissues), and death. Because of the actual and potential harm to Pt 1 and the potential for harm to other patients with possible ectopic pregnancy symptoms, an immediate Jeopardy (IJ - a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for A2407 42 CFR 482.24(d)(3) on 3/26/26 at 11:41 a.m. with the Vice President of Operations (VPO), the Interim Director of Risk Management (IDRM), the Risk Management Manager (RMM), The Director of Quality Outcomes (DQO), and the Director of Emergency Services (DED). The IJ (immediate Jeopardy) template was provided to the facility. The hospital submitted an IJ Plan of Removal (Version One) on 3/26/26 at 4:14 p.m., and it was unacceptable. The hospital submitted an IJ Plan of Removal (Version Two point one) on 3/27/26 at 11:27 a.m. After consultation with CMS, the Plan of Removal was accepted on 3/27/26 at 11:50 a.m. On 3/27/26 the survey team validated all providers currently working were being educated on the IJ for A2407 Stabilizing Treatment response time of Obstetric on-call providers after ED Provider request for patient consultation, and the hospital implement systemic changes to ensure all providers that work in the ED to be educated before coming back to work. The IJ was removed onsite with the VPO, the RMM, the DED, and the Director of Women’s and Newborn Services (DWNS) in attendance on 3/27/26 at 1:10 p.m. EMTALA violations remained following removal of the IJ The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 49884 Based on interview and record review, the hospital failed to provide stabilizing measures within its capacity and capability for one of 20 patients, Patient (Pt) 1, when Pt 1 arrived at the Emergency Department (ED) by ambulance on 3/8/26 with 10 out of 10 abdominal (stomach) pain, nausea/vomiting, and episodes of passing out. The ED Physician (EDP 1) determined through ultrasound (US picture inside body) that Pt 1 had no definite intrauterine (in womb) pregnancy and had a “left adnexal mass with peripheral vascularity concerning for ectopic pregnancy, potentially ruptured”. EDP 1 made several unsuccessful efforts to contact the on call Obstetrician (OB- Specializes in care of women during pregnancy, delivery and after delivery) specialist to address the emergency medical condition (EMC) of Pt 1’s ectopic pregnancy. EDP 1 acted on the EMC by paging the on call OB on 3/9/26 at 12:57 a.m.; however, the on call OB did not respond within the timeframe outlined in the facility’s policy and procedure (P&P) requiring a response within 30 minutes. The OB assessed Pt 1 at approximately 3:00 a.m., resulting in a two hour and three minute delay. Pt 1 was admitted to the hospital and taken to the operating room (OR) for surgery on 3/9/26 at 4:22 a.m. These failures resulted in a two hour and three minute delay in securing an emergent OB specialist consultation for Pt 1. As a consequence, the timely initiation of stabilizing care and necessary surgical intervention for a ruptured ectopic pregnancy was significantly delayed. During this period, Pt 1 continued to experience active internal hemorrhage-a rapid and severe loss of blood-which ultimately required transfusion (replacement) of one unit of blood. This delay subjected Pt 1 to avoidable pain and suffering, prolonged exposure risk for hemodynamic instability (dangerously inadequate blood flow and oxygen delivery to vital tissues), and an increased risk of life threatening deterioration, including the potential for her heart to not function adequately, and death. The failure to act with the urgency required for this critical clinical emergency placed Pt 1 in a situation of substantial and unnecessary jeopardy. Because of the actual and potential harm to Pt 1 and other patients with possible ectopic pregnancy symptoms related to the hospital’s inability to provide timely stabilizing treatment that was within their capability and capacity, an Immediate Jeopardy (IJ a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) situation was called for A2407 42 CFR 482.24(d)(3) on 3/26/26 at 11:41 a.m. with the Vice President of Operations (VPO), the Interim Director of Risk Management (IDRM), the Risk Management Manager (RMM), The Director of Quality Outcomes (DQO), and the Director of Emergency Services (DED). The IJ (immediate Jeopardy) template was provided to the facility. The hospital submitted an IJ Plan of Removal (Version One) on 3/26/26 at 4:14 p.m., and it was unacceptable. The hospital submitted an IJ Plan of Removal (Version Two point one) on 3/27/26 at 11:27 a.m. After consultation with CMS, the Plan of Removal was accepted on 3/27/26 at 11:50 a.m. On 3/27/26 the survey team validated all providers currently working were being educated on the IJ for A2407 Stabilizing Treatment response time of Obstetric on-call providers after ED Provider request for patient consultation, and the hospital implement systemic changes to ensure all providers that work in the ED to be educated before coming back to work. The IJ was removed onsite with the VPO, the RMM, the DED, and the Director of Women’s and Newborn Services (DWNS) in attendance on 3/27/26 at 1:10 p.m. EMTALA violations remained following removal of the IJ Findings: During a concurrent interview and record review on 3/25/26 at 11:09 a.m. with, Manager of Emergency Services (MES) 1, Pt 1’s electronic medical record (EMR) for the ED visit on 3/8/26 to 3/9/26 was viewed and reviewed. The document titled, “ED Pt Care Timeline (EDCT)”, dated 3/8/26 at 10:10 p.m. to 3/9/26 at 4:22 a.m., indicated, Pt 1 arrived at the ED on 3/8/26 at 10:10 p.m . by ambulance with abdominal pain. At 10:12 p.m., triage staff began a comprehensive evaluation and recorded vital signs (VS): Temperature (T): 95.3 degrees Fahrenheit (°F - a unit measure), HR 125 beats per minute (bpm-normal 60-100), respiratory rate 32 breaths/min (RR- normal 12-20), Blood Pressure (BP) 119/64 millimeters of mercury (mmHg- a unit of pressure measurement-Normal), and oxygenation (SpO2 - amount of oxygen in blood) 99% on 6 liters per minute (l - a unit of measure- normal 95-100% on room air) of oxygen by nasal cannula (a tube that attaches to the nose to give supplemental oxygen). Pt 1’s updated chief complaint was abdominal pain during a six week pregnancy, worsening over a week with vomiting; pain was 10/10, the triage nurse documented “acute distress” and assigned an ESI (scale used to determine level of acuity or seriousness for the chief complaint with the scale ranging from 1-5, 1 representing the most serious) of 3 (stable, will require two or more resources to reach disposition from the ED). MES 1 stated she would have given Pt 1 an ESI score of 2 (high risk situation, must be seen quickly). MES 1 stated her rational for an ESI of two was Pt 1 was six weeks pregnant, had 10 out of 10 pain, vomiting, and was in acute distress, which indicated an ESI of 2. MES 1 stated the assessment indicated Pt 1 needed to be seen right away. During a concurrent interview and record review on 3/25/26 at 11:15 a.m. with, MES 1, the document titled, “EDCT”, dated 3/8/26 at 4:22 a.m., and Pt 1’s “ED Provider Note (EDPN)”, dated 3/8/26 at10:47 p.m., were reviewed. The “EDCT” indicated, at 10:22 p.m., EDP 1 began Pt 1’s Medical Screening Exam (MSE - the examination conducted by a Qualified Medical Professional [QMP] for the purpose of determining if an emergency medical condition exists). EDP 1 ordered pain medication, laboratory tests, an electrocardiogram (EKG- heart test), and imaging studies (medical images to show inside the body). MES 1 stated all lab orders and imaging orders were STAT (immediately high priority). The “EDPN” indicated, Pt 1, was six weeks pregnant brought in by ambulance after someone witnessed her passing out for 30 seconds and she was vomiting. Pt 1’s abdominal pain has worsened since beginning a week ago. Pt 1 reported she had an ultrasound (US- medical scan to see inside the body) last week with her primary OB physician which revealed a concerning fluid collection. EDP 1’s physical exam indicated, Patient had abdominal (stomach) tenderness (more tender on left side than right), and she was not in acute distress. During a concurrent interview and record review on 3/25/26 at 11:30 a.m. with, MES 1, the document titled, “EDCT”, dated 3/8/26 to 3/9/26, and “US OB First Trimester [initial stage of pregnancy] Less Than 14 Weeks (OB US)”, dated 3/9/26 were reviewed. The “EDCT” indicated, on 3/8/26 at 10:30 p.m., Registered Nurse (RN) 2, Pt 1’s primary nurse, completed a head to toe assessment and documented fast breathing, tachycardia, nausea and vomiting, anxiety (nervous), and abdominal tenderness. At 10:34 p.m., RN 2 administered 50 micrograms (mcg-a unit of measure) fentanyl (powerful opioid for severe pain) by intravenous line (IV- injected directly into a vein) without a documented pain score; at 11:04 p.m., pain was 8/10 (severe) upon re-assessment. MES 1 stated nurses were expected to assess pain before administering pain medications, to ensure the patient received the best pain medication in relation to the pain score. At 11:11 p.m., the Complete Blood Count (CBC-blood test for cell types and numbers) indicated abnormalities: white blood cells (WBC-fight infection) 12.4, Red Blood Cells (RBC carry oxygen) 2.78, Hemoglobin (Hgb- holds onto oxygen in RBC) 8.8, and Hematocrit (Hct- percentage of blood with RBC) 25.9%. MES 1 stated, without another CBC to compare the results to there was no way to tell if the results showed acute blood loss (a critical, rapid reduction in red blood cells due to hemorrhage). At 11:17 p.m., a pelvic (area below the stomach) US was ordered, and Pt 1 was transported at 11:29 p.m.; the exam finished at 12:08 a.m. At 12:15 a.m., Pt 1’s VS were T 97.8°F, HR 118 bpm, RR 24, BP 98/61 mmHg (lower than initial reading), and SpO2 100% on room air. The “US OB”, resulted on 2/9/26 at 12:46 a.m., indicated, “ ...IMPRESSION: No definite intrauterine [inside womb] pregnancy identified, left adnexal [growth that develops near uterus] mass ...concerning for ectopic pregnancy, potentially ruptured given the free fluid ...” (a life- threatening condition where a fertilized egg implants outside of the uterus, in this case the fallopian tube which is the slender tube connected to the uterus) During a concurrent interview and record review on 3/25/26 at 11:40 a.m. with, the DWNS, the documents titled, “EDCT”, dated 3/9/26, “EDPN”, dated 3/7/26, and the “History and Physical (H&P)”, written by Obstetrician Physician (OBP) 1, dated 3/9/26 at 3 a.m. were reviewed. The “EDPN” indicated, at 12:57 a.m. EDP 1 documented Pt 1’s US was concerning for ectopic pregnancy, and paged Pt 1’s primary physician (OBP 3). The DWNS stated that the exchange service would have known OBP 1 was on-call for OBP 3’s patients. The “EDPN” indicated, at 1:07 a.m., a hemogram (blood test) showing showed worsening anemia: WBC 11.2, RBC 2.27, Hgb 7.2, Hct 21.7%. The “EDPN” indicated, at 1:29 a.m. EDP 1 re paged the primary physician through the telephone exchange service, and that the exchange service was “giving pushback” claiming that EDP 1 needed to wait 30 minutes before re-paging. EDP 1 documented, “ ...This provision is not specified within bylaws [rules], and this consult falls within emergent framework so have asked them to be paged again”. At 1:56 a.m. EDP 1 called the on-call physician assigned to the ED (OBP 2), and the call went to voicemail. At 2 a.m. EDP 1 documented, “ ... [OBP 1] is on-call, called directly 2/2 [secondary to] concern for emergent need, no answer”, EDP 1 sent a text at the same time. The “EDCT” indicated at 2:17 a.m. Pt 1 began receiving a blood transfusion (transferring blood into the patient to improve blood oxygen-carrying capacity and restore blood volume). The “EDPN” indicated EDP 1 called the Labor and Delivery (L&D) Unit (Special Unit that cares for pregnant and newly delivered patients) and was informed OBP 1 was in the Operating Room (OR), he left a message with L&D staff to have OBP 1 call after surgery. At 2:30 a.m. EDP 1 re paged OB 1, and at 2:38 a.m. OBP 1 called, saying they would evaluate Pt 1. The document titled “H&P”, indicated, Pt 1 had pelvic pain for over a week, worsening to vomiting, and a pelvic US on 3/3/26 showing a possible gestational sac (first signs of early pregnancy) and a large peritoneal fluid collection (abnormal buildup of fluid in the abdominal space). OBP 1’s plan was to perform surgery for an ectopic pregnancy removal. OBP 1 saw Pt 1 two hours and three minutes after EDP 1 began paging for an OB consultation. The “EDCT” indicated, at 4:22 a.m., Pt 1 went to the operating room (OR). During an interview and record review on 3/25/26 at 11:48 a.m., the DWNS reviewed the March 2026 “Who’s On Call” schedule. The 3/8/26 schedule indicated, OB 1 covered Labor, Antepartum (care for high risk pregnant patients), and post partum (care for mother and baby after delivery), and OB 2 covered L&D triage (quick look area for pregnant patients), the ED, and the rest of the hospital. The DWNS stated that on 3/8/26 the role of OB 1 on the posted on-call schedule was assigned to OBP 1, and OB 2 was assigned to OBP 2. The DWNS stated Pt 1’s primary physician, OBP 3, signed out to OBP 1 because OBP 1 was on call for their group. OBP 1 was responsible for L&D deliveries, and OBP 2 covered ED consultations. However, OBP 1 would have handled Pt 1’s consultation since Pt 1’s primary OB physician belonged to OBP 1’s group. During a concurrent interview and record review on 3/5/26 at 11:55 a.m. with EDP 1, Pt 1’s “EDCT” and “EDPN”, dated 3/8/26 were reviewed. On 3/8/26, EDP 1 served as Pt 1’s primary ED physician. EDP 1 stated he typically paged the ED Unit Clerk (UC) to contact consultants or called on call providers directly. EDP1 stated some providers had direct numbers on the online call schedule, but if calls routed through an exchange (telephone answering service) that could take a “couple [of] minutes”, for a return call. EDP 1 stated he began calling for an OB Physician at around 1 a.m. EDP 1 stated Pt 1 identified OBP 3 as her primary OB. Because the visit occurred after 5 p.m., the group’s on call provider was responsible for all patients. EDP 1 contacted OBP 3’s exchange but became frustrated when staff refused to re page until 30 minutes had passed without a response. EBP 1 insisted on a re page and then paged again at 1:56 a.m., also paging the general unassigned OB Physician (OBP 2). EDP 1 stated the delay was unusual and, because Pt 1’s case was urgent, he was not going to “just sit around and wait” so he continued to reach out until he got ahold of someone. During an interview on 3/5/26 at 12:05 p.m. with EDP 1, EDP 1 stated, when he received Pt 1’s CBC results, he had no recent labs for comparison. After speaking with Pt 1, he determined the anemia (deficiency of healthy RBCs or Hgb, reducing the blood’s ability to carry oxygen to the body) was acute (new onset). EBP 1 stated the OB response time “wasn’t what you want.” EDP 1 stated he called the L&D Unit directly searching for the on-call OB Physician. EBP 1 stated contacting L&D was successful, and OBP 1 returned the call before OBP 2. OBP 1 assessed Pt 1 and took her to surgery. EDP 1 stated Pt 1 was hemorrhaging into her abdominal cavity. EBP 1 stated he would have contacted the OB Chair if no OB provider responded. EBP 1 also stated emergent consultations required OB arrival within 15 minutes and classified Pt 1’s case as urgent but did not define expected response time. During a concurrent interview and record review on 3/5/26 at 12:10 p.m. with EDP 1, Pt 1’s “EDPN”, dated 3/8/26 were reviewed. The “EDPN” written by EBP 1, dated 2/8/26 indicated EBP 1 documented at 2 a.m., “[OBP 1] is on call, called directly 2/2 [secondary to] concern for emergent need ...” EDP 1 stated the first callback should have occurred immediately, even if staff were in the OR. EDP 1 stated that in his opinion, what could have been improved would have been getting the first callback immediately, even if the team was in the operating room. EDP 1 stated that, looking back, he might have called Labor & Delivery at the same time as sending the second page, because the L&D department generally knew where the OB physicians were. EDP 1 stated he spoke with the OB Chair (OBC) about Pt 1’s case the next day, to relay his difficulty in reaching an OB Physician. During a review of Pt 1’s EMR document titled, “Post Operative Brief Note (POBN)”, dated 3/9/26 at 5:40 a.m., the “POBN” (record written by surgeon to document procedure details, and findings), indicated, Pt 1’s diagnosis was a ruptured ectopic pregnancy. During surgery, OBP 1 identified an enlarged, hemorrhagic (bleeding) left fallopian tube and hemoperitoneum (free blood in the abdominal cavity), removed the left fallopian tube, and removed 700 mL of blood from the abdomen. During a review of the hospital document titled, “Ambulance PCR (APCR)”, dated 3/8/26 at 9:09 p.m., the “APCR” (a report with all information relating to a call for an ambulance including treatment provided) indicated, Emergency Medical Services (EMS) was dispatched for a 36-year-old patient experiencing abdominal pain. Upon arrival Pt 1 was found upstairs on a bed in obvious distress. Pt 1 was breathing rapidly and reported having sharp constant 10 out of 10 pains in her pelvis region on the left side. Pt 1’s pain had been ongoing for approximately 10 minutes before EMS arrival. The “APCR” indicated, Pt 1 was six weeks pregnant. The “APCR” indicated Pt 1 reported to EMS she was having difficulty breathing and was placed on supplemental oxygen. Pt 1 reported to EMS she was having left side weakness and chest pain and began vomiting. Upon arrival at the ED, EMS gave report to the ED triage nurse. Pt 1’s EMS VS at 9:42 were 130/blank mmHg; HR 82 bpm; RR 22; SpO2 100% on oxygen, and a pain score of 10. The EMS VS for Pt 1 at 10:17 p.m. were BP 119/64 mmHg; HR 125 bpm; RR 28 breaths per minute; SpO2 100% on oxygen. EMS documented arrival at the ED on 3/7/26 at 9:59 p.m., and documented transfer of Pt 1’s care to the ED RN at 10:26 p.m. During a telephone interview on 3/25/26 at 2:09 p.m. with Pt 1, Pt 1 stated she was doing fine now since her surgical procedure. Pt 1 stated that she did not remember much about her visit, because she was “passed out almost the whole time.” Pt 1 stated that she was brought into the ED by ambulance from her home. Pt 1 stated that the Emergency Medical Services (EMS) staff did not give a “great report”, to the triage nurse. Pt 1 stated that she had experienced a loss of consciousness (passed out) on the way to the ED. Pt 1 stated that OBP 3 was her primary OB physician and she called him several hours prior to her ED visit, and he suggested she go to the ED. Pt 1 stated she was moved to a hallway bed and she was in a lot of pain, and the RN gave her pain medication. Pt 1 stated that “no one called the ED MD” when she passed out in the hallway bed while the RN and the phlebotomist (someone who draws blood) were drawing her blood for labs. Pt 1 stated EDP 1 should have contacted the on-call provider within 90 minutes and should not have documented in her medical record that she was not in distress, because she was. When asked if EDP 1 was actively providing care, and working her up for a possible ectopic pregnancy, Pt 1 responded that “he was towards the end saying it was a life and death situation by then.” Pt 1 stated her diagnosis was not completed in a timely manner, and EDP 1 saw she was in pain, and could have gotten her into the OR much quicker. Pt 1 stated the on-call OB physician should have been called right away in her opinion. During a telephone interview on 3/25/26 at 2:40 p.m. with OBP 2, OBP 2 stated, when he was on-call, he received phone calls all night. OBP 2 stated that some of the phone calls do not go through to his phone. OBP 2 stated that the phone, “doesn’t always work”, even though he has the hospitals WIFI on. OBP 2 stated he believed the issue was due to poor cellular service. OBP 2 stated he had been told in the past when he was on-call that he could not be reached, that his phone was going to voicemail, but he never received the call. The OBP 2 stated he relayed the information to the hospital, and he agreed that his phone should work so he could be reached. When asked what his process was when he received a call from the ED for a consultation for a possible ectopic pregnancy, OBP 2 stated he asked for the chief complaint, and the blood tests indicating how much pregnancy hormone the patient had. OBP 2 stated if the patient’s hormone labs indicated a pregnancy, a US scan indicated a possible ectopic, and the patient was having pain, the patient would need to go to the OR. When asked if a ruptured ectopic pregnancy was an emergent condition, OBP 2 stated, depends if the patient was hemodynamically stable (HR and BP is adequate to ensure oxygen travels to the body tissues). OBP 2 stated the requirement for an urgent surgical case or an urgent cesarean section (C/S -surgical cut into womb to remove a baby) was 30 minutes. OBP 2 stated that the morning of Pt 1’s visit someone did call him at six a.m. about a patient in the ED, but the patient had already gone to surgery. OBP 2 stated he only took call for patients without a primary OB. OBP 2 stated on the morning 3/9/26, he was in a C/S with OBP 1. OBP 2 stated, at least two doctors were in house (at the hospital) and typically assist each other when performing a C/S. OBP 2 stated that a C/S usually took about 30 minutes to perform. OBP 2 stated that OBP 1 went to see Pt 1 after the C/S. OBP 2 stated the C/S was around 1:30 a.m. OBP 1 was not available for interview during the survey . During an interview on 3/25/26 at 2:54 p.m. with the DWNS, the DWNS stated the on-call providers OB 1 and OB 2 work together to ensure all patients were taken care of. The DWNS stated if OBP 1 was in a delivery or a procedure OBP 2 would cover the remaining patients. When asked why neither OBP1 nor OBP 2 answered their pages and calls, the DWNS stated she did not know if perhaps OBP 1’s phone had the ringer off because she was in surgery. The DWNS did not know why OBP 2 did not answer the page. The DWNS stated she had heard there were OB Physicians who were not getting calls on their cell phone when they were in the hospital, but the hospital re-evaluated the cellular service “a few months ago”, and cell coverage was, “really good”. The DWNS stated there was telephone line in the on-call room, that does not require cellular coverage. The DWNS stated if OBP 2 was having issues with periodic coverage on their cell phone, he would have to tell the ED Unit Clerk (staff who perform secretarial duties, and page on-call providers) which phone number to call in the call room. The DWNS stated the normal response when both on-call physicians were in the same OR, was for the non-primary physician to break away and go see the patient requiring consultation. The DWNS stated if both on-call physicians were busy with patients, in the OR, or attending a delivery, there was always a third person available to call. During a concurrent interview and record review on 3/26/26 with RN 2, Pt 1’s “EDCT”, dated 3/8/26 and 3/9/26 was reviewed. RN 2 stated she was Pt 1’s primary nurse on 3/8/26 from 10:29 p.m. to 3/9/26 at 2:05 a.m. RN 2 stated she recalled Pt 1’s visit. RN 2 stated she recalled Pt 1 looking like she was in pain, so she administered pain medications as soon as possible. RN 2 stated she was aware when patients had a consultation pending, because she looked at the orders, and she does keep an eye on how long the patient’s wait for a consultation. RN 2 stated her practice was to let the physician know when imaging was taking a long time. RN 2 stated in Pt 1’s case both she and EDP 1 were monitoring how long the consultation was taking to get completed, but it was usually the ED physician that contacted whichever physician needed to intervene. RN 2 stated she assessed her patient’s VS every hour or sooner. RN 2 stated if a patient had low blood pressure, was breathing rapidly, or had a fast heart rate, she let the physician know. RN 2 stated she also monitored the EMR for any results from lab or imaging, and notified the physician when the results were received, in case the physician did not have a chance to review them. RN 2 stated how quickly the OB on-call physician responded to a consultation request depended on how busy the ED and OB department were. RN 2 stated a ruptured ectopic pregnancy would be considered a medical emergency. During an interview on 3/26/26 at 8:30 a.m. with the Obstetrician Department Chair (OBC ), the OBC stated her role as the Department Chair was to act as a point of contact for the RN’s and the physicians. The OBC stated she provided expertise to physicians and nursing staff, delt with any physician behavior issues and assisted with peer review (mandatory quality control process where physicians evaluate the clinical work of their peers to ensure adherence to standards and improve patient safety). The OBC stated she was aware of Pt 1’s case the day the incident occurred. The OBC stated, EDP 1 sent her a text message relaying his concern about the inability to get in contact with an on-call OB physician. The OBC reviewed Pt 1’s medical record and spoke to OBP 1. The OBC stated that EDP 1 initially called OBP 3 when OPB 2 was on-call for the provider group. The OBC stated calling the on-call physician (OBP 2) would have been the fastest way for Pt 1 to receive care by an OB physician. The OBC stated OBP 1 was in a “STAT C/S [emergency-performed immediately within 15-30 minutes]” and could not go to assess Pt 1 in the ED. When asked whether a response time exceeding two hours was above the expected timeframe for an OB consultation in the Emergency Department, the OBC indicated that she acknowledged there was a delay in the OB Physician responding to the page from EDP 1. The OBC stated OBP 2 reported his calls were not going through when he was in the call room, but in this case OBP 2 was in the OR so there should not be any reason his calls were not going through. The OBC stated it was unusual for an ED provider to contact the L&D department looking for the OB physician on-call. The OBC stated the ED Physician should not have to get ahold of the OB on-call by chasing them down. The OBC stated, “I think medical Bylaws say 30 minutes from home”, to respond to a request for an emergent consultation request. The OBC stated, when the OBs were on-call, they stayed in-house, and the same time frame applied; however, in practice, they usually responded much faster than that, and an ectopic pregnancy was considered a medical emergency. During an interview on 3/26/26 at 8:50 a.m. with Patient Care Technician (PCT)1, PCT 1 stated the PCT’s worked as UC’s and one of the roles was to contact on-call providers for the ED providers. PCT 1 stated the ED physician would contact the UC requesting a certain type of specialist and the UC would look up the contact information on the who’s on call list in the computer. The PCT stated the UC got the specialist on the phone and gave the specialist the ED providers phone number and usually the patient’s name for the consultation. PCT 1 stated when contacting an OB on-call physician she called the posted OB 2 number from the call list. PCT 1 stated if there was no-answer a voicemail was left. PCT 1 stated after completing the call a message was sent to the ED provider letting them know the call out was completed and what the results were (message or spoke to provider). PCT 1 stated the physicians told the UC’s if a second call was needed, the UCs do not keep track of whether the consulting provider responded. PCT 1 stated it was uncommon to have to re-page an OB on-call physician. PCT 1 works the day shift from 7 a.m. to 7:30 p.m. PCT 1 stated, “usually” she was successful in reaching the on-call providers using the hospital’s posted on-call list. During an interview on 3/27/26 at 12:40 p.m. with Medical Doctor (MD) 1, MD 1 stated she served as an ED Physician and had received education on the updated on call procedures for the OB physicians. She explained that she was re educated on the policy and procedure for contacting OB on call providers for consultations. She stated that the information provided indicated that for OB consultations, if the ED Physician contacted the primary physician first, the on call provider then had 15 minutes to return the call; if there was no response, staff were to contact the on call provider directly. She added that when staff contacted the on call providers, they also had 15 minutes to return the call, and if no response was received, the case was escalated to the OB Chair or ED Chair. MD 1 stated she considered a ruptured ectopic pregnancy an emergent condition. During an interview on 3/27/26 at 12:44 p.m. with Physician Assistant (PA) 1, PA 1 stated he served as an ED Provider, and he received education today (3/27/26) about the on-call process to contact OB Physicians. PA 1 stated he got the on-call specialist name and phone number from the hospital’s online call schedule. PA 1 stated if a patient had a primary physician he would contact that provider first to see if they were on-call, and if the provider did not respond within 15 minutes, he would escalate to the OB physician assigned to the ED. PA 1 stated he would call the OB or ED Chair before calling an overhead OB STAT. PA 1 stated he would consider a ruptured ectopic pregnancy emergent. PA 1 stated the OB consultant would need to assess the patient within 30 minutes. During an interview on 3/27/26 at 12:51 p.m. with PA 2, PA 2 stated that he had served as an ED provider. He explained that recent education occurred because there had been a delay in obtaining a response from an OB specialist. He stated that the patient needed an emergent consultation, and due to the delay and multiple attempts to contact the consulting OB specialist, the patient experienced a delay in care. PA 2 stated that staff had educated him that when an ED patient required an OB consultation, the ED provider should first contact the patient’s primary physician. If there was no response within 15 minutes, the ED provider would then contact the listed on call OB physician. He stated that if the ED provider could not reach the listed on call OB physician within 15 minutes, the ED provider should contact the OB or MD Chair. PA 2 stated that he would have considered a ruptured ectopic pregnancy a reason to call OB STAT overhead if he could not reach the on call physicians. During an interview on 3/27/26 at 12:58 p.m. with MD 2, MD 2 stated he served as an ED Physician, and leadership had spoken to him about the reason an IJ was called at the hospital. MD 2 stated the education was more of a re-education about the process of contacting an OB consulting physician. MD 2 stated that he was aware of the policy expectation to receive a call back within 15 min of calling an OB consulting physician, and if there was no response to escalate to the next person. MD 2 stated in the event of an emergency the consulting physician must respond in person within 30 minutes. MD 2 stated just the diagnosis of a ruptured ectopic in and of itself, does not mean emergent, things change, not emergent can turn into emergent. MD 2 stated he would consider Pt 1’s case emergent because she received a blood transfusion. During a telephone interview on 3/27/26 at 2 p.m. with Complainant (CO) 1, CO 1 stated he was Pt 1’s partner and sent in a complaint to the California Department of Public Health (CDPH), regarding Pt 1’s ED visit care on 3/8/26 and 3/9/26. CO 1 stated he was bedside with Pt 1 throughout her hospital stay in the ED, beginning after triage, until an hour before she was taken to the OR for surgery. CO 1 stated he was not allowed in the US room, during Pt 1’s US. CO 1 stated he worked as a physician and was concerned that Pt 1 did not receive an appropriate medical screening examination, or stabilization. CO 1 stated Pt 1 called the ambulance from home for severe abdominal pain that she rated as 10 out of 10, and she was unable to walk to the car CO 1 stated Pt 1 was transferred by gurney to the ambulance and taken to the hospital. CO 1 stated Pt 1 reported multiple episodes of passing out when she was on the way to the hospital. CO 1 stated he did not know what Pt 1’s ESI score was but that she was placed in the hallway for over two and a half hours. CO 1 stated it was approximately 45 minutes before the ED Physician saw Pt 1, so he was concerned Pt 1 did not receive an appropriate triage. CO 1 stated Pt 1’s differential diagnosis (a list of potential concerns a physician created that could be causing a patient’s symptoms) was a ruptured ectopic pregnancy, it should not have taken six and a half hours to get into the OR. CO 1 stated he did not know whether the ED Physician consulted with the OB on-call or her primary OB. CO 1 stated he had concerns about the on-call paging system since it took a long time to meet with the OB Physician. CO 1 stated he was also concerned about EDP 1’s documentation, due to EDP 1 documenting Pt 1 as “not in acute distress”. CO 1 stated that he understood the removal of Pt 1’s fallopian tube was unlikely to have changed even with a faster OR time, but the patient was in acute distress and was losing blood into the abdomen. CO 1 stated that he did not know the hospital’s triage system, so he could not explain the delay in assessing Pt 1 or why Pt 1 was placed in a hallway instead of a monitored room. CO 1 stated that Pt 1 was discharged home after surgery. During a review of the hospital’s P&P titled, “Physician On-Call Expectations”, dated 9/12/25, the P&P indicated, “ ...In the circumstance where an emergency department physician has requested that an on-call physician either attends the patient in the emergency department or admits the patient to the hospital ... the on-call physician is obligated to meet the request. ...If an emergency department (ED) or inpatient physician or transfer center determines that the individual requires the services of a physician listed by the hospital on its list of on-call physicians, the on-call physician must respond. a. Emergency Department i. Emergent Issue: 15 minutes for telephone response, 30 minutes for physical response ...” During a review of the hospital’s P&P titled, “Medical Screening And Treatment/Transfer Policy And Procedure”, dated 11/7/22, the P&P indicated, “ ...C. Consultation: When necessary, the examination and evaluation shall include consultation with specialty physicians qualified to give an opinion or to render treatment necessary to stabilize the individual. Such consultation may be obtained via telephone. However, where the emergency provider determines it medically necessary, the consultation shall include review of the individual’s medical record and examination and treatment of the individual in person by the specialty physician. If an emergency provider determines that the individual requires the services of a provider listed by the hospital on its list of on-call physicians and, after being notified, the on-call physician fails or refuses to appear within a reasonable period of time, and the physician determines that without the services of the on-call physician, the benefits of transfer outweigh the risks of transfer, the provider is responsible for transferring the individual and will provide the name and address of the on-call physician to the receiving medical facility at the time of transfer ...” During a review of the hospital’s P&P titled, “Call Coverage”, dated 12/17/25, the P&P indicated, “ ...Emergency Call Coverage Response Times 1. If an emergency department (ED) ... determines that a patient requires the services of a physician listed by the hospital on the Emergency Call Coverage Schedule, the on call physician must respond according to the timeframes listed herein: a. Emergency Department: i. Emergent Medical Condition: 15 minutes for Emergency Call Coverage Physician’s telephone response; 30 minutes for Emergency Call Coverage physician’s physical response ....” During a review of a professional reference titled, “ACOG PRACTICE BULLETIN NUMBER 193”, dated 3/2018, written by The American College of Obstructions and Gynecologists (ACOG)- a Clinical Management Guidelines for Obstetrician-Gynecologists, the professional reference indicated, “ ...Tubal Ectopic Pregnancy Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. ...However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. ...Background ... Despite improvements in diagnosis and management, ruptured ectopic pregnancy continues to be a significant cause of pregnancy-related mortality (death) and morbidity (illness). ...Clinical Considerations and Recommendations ... Women with clinical signs and physical symptoms of a ruptured ectopic pregnancy, such as hemodynamic instability or an acute abdomen [sudden onset, severe abdominal pain], should be evaluated and treated urgently. Early diagnosis is aided by a high index of suspicion [strong, forward-thinking approach and awareness that a serious condition may exist, even without obvious symptoms or conclusive evidence]. ...Summary of recommendations; The following recommendations are based on good and consistent scientific evidence ...Surgical management of ectopic pregnancy is required when a patient is exhibiting any of the following: hemodynamic instability, symptoms of an ongoing ruptured ectopic mass (such as pelvic pain), or signs of intraperitoneal (space in the abdominal cavity containing organs) bleeding. During a review of a professional reference titled, “Ectopic Pregnancy”, dated 3/27/25, the professional reference indicated, “ ...Ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity ... Ectopic pregnancy often causes lower abdominal pain, typically on one side, along with vaginal bleeding. Symptoms like dizziness, fainting, shoulder pain, or severe pelvic pain may indicate a ruptured ectopic pregnancy. ... Management primarily aims to preserve fertility, improve diagnostic accuracy, and provide psychological support. ... Advanced or ruptured cases typically require urgent surgical intervention. ... While the mortality rate from ruptured ectopic pregnancies has declined over the past few decades, they still contribute to pregnancy-related deaths. ... Evaluation of vital signs for tachycardia and hypotension is pivotal in determining the patient’s hemodynamic stability. ... The patient’s hemodynamic stability directs the initial management approach for an ectopic pregnancy. Any patient exhibiting signs of a ruptured ectopic pregnancy should be urgently transferred for surgical intervention. ... However, delayed diagnosis can lead to tubal rupture, resulting in life-threatening hemorrhage and hemodynamic instability. In such cases, emergency surgical intervention is required, which may involve salpingectomy [surgical removal of fallopian tubes], potentially impacting future fertility ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 45929 Based on observation, interview and record review, the hospital failed to have an effective governing body (GB) that is legally responsible for the conduct of the hospital when: 1. Resources and oversight were not provided to ensure the hospital maintained an effective, comprehensive, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI-is a systematic approach to improving the quality of care and services delivered to patients) program when: a. The program did not implement effective actions to address the long-standing problem of the hospital practice to provide care to inpatients in the emergency Department (ED- an outpatient hospital department that provides immediate medical care to patient with urgent or life-threatening conditions) the QAPI program has not implemented actions to sustain improvement (refer to A-0315). b. The hospital failed to recognize, analyze the cause, and create clear expectations related to excessive use of force against one of seventy-two patients (Patient [Pt] 1) (Refer to A-0286). 2. Resources and oversight were not provided to ensure the hospital had a well-organized and effective nursing services when the hospital failed to develop individualized care plans, follow hospital policies and procedures, follow physician orders and standards of practice (Refer to A-0396, A-0398, and A-0405). 3. Resources and oversight were not provided to ensure an active Infection Prevention and Control program to ensure a clean and sanitary environment in accordance with hospital policies and procedures and national standards of practice for infection control to prevent and control infections among patients, personnel and visitors (Refer to A-0750). 4. Resources and oversight were not provided to ensure an organized food and nutrition services was organized in a manner appropriate to the scope and complexity of the food service operations when: the hospital policy and procedure regarding nutritional screening and assessment did not follow current standards o practice according to the Academy of Nutrition and Dietetics (Refer to A-0619). Therapeutic diet orders were not followed when the hospital’s diet manual and the department’s policy and procedure for nutrition supplementation did not provide clear parameters when the Registered Dietitian initiated nutrition supplements (Refer to A-0630). 5. Resources and oversight were not provided to ensure safe and effective pharmaceutical services to meet the needs of four of 72 sampled patients (Pt 6, Pt 9, Pt 16, and Pt 71) and no system was in place to accurately record receipt and disposition of all controlled substances (drugs whose manufacturing, possession and use are regulated by the federal government) including patient’s own medications (POM) (Refer to A-0494 and A-0500). The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner for all patients”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45929 Based on observation, interview, video recording review, and record review, the hospital failed to protect and promote each patient’s rights when: 1. Care was not delivered in a safe setting for all patients including the provision of respect, dignity and comfort (Refer to A-0144), 2. All patients were not given the right to make informed decisions when a surgical consent was not signed (Refer to A-0131), and 3. Language barriers were not accommodated for all identified non-English Speaking patients (Refer to A-0117). The cumulative effect of these systemic problems resulted in the hospital’s inability to provide care in a safe and effective manner in accordance with the statutory-mandated Condition of Participation for Patient Rights.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 40644 Based on observation, interview and record review, the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program when there was no effective oversight or monitoring for the inappropriate use of excessive force on one (1) of seventy-two (72) sampled patients (Pt) 1. (Refer to A286) The cumulative effects of these systemic problems resulted in the hospital’s inability to provide patient care in a safe and effective manner in accordance with the statutory-mandated Condition of Participation for QAPI.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 49884 Based on observations, interviews, and record review, the facility failed to have a well-organized and effective nursing service when: 1. The hospital failed to develop and maintain an individualized care plan (CP-a document that outlines a patient’s health conditions, treatments and other information to guide their care and ensure continuity) for one of 27 patients (Pt 6) when Pt 6’s CP did not include important details about her pain location, effective medications, or other pain management interventions, as required by hospital Policy and Procedure (P&P). (Refer to A-0396, Finding 1). 2. For one of five sampled patients (Pt 15) the CP did not identify her as non-English speaker or address her communication needs to ensure she fully understands her care. (Refer to A-0396, Finding 2). 3. Nursing staff failed to perform a head-to-toe assessment (thoroughly examine the body) for one of 10 patients (Pt 3) when Pt 3 was brought to the emergency department (ED- provides immediate medical care to patients with urgent or life-threatening conditions) by ambulance after a motorcycle accident and the nurse did not remove his clothing to check for injuries and did not listen to his heart, lungs, and abdominal (stomach area) sounds (an assessment using a stethoscope [a device used to listen to sounds inside the body] helps the nurse listen to the heart, lungs, and stomach to check if the body is working normally). (Refer to A-0398 Finding 1). 4. Three of three patients (Pt 2, Pt 21 and Pt 22) did not have their skin assessed and documented each shift by ED nursing staff, and Pt 21 did not have a dual nurse skin assessment (a method where two nurses work together to thoroughly assess a patient’s skin for any signs of injury or potential risk factors) when transferred to another patient care area per hospital P&P titled, “Pressure Injury Risk Assessment, Prevention, Staging and Treatment”, “Admission & Ongoing Assessment - Nursing (Acute Care)”, and “Documentation in the Health Record”. (Refer to A-0398, Finding 2). 5. One of 10 patients (Pt 22) had an inpatient physician order and held in the ED, did not have a head-to-toe assessment completed by ED nursing staff according to hospital P&P titled, “Admission & Ongoing Assessment - Nursing (Acute Care)”. (Refer to A-0398, Finding 3). 6. Two out of 10 sampled patients (Pt 2 and Pt 21) had an inpatient physician order and held in the ED were not provided hygiene care according to hospital Policy and Procedure (P&P) titled “Oral Care”, and the “Patient Care Tech 1 Job Description”. (Refer to A-0398, Finding 4). 7. One out of 10 sampled patients (Pt 2) did not receive a meal or snacks while admitted and held in the ED on 3/27/25 according to physician order. (Refer to A-0398, Finding 5) 8. Nursing staff failed to complete a nutritional risk screening for two of 12 patients (Pt 2 and Pt 21) or it was not completed accurately within 24 hours of admission according to the hospital’s P&P titled, “Nutritional Care and Documentation in the EHR [Electronic Health Record].” (Refer to A-0398, Finding 6). 9. Nursing staff failed to ensure an enteral feeding (a method of providing nutrition directly into the gastrointestinal tract through a tube) was labeled with the date and time of change for one of two patients (Patient 65) in accordance with hospital P&P. (Refer to A-0398, Finding 7). 10. Nursing staff did not administer intravenous (IV, into the vein) magnesium (a naturally occurring mineral compound needed in the body) at the ordered time and rate and did not administer PRN (as needed) intravenous blood pressure medication according to physician’s orders for one of 72 sampled patients (Pt 12). (Refer to A-0405, Finding 1). 11. Nursing staff did not administer IV vancomycin (an antibiotic to treat infection) at the scheduled time for one of 72 patients (Pt 16). (Refer to A-405, Finding 2). 12. An intramuscular (IM, into the muscle) medication administered to one of 72 patients (Pt 1), was prepared by one Licensed Nurse (LN - ANM 4, Assistant Nursing Manager 4) and administered by another LN (Registered Nurse 1) and the LNs did not follow acceptable standards of safe medication administration. (Refer to A-0405, Finding 3). The cumulative effect of these system problems resulted in the hospital’s inability to provide quality nursing care in a safe setting.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 43258 Based on observation, interview, and record review, the hospital failed to ensure safe and effective pharmaceutical services to meet the needs of four of 72 sampled patients (Patient 6, Patient 9, Patient 16, and Patient 71) when: 1. Patient 16’s (Pt 16) vancomycin (an antibiotic to treat infection) trough (a blood level to measure the amount of antibiotic in the body) levels were not obtained in accordance with professional standards to guide dosing and monitor safety, despite Pt 16 receiving multiple doses of the antibiotic (Please refer to A-0500); 2. Multiple incomplete and unclear PRN (as needed) pain medication orders were not clarified for indication for use (e.g. mild, moderate, or severe pain) prior to administration for Pt 6 and Pt 9 (Please refer to A-0500); 3. A pain assessment was not completed before an opioid pain medication (a class of medication identified as high-risk/high-alert medications - drugs that bear a heightened risk of causing significant patient harm when used in error) was administered to Pt 9 (Please refer to A-0500); and 4. Current and accurate records were not kept for the receipt and disposition for all scheduled drugs, including patient’s own medications (POM, personal belongings) categorized as controlled substances (drugs regulated by the government due to potential for abuse, misuse, or health risks) for Pt 71 in accordance with professional standards when staff stored Pt 71’s POM and were not able to determine whether the POM contained controlled substances. The pharmacy did not have a system in place to accurately record receipt and disposition of POM stored in the pharmacy. (refer to A-0494) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 28773 Based on observation, staff interview, and review of hospital documents, the hospital failed to ensure the food and nutrition services was organized in a manner appropriate to the scope and complexity of the food service operations when: 1. Food and Nutrition Services was not organized effectively when the structure of the hospital policy and procedure regarding nutrition screening and assessment was not following current standards of practice according to the Academy of Nutrition and Dietetics. (Refer A-0619); and 2. Therapeutic diet orders were not followed when the hospital’s diet manual and the department’s policy and procedure for nutrition supplementation did not provide clear parameters when the Registered Dietitian initiated nutrition supplements. (Refer to A-0630). The cumulative effect of these systemic problems resulted in the inability of the hospital’s food and nutrition services to direct and staff in such a manner to ensure that the nutritional needs of the patients were met in accordance with practitioners’ orders and acceptable standards of practice. The system problems resulted in the facility’s inability to meet the Condition of Participation for Food and Dietetic Services.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 45977 Based on observation, interview, and record review, the hospital failed to have an active Infection Prevention and Control program which adhered to nationally recognized infection prevention and control guidelines for the surveillance, prevention, and control of hospital acquired infections (infection one gets while receiving treatment in a healthcare facility) and other infectious diseases, when: 1. In two of two sampled rooms (The Inpatient and Outpatient Sterile Processing Decontamination [SPD] rooms), SPD staff did not clean and maintain the floors and six of six washer conveyors (a sterile processing room conveyor system is a specialized material handling solution designed for healthcare environments like hospitals and surgical centers. Its main purpose is to automate the transportation of medical instruments and supplies throughout the sterile processing workflow, from decontamination to sterilization and storage.) in accordance with manufacturer’s instructions. A white substance was found on the floor in the Inpatient Decontamination room. In six of six conveyor systems, white residue and black debris was observed (Refer to A-750, Finding 1). 2. Staff failed to ensure a biohazardous waste container (a special container to dispose of items that might have germs, blood, needles, glass, medication, and sharp objects) was closed in an ultrasound (a test using soundwaves to make pictures of the body) treatment room (Ultrasound Room 2) that was not in use, and in accordance with the hospital’s policy and national guidelines (Refer to A-750, Finding 2). 3. Staff failed to ensure the hospitals policy for transporting contaminated (dirty or with germs that could make people sick) instruments was followed and there were no biohazardous labels or containers for contaminated vaginal ultrasound probe transportation (Refer to A-750, Finding 3). 4. Soiled adhesive from tape was left on the walls in in two of two sampled obstetric (OB - a branch of medicine that deals with pregnancy, childbirth) operating area rooms (C-Section 2 and Clean Supply Room) and should have been removed and cleaned in accordance with infection control standards (Refer to A-750, Finding 4). 5. Staff did not document the monitoring for cooling of potentially hazardous foods that were located in the hospital walk-in refrigerator in accordance with hospital policies and procedures and standards of practice (Refer to A-750, Finding 5). 6. Food items stored in a reach-in refrigerator in the hospital kitchen were greater than 41 degrees Fahrenheit (F) and not in accordance with standards of practice (Refer to A-750, Finding 6). 7. Areas of the kitchen and adjacent areas were not maintained in a sanitary manner in accordance with standards of practice. The cooks’ tool cabinet was disorganized and had food crumbs., The catering/doctors’ lounge cooking line had a build up of black grime and the cafeteria cooking line had a build-up of food on the floor under the equipment and under the counter refrigerators had food crumbs on the shelves (Refer to A-750, Finding 7). 8. In the NICU (neonatal intensive care unit), bottles were being washed in a handwashing sink and a sanitizer that is not food safe was being used to sanitize the bottle preparation counter and staff did not follow standards of practice for these items (Refer to A-750, Finding 1). 9. The hospital failed to ensure a single-use only syringe used to administer medications was discarded after use in accordance with hospital policy and procedure (Refer to A-750, Finding 1). The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe setting.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 45929 Based on interview and record review, the hospital failed to meet California Code of Regulations, Title 22. Social Security Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 1. General Acute Care Hospitals, Article 3 Basic Services, §70217 (a)(1)(8)(9)(10)(11) when nurse to patient staffing ratios (N-P, refers to the number of patients a single nurse is responsible for at a given time) in: 1. The Intensive Care Units (ICU- 24-hour care for patients with life-threatening illiness or injuries) nurse to patient (N-P) ratios on 3/25/25, 3/26/25, 3/27/25, 3/28/25, and 3/29/25 were 1:3; 2. The Emergency Department (ED, a department a hospital that provides immediate medical care to patients experiencing serious or life-threatening conditions) N-P ratio on 4/10/25 were greater than 1:4; 3. The 1 North Step-down Unit (providing patient care between intensive care and acute care levels) N-P ratios on 3/24/25 to 3/28/24 and 4/20/25 to 4/21/25 were greater than 1:3; 4. The Cardiac Progressive Care Units (CPCU- a telemetry unit [where vital signs monitor that continuously transmit data, such as heart rate, breathing, and blood pressure to a nearby location] caring for patients with heart issues) N-P ratios on 3/25/25 to 3/29/25 and 4/20/25 to 4/21/25 were 1:5; 5. The Medical/Surgical (M/S-a hospital department whre patients recieve care for a wide range of conditions) units N-P ratios on 4/27/25, 4/28/25, 4/29/25, and 4/30/25 were greater than 1:5. These failures had the potential to result in patients to receive lower quality of care, compromised patient safety, and increase medical errors which could negatively impact the health and recovery of patients. Findings: 1. During a concurrent interview and record review on 6/10/25 at 9:37 a.m. with Nurse Manager (NM) 3, the “Medical ICU Staffing Assignment Sheets (MIS)”, dated 3/25/25 to 3/29/25, were reviewed. NM 3 stated on 3/25/25 one day shift nurse was assigned three patients. NM 3 stated on 3/26/25 four day shift nurses were assigned three patients each. NM 3 stated on 3/27/25 two day shift nurses were assigned three patients each. NM 3 stated on 3/28/25 five day shift nurses and three night shift nurses were assigned three patients each. NM 3 stated on 3/29/25 four day shift nurses were assigned three patients each. NM 3 stated the required N-P (nurse to patient) ratio for the ICUs was one nurse for two patients. During a concurrent interview and record review on 6/10/25 at 9:40 a.m. with NM 3, the “Surgical ICU Staffing Assignment Sheets (SIS)”, dated 3/25/25 to 3/29/25, was reviewed. NM 3 stated on 3/25/25 two day shift nurses were assigned three patients each. NM 3 stated on 3/26/25 two day shift nurses and two night shift nurses were assigned three patients each. 2. During a concurrent interview and record review on 6/10/25 at 10:16 a.m. with Emergency Department Manager (EDM) 2, the “ED Assignment Sheet (EDA)”, dated 4/10/25, and “ED Census (EDC)”, dated 4/10/25, were reviewed. EDM 2 stated 30 nurses were on the EDA for day shift on 4/10/25. The EDC indicated a patient census of 139 on 4/10/25 at 3:00 p.m. EDM 2 stated the average N-P ratio for the shift was greater than 1:4 (one nurse to four patients). EDM 2 stated the N-P ratio for the ED should be less than or equal to 1:4. During a review of a professional reference titled, “Injuries Caused by Emergency Room Understaffing (ICERU)”, dated 3/9/20, the “ICERU” indicated, “ ...When emergency rooms are understaffed ...patients with serious conditions may be overlooked and don’t receive the care they need ... common mistakes that can occur in an understaffed emergency room include ... Failing to diagnose a patient ... patients being given the incorrect medication ... patients being given incorrect blood transfusions ... errors caused by miscommunications and failure to thoroughly read a patient’s chart ... treatment of the wrong patient ... ignoring patient’s concerns ... Any of these incidences can lead to a serious illness or injury that could have been prevented with proper emergency room staffing ...”. 3. During a concurrent interview and record review on 6/10/25 at 9:45 a.m. with Nurse Manager (NM) 2, the “1 North Step-down Assignment Sheets (NSA)”, dated 3/24/25 to 3/28/25 and 4/20/25 to 4/21/25, were reviewed. NM 2 stated nurses caring for Step-down patients should be assigned no more than three patients. NM 2 stated on 3/24/25 four day shift nurses and five night shift nurses assigned in Step-down unit had a N-P ratios of 1:4 or 1:5. NM 2 stated on 3/25/25 three day shift nurses and two night shift nurses assigned in Step-down patients had N-P ratios of 1:4 or 1:5. NM 2 stated on 3/26/25 two night-shift nurses assigned in Step-down had N-P ratios of 1:4. NM 2 stated on 3/27/25 two day shift nurses assigned in Step-down had N-P ratios of 1:4. NM 2 stated on 3/28/25 two day shift nurses assigned in Step-down had N-P ratios of 1:4. NM 2 stated on 4/20/25 two day shift nurses assigned in Step-down had N-P ratios of 1:4. NM 2 stated on 4/21/25 one day shift nurse assigned in Step-down had N-P ratios of 1:4. 4. During a concurrent interview and record review on 6/10/25 at 9:24 a.m. with Nurse Manager (NM) 1, the “Tower 2 CPCU 3rd & 4th Floor Assignment Sheets (T2AS)”, dated 3/25/25 to 3/29/25 and 4/20/25 to 4/21/25, were reviewed. NM 1 stated nurses caring for telemetry patients should have a N-P ratio of no more than 1:4. NM 1 stated the T2AS accurately reflect staffing assignments on the reviewed dates. The T2AS indicated on 3/25/25 four nurses on day shift and four nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 3/26/25 two nurses on day shift and four nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 3/27/25 four nurses on day shift and four nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 3/27/25 four nurses on day shift and four nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 3/28/25 four nurses on day-shift and four nurses on night-shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 3/29/25 four nurses on day-shift and four nurses on night-shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 4/20/25 12 nurses on day-shift and four nurses on night-shift caring for telemetry patients had a N-P ratio of 1:5. The T2AS indicated on 4/21/25 four nurses on day-shift and four nurses on night-shift caring for telemetry patients had a N-P ratio of 1:5. During a concurrent interview and record review on 6/10/25 at 9:48 a.m. with Nurse Manager (NM) 2, the “T3 3rd floor CPCU Assignment Sheets (T33AS)”, dated 3/25/25 to 3/29/25 and 4/20/25 to 4/21/25, were reviewed. NM 2 stated the T33AS accurately reflect the staffing assignments on the reviewed dates. The T33AS indicated on 3/25/25 six nurses on day shift and two nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T33AS indicated on 3/26/25 two nurses on day shift and two nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T33AS indicated on 3/27/25 two nurses on day shift and two nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T33AS indicated on 3/28/25 six nurses on day shift and six nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T33AS indicated on 3/29/25 two nurses on day shift and two nurses on night shift caring for telemetry patients had a N-P ratio of 1:5. The T33AS indicated on 4/20/25 four nurses on day shift caring for telemetry patients had a N-P ratio of 1:5. The T33AS indicated on 4/21/25 three nurses on day shift caring for telemetry patients had a N-P ratio of 1:5. 5. During a concurrent interview and record review on 6/10/25 at 10:02 a.m. with Nurse Manager (NM) 11, the “2nd floor Medical Surgical Assignment sheets (2MS)” and “5th floor Medical Surgical Assignment Sheets (5MS)”, dated 4/27/25 to 4/30/25, were reviewed. NM 11 stated 2MS and 5MS accurately reflect the N-P ratios for the reviewed dates. NM 11 stated the appropriate N-P ratio for M/S units was 1:5. 2MS indicated on 4/28/25, 4/29/25, and 5/30/25 five day shift nurses were assigned N-P ratios of 1:6 each. 5MS indicated on 4/27/25 four day shift nurses were assigned N-P ratios of 1:6 each and on 4/29/25 five day shift nurses were assigned N-P ratios of 1:6 each. During a review of a professional reference titled, “How staffing shortages affect patient safety in healthcare and nursing (HSS)”, dated 3/5/24, the “HSS” indicated, “ ... Having appropriate and adequate nurse staffing is one of the basic elements of healthcare organization management and for good reason. Nurses not only provide care to multiple patients per shift, but nurse teams are the sentinels of healthcare safety, monitoring patients 24-hours a day and responding to their needs in real-time. Such responsibilities require constant vigilance from nurses who have the right skills to handle the kinds of patients they’re caring for and their particular needs. Appropriate nurse staffing is complicated and involves many variables, from nurse skill mix to patient acuity, but at its most basic, having enough nurses at the bedside to effectively monitor and respond to patients and their needs is imperative for quality management. Because of this, it makes sense that research has tied so many safety and quality indicators to nurse staffing. Nurse-to-patient ratios and overall nurse workload are linked to safety factors like medication errors, pneumonia, and even in-hospital mortality [death] ...”.”

“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: 45929 Based on observation, interview, and record review, the hospital failed to protect Patient (Pt) 15’s rights when the hospital identified Pt 15 as a non-English speaker and did not provide necessary accommodation to overcome the barrier. This failure had the potential for ineffective communication, which could have lead to miscommunication and compromising the quality of care and patient safety. Findings: During a concurrent interview and record review on 6/6/25 at 10:32 a.m. with Emergency Department Manager (EDM) 1, Pt 15’s “Electronic Medical Record (EMR)” was reviewed. The EMR indicated Pt 15 spoke Spanish and needed an interpreter. EDM 1 stated Spanish speaking as a primary language is considered a communication barrier. During a concurrent interview and record review on 6/6/25 at 1035 a.m. with Emergency Department Manager (EDM) 1, Pt 15’s “Emergency Department Timeline (EDT)”, dated 6/2/25 to 6/3/25 was reviewed. The EDT indicated Pt 15 arrived in the Emergency Department (ED) on 6/2/25 at 2:03 a.m. with a complaint of abdomen pain. The EDT indicated Registered Nurse (RN) 20 triaged (performed a preliminary assessment of the patient to determine urgency of treatment required) Pt 15. EDM 1 stated RN 20 did not speak Spanish. The EDT indicated, “ ... 02:09 [2:09 a.m.] ... Risk Assessment ... Communication Barriers: None ... Domestic Violence Screening Safe in Home: Yes ... Safe in Relationship: Yes ... [RN 20] ...”. EDM 1 stated RN 20 would have had the Language Service Line pad (an electronic pad that allows access to an interpreter 24 hours a day, 7 days a week) at the triage station and RN 20 “ ... always ...” used the interpreter line and documented in the patient’s EMR. EDM 1 stated there was no documentation of interpreter use. During a concurrent interview and record review on 6/6/25 at 10:45 a.m. with EDM 1, Pt 15’s “Interpreter Flowsheet (IFS)”, dated 6/2/25 to 6/6/25, was reviewed. EDM 1 stated the IFS indicated the first use of an interpreter for Pt 15 was on 6/2/25 at 5:30 a.m. During a review the hospital policy & procedure (P&P) titled, “Interpreters/Translation: Non-English/limited English Proficient & Deaf/Hearing Impaired”, dated 6/14/24, the P&P indicated, “ ... PROCEDURE ... All staff registering a patient ...who has or think may have limited English proficiency ... must identify the patient’s preferred means of communication. This can be accomplished in several ways: i. Ask the patient what language she speaks or use the Language Identification Card. Ii. Access all interpreter services by dialing 15 ...”. During a review of a professional reference titled, “Safety first: The importance of interpreters & translated documents in preventing patient harm”, the reference indicated, “ ... When used effectively, interpreters and translated documents not only enable providers to communicate with their LEP [limited English proficiency] and NEP [non-English proficiency] patients, but also help promote patient safety by preventing medical errors and patient harm, which will minimize health disparities within this population ... open communication channels with their provider allows these patients to truly be in the center of their care ...”.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45929 Based on interview and record review, the hospital failed to ensure patient’s rights to make informed decisions about care for one of 10 sampled patients (Patient 7) when Pt 7 underwent a surgical procedure for Left Lower Extremity Tendon-Achilles Lengthening via Triple Hemi Section (a surgical procedure to correct a shortened Achilles tendon in the heel), Left Midfoot Wedge Osteotomy (removal of a wedge-shaped piece bone from the foot to correct a deformity) and Application of Allograft of Bone (transplant of bone tissue from a donor) and the hospital did not have a signed consent (the process where a patient voluntarily authorizes a healthcare provider to perform a surgical procedure after being fully informed about the procedure’s risks, benefits, and alternatives) for the procedures. These failures denied Patient (Pt) 7 of his right to make informed decisions and participate in his care. Findings: During a review of Pt 7’s “History & Physical (H&P)”, dated 5/27/25, the H&P indicated, Pt 7 had a history of insulin (a medication used to managed blood sugar levels) dependent diabetes mellitus (when the body does not produce the hormone insulin to regulate blood sugar) with retinopathy (damage to small blood vessels in the eyes leading to blindness), neuropathy (damage to the nerves leading to numbness, pain and impaired function), chronic kidney disease (where the kidneys cannot filter blood properly), hypertension (high blood pressure), obesity (excessive fat accumulation) and charcot foot (a serious condition causing bone and joint damage in the foot associated with nerve damage). The H&P indicated Pt 7 came to the hospital with a worsening left foot wound with infection. During a review of Pt 7’s “Operative Report (OR)”, dated 5/30/25, the OR indicated, Pt 7 underwent the following operative procedures, “ ... Left lower extremity tendon-Achilles lengthening via triple hemi section ... Left midfoot wedge osteotomy ... Application of allograft of bone [transplant of bone tissue from a donor] ... left foot ... Left foot excisional operative debridement down to and including muscle [removal of dead tissue from skin to muscle to promote wound healing] ... Left foot adjacent tissue transfer/rearrangement with rotational skin plasty [moving a flap of healthy tissue form an area next to a damaged site]... Preparation of recipient site, left foot [cleaning, debriding, and ensuring the area is free of infection or dead tissue before a graft is applied] ... Application of multiplanar external fixation, left lower extremity [use of a device with pins and/or wires inserted through the skin and into the bone to stabilize and align a fracture or deformity in the leg] ... Application of 18 antimicrobial Biopatches, left lower extremity [specialized dressings to protect the insertion site of medical device from infection] ... Application of [closed-suction medical device, to drain body fluids from surgical sites] ... left foot ...” under general anesthesia [a state on controlled reversible unconsciousness, unable to feel pain]. During a concurrent interview and record review on 6/5/25 at 9:50 a.m. with Nurse Manager (NM) 2, a copy of the signed consent for Pt 7’s operative procedure on 5/30/25 was requested. During an interview on 6/9/25 at 5:05 p.m. with the Manager of Quality Outcomes (MQO), the MQO stated Pt 7’s did not have a signed consent for the operative procedures on 5/30/25 in Pt 7’s medical record. During a review of the hospital policy and procedure (P&P) titled, “Consents”, dated 4/13/23, the P&P indicated, “ ... Verification of Consent ... The role of the hospital is limited to verifying that the physician has obtained the patients informed consent before the physician performs the procedure ... PROCEDURE ...Obtaining Consent ... Informed Consent is to be given for all invasive, complex, medical procedures such as ... All procedures performed in the operating room ... Verification of consent takes place once the physician has ordered the appropriate medical treatment. It is the responsibility of licensed personnel to verbally verify with the patient ... that a discussion has taken place between the physician ... about the procedure including the risks, benefits, and alternative ... Once the verification is complete, the patient will be asked to read and sign one of the following forms, as applicable ... Verification Consent to surgery ... Other Medical Services ...”.”

“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: 47205 Based on observation, interview, review of video recording, and record review, the hospital failed to provide care in a safe setting for seven (7) of nine (9) sampled patients (Patient (Pt) Pt 1, Pt 6, Pt 10, Pt 50, Pt 51, Pt 52, and Pt 67 when: 1. Emergency Department (ED) staff and hospital Security Officers (SOs) initiated a physical take-down (a physical maneuver or intervention to restrain or control a person, often in a potentially violent or combative situation) of Pt 1 without Pt 1 exhibiting evidence of physical escalation in behavior and not in accordance with hospital policy and procedure (P&P). Pt 1 was admitted to the Special Care Unit (SCU-a locked unit within the ED) for bizarre verbal statements. Pt 1 was assessed as cooperative and re-directable and was not assessed as a risk of exhibiting aggressive physical behavior. The inappropriate physical takedown of Pt 1 by SOs prompted the unnecessary administration of medications to chemically restrain Pt 1. The administration of medication to Pt 1 was given over Pt 1’s verbal objection. These failures violated Pt 1’s right to receive care in a safe setting, which includes the provision of respect, dignity, and comfort resulting in avoidable mental anguish and suffering with the potential to cause physical injury related to the physical take-down, and use of physical and chemical restraints. 2. The hospital kept patients who had orders for admission to a hospital unit in the ED for most or all of their stay, denying them the safety and comfort of an inpatient room and bed. These failures resulted in Pt 10, 50, 51, 52, and 67 receiving their inpatient care in the hallway of the Emergency Department where they were on gurneys rather than on the more comfortable hospital beds. Pt 10, 50, 51, 52, and 67 did not have easy access to a bathroom for toileting and hygiene, did not have the option of turning off overhead lights for comfort and sleeping. They were exposed to high foot traffic (lots of people walking around them.) Noise and talking made it difficult to relax and sleep, along with the crowded condition of the Emergency Department. Each of these patients came into the ED with various illness or injuries, and each had physicians’ orders to admit to an inpatient unit of the hospital. All were kept in the ED on gurneys in the hallways, not in a room. Findings: 1. During a review of an Entity Reported Incident (ERI) submitted to the California Department of Public Health (CDPH) on 5/13/25. The ERI indicated “...Date of Alleged Event: 5/9/25... Description of Event and additional details: During chart review on 5/12/25, documentation by ED RN on 5/10/25 found in the chart that stated the following: patient had confided in staff member that during episode when she was placed in restraints an officer had touched her breast inappropriately three times.” Pt discharged on 5/11/25...” During a review of Pt 1’s “Face Sheet (FS)” dated 5/9/25, the FS indicated, “...[Pt 1] arrived at the ED on 5/9/25 at 17:27 (5:27 p.m.)... Discharge Date/Time: 5/11/25 at 21:40 (9:40 p.m.)...” During a review of Pt 1’s “ED Provider Notes (ED Note)” dated 5/9/25, the ED Note indicated, Pt 1 arrived to the ED after an alleged assault in which Pt 1 stated she was hit on the backside of her care by police. Pt 1 with complaints of headache and nausea. Pt 1 denied any type of suicidal ideations but appeared to have delusions when she was then placed on a 1799 hold (a short-term, 24-hour psychiatric detention used in California hospitals for gravely disabled [a condition in which a person is unable to provide for their basic personal needs for food, clothing, shelter, personal safety, or necessary medical care]). Pt 1 attempted to elope from the SCU and did not follow verbal redirection from staff and was placed on four-point restraints, administered diphenhydramine/haloperidol/lorazepam (antianxiety medication) via intermuscular (IM) injection. The ED note indicated Pt 1 was cleared medically but was awaiting psychiatric recommendations. During a record review of Pt 1’s “ED Timeline” dated 5/9/25 the timeline indicated Pt 1 “...18:10 (6:10 p.m.)...Transfer to SCU...18:20 (6:20 p.m.)...Patient called nurse phone, making paranoid and delusional statements. Patient refusing to lay in bed, states “You guys are hurting me in here and hurting my baby.” ...MD notified, orders received. ...18:20:12 (6:20:12 p.m.) Orders Placed...New - Lorazepam... injection 2 mg... 18:24...Continuous Observation: Awake, Ambulating, Yelling, shouting, screaming at staff (pt took off the badge reader and started hitting the door with it)...18:30 (6:30 p.m.)...While waiting for medication approval by pharmacy, patient observe by patient observer to rip badge reader inside of SCCU off the wall and hit the SCU door. Security and writer entered SCU, patient escorted to bed by Security. Patient refused to sit on bed and became physically combative with Security by kicking them. Additional staff and Security entered SCU and got patient in bed. Orders received and carried out. Badge reader removed from SCU...” During a review of the hospital document titled “SCU Door and Phone Info” undated, the document indicated the layout of the SCU in the “Green Zone” area of the ED. The SCU is a locked unit, with staff badge reader pads at 3 doors (Interior Door, SCU North (N) Door and SCU east (E) door). The SCU has 1 room (first room) where patients admitted to the SCU can change out of street clothes into paper scrubs placing items in lockers and the other room is reserved for patients requiring isolation or minor patients. The second room in the SCU is a large area where multiple patients can be admitted and placed on gurneys (a wheeled stretcher used for transporting hospital patients). These areas were under continuous observation by staff, with all hazardous risks removed. In the SCU patients communicated with staff by using a telephone located between the Interior and N doors. During a concurrent interview and medical record review on 6/5/25 at 1:15 p.m., with RN 1 and ED Manager (EDM) 1, RN 1 confirmed she was familiar with the event involving Pt 1. RN 1 described Pt 1 was admitted to the SCU for bizarre psychiatric behavior. RN 1 described Pt 1 was at the phone and made bizarre statements, and told RN 1 she did not want to be in SCU. RN 1 stated she communicated and provided verbal reassurance with Pt 1 being directable. RN 1 explained she was with another patient when she learned Pt 1 had removed the badge reader from the wall, disconnected it, and hit the door. RN 1 stated Pt 1 was not redirectable, and Pt 1’s bizarre behavior escalated. RN 1 stated she and 2 SO’s responded, SO’s leading the way entering the SCU through the interior door. RN 1 explained she attempted de-escalation by attempting to administer lorazepam but a pharmacy check was needed. RN 1 stated when de-escalation was unsuccessful, the team had to make physical contact. RN 1 stated Pt 1 was yelling, holding the badge reader in her hands and gesturing. RN 1 stated Pt 1 would not sit on the gurney, was struggling against the SO’s hold when Pt 1 started to kick at the SO’s. RN 1 stated she asked the SO’s if additional help was needed, with the SO responding he had hit the “panic” button already. RN 1 responded she was aware that Pt 1 had reported she had been attacked by neighbors and police officers before this visit to the ED. RN 1 explained the team moved the bed to make room for the additional staff she had requested (2 male PCTs) come in to help. RN 1 described the physical take-down continued with one SO at each upper extremity (both arms) with PCTs holding lower extremities (both legs) and RN 1 holding both knees. RN 1 stated additional officers arrived Pt 1 became violent. RN 1 stated she went out to the desk to get locking restraints. RN 1 clarified that Security applies the locking restraints because they have special training. RN 1 stated Pt 1 was subdued and the SO’s proceeded to apply the restraints. RN 1 confirmed application of 4-point locking restraints was the goal. RN 1 explained a 4th SO (SO #?) assisted at the head of the bed once arrived. RN 1 stated SO ## was not able to hold [Pt 1’s] head down, so he held her down by both shoulders. RN 1 stated restraints were successfully applied with no apparent injury to either Pt 1 or hospital staff. RN 1 stated Pt 1 yelled at staff the entire time. RN 1 stated a code assessment (a process used in ED to overhead page alerting additional staff and provider to respond to a patient emergency event) was called. RN 1 stated a doctor came down (did not recall doctor name) and ordered haloperidol and diphenhydramine medications to be administered IM, and a restraint order. RN 1 state she gave lorazepam after Pt 1 was 4-point restrained and a short time after she gave the haloperidol and diphenhydramine. RN 1 explained this event occurred close to change of shift and at 7:30 p.m., when she left, Pt 1 was still agitated. RN 1 responded she did not recall if Pt 1 had a history of psychiatric or mental/behavioral health disease. RN 1 stated she did not recall seeing any inappropriate touching. A request to review surveillance video was submitted. During an interview on 6/9/25 at 9:08 a.m., with Medical Doctor (MD) 2, MD 2 stated Pt 1 came in [to the ED] “herself” alleging assault at a property she owned while trying to collect rent from tenant. MD 2 stated after her initial exam she ordered Pt 1 be placed on a 1799 hold (lasts up to 24 hours and applies when a doctor believes someone is a danger to themselves or others due to a mental health crisis), and initiated orders for a “trauma work up” this included laboratory tests, and imaging studies (x-rays) MD 2 responded she did not order a urine sample to check for substance abuse/use because she did not believe Pt 1’s bizarre behavior was caused by substance use. MD 2 stated she explained to Pt 1 that she would be moved to another secure area [SCU] while waiting for a psychiatric liaison evaluation for safety, but did not explain the details of restrictions under 1799 (such as not being able to leave, being asked to change into paper scrubs, etc.). MD 2 states she later met with Social Worker/Psychiatric Liaison (SW) 1 who assessed and determined that Pt 1 did not meet criteria and recommended the 1799 hold be lifted, MD 2 stated she was not in agreement with SW 1’s recommendation. MD 2 stated she proceeded with the order to have the psychiatric assessment (done via telemedicine) due to her concern for Pt 1’s psychiatric safety considering Pt 1 did not have a known past medical history of mental/behavioral disease. During an interview and record review on 6/9/25 at 10:50 a.m., with SW 1, and Behavioral Health Supervisor, (BHS), SW1 stated her role as a Psychiatric Liaison is to perform mental health assessments in the ED, reporting to [hospital] behavioral health leadership. SW1 referred to her note dated 5/9/25 at 10:40 p.m. SW1 stated she assessed Pt 1 and recommended the 1799 hold be lifted. SW1 stated MD 2 was still concerned by Pt 1’s statements and decided not to lift the 1799 hold. SW1 stated Pt 1 reported a tenant on her property had assaulted her. SW1 stated Pt 1 did not make any report to SW or staff of any abuse while in the ED. SW1 stated she was told haloperidol was administered and Pt 1 requested the restraints to be loosened. SW1 described Pt 1 to be calm cooperative, with normal cognitive abilities and appropriate behavior. SW 1 stated the primary RN coordinates the psychiatric consult. SW 1 stated she did not recall if she alerted the RN about Pt 1’s request to loosen the restraints. SW 1 stated the process is the nurse is notified and documentation is completed. SW 1 stated best practice is to document, because “we say if it’s not documented it wasn’t done.” Pt 1’s EHR did not indicated SW 1 documented the event. BHS 1 stated it is fair to say that it should have been documented by SW. BHS responded “yes” there is potential harm to the with the use of restraints, if they are saying they are too tight, staff should be looking at skin. BHS stated this is definitely an opportunity to pass on to the staff (importance of documenting and communicating patient needs with clinical staff). During a concurrent interview and surveillance video review on 6/9/24 at 11:10 a.m., with Security Operations Manager (SOM) 1, and Vice President (VP) of Regulatory, Risk, and Medical Affairs (VPR), the video recording of the incident with Pt 1 was reviewed. The date and time stamp on the video was 5/9/25 at 6:23 p.m. views of multiple cameras into the SCU were displayed. Video review begins: At 6:23 p.m., Pt 1, in paper scrubs, was standing by the “sally port (Interior door)” and the “security door (N door),” both locked entry/exit doors into and out of the SCU area. Pt 1 was holding an emesis bag in her left hand. At 6:23:12 p.m., - Pt 1 remained standing by the doors (interior and N). Pt 1 began to swing her right arm, and walking back and forth (pacing). Pt 1 looked at the around and focused on the badge reader to the left of the interior door. At 6:24 p.m., Pt 1 pulled badge reader from the wall, still holding the badge reader in her right hand. Pt 1 looks at the badge reader in her right hand then looks out the windows (where staff sit at security desk), looks at the badge reader in her hand again then after a short pause Pt 1 hit the window with her right hand holding the badge reader 2 times. Pt 1 was trying to speak with staff through the windows as staff began walking into the main SCU area through the first room. At 6:25 p.m., SOs (SO 1 and SO 2) enter the SCU through the interior door. Pt 1 remained near the interior door, did not appear to try to run past or hit the SO’s. SO’s immediately grabbed Pt 1 by her arms and forcibly dragged Pt 1 over to and lifted and slammed Pt 1 onto the gurney. RN 1 entered after SO’s, and left the SCU shortly after. Pt 1 continued to struggle against being held down when RN 1 re-enters with restraints. Pt 1 continued to struggle with SO’s, RN 1 gestures to staff waiting out in the ED. PCT1 and PCT 2 enter SCU and immediately begin to pin Pt 1’s arms and legs down onto the gurney while SO’s attempted to apply restraints. At 6:27 p.m., SO 2 is possibly speaking to Pt 1, there is no audio present on video. SO 3, is positioned at the head near Pt 1’s right (RT) hand, PCT 1, and PCT 2 positioned one at each leg, while locking restraints are applied to bilateral upper extremities (BUE- wrists) and bilateral lower extremities (BLE- ankles). At 6:28 p.m., SO 4 enters the SCU. SOM 1 agreed that at point there were 4 SO’s, 2 PCT’s, and 1 RN, in the SCU holding Pt 1 down. SO 4 helps SO 2 apply left (LT) wrist restraint. PCTs are still holding Pt 1 down at the knees. Possible restraint readjustment by SO 2. At 6:29:45 All 4 limbs were restrained. At 6:30 p.m., staff released physical hold of legs and Assistant Nurse Manager (ANM) 4 handed a syringe to RN 1. Unable to view location of administration, view was obstructed. At 6:30 p.m., Pt 1 was in 4-point restraints, and was lifting her head up and off the gurney and flailing back and forth, both gurney side rails were up. At 6:31 p.m., ANM 4 is seated at the monitor/security station. At 6:32 p.m., staff exit the SCU. PCT 1 remained to return Pt 1 to SCU bed 6 area. PCT 1 exits the SCU. At 6:33 p.m., video ends. SOM 1 explained the “DVR’s (Digital Video Recording- a machine used to make and watch recordings of television programs) are pulled and archived” in response to an IRIS report (hospital occurrence or adverse incident reporting system). In response to this request, security department pulled the video from the DVR focusing only on the physical take-down portion of the available recording due to the allegation of sexual abuse. SOM 1 states, yes, the surveillance video has audio recording capacity. A request to review the video including audio is made. During a concurrent interview and video surveillance with sound/audio review on 6/9/25 at 2:04 p.m., with Patient Care Technician (PCT) 1 and SO 1, SO 1, stated he was the SO assigned to SCU on 5/9 with SO 2 responding as he rounded in the ED. SO 1 stated the SO role is to deescalate the patient and try to get the patient to comply as instructed in Crisis Prevention Intervention (CPI- a training program focused on preventing and managing challenging behaviors in a safe and respectful manner). SO 1 stated Pt 1 began to show signs of aggression, and he did not remember what Pt 1 was saying. SO 1 stated Pt 1 did not want to sit down, had just gotten changed out, and “what agitated her was that she couldn’t take her necklace in the SCU. [It was] locked up with property.” SO 1 explained that as soon as he and SO 2 opened the interior door, Pt 1 tried to rush through the door. SO 1 stated he may have said something to Pt 1 possibly “calm down, relax, stuff like that.” PCT 1 stated his role on 5/9/25 was to assist nurses in the green zone with patient care. PCT 1 stated being a newer employee in the ED, de-escalation [techniques] were new to him, and he has received a training led by RN 1 on how to manage SCU patients. PCT 1 stated he and another PCT (PCT 2) had been standing by outside the SCU and awaiting nurse instructions or request for assistance. RN 1 signaled to the PCTs that the come into the SCU to help calm Pt 1. PCT 1 stated RN 1 called a code assessment. PCT 1 acknowledged there were 5 staff physically holding Pt 1 down, trying to get Pt 1 to lie down. PCT 1 stated SO 3 arrived and the team decided to move Pt 1 out to SCU 2 to isolate and cut down stimulation for Pt 1. PCT 1 stated after learning that another patient was expected to be roomed in SCU 2, with a greater need for the isolation, Pt 1 was moved back to bed 6. Pt 1 is heard to state she is “thirsty and hungry” at 6:32 p.m., proceeds lie down, moves about a bit then lays supine on gurney with video ending at 6:33 p.m. PCT 1 stated he did not address Pt 1’s request for food and drink directly. PCT 1 stated he could not give her anything to drink or eat, so he was not comfortable giving anything to Pt 1. PCT 1 stated he did tell the nurse. PCT 1 stated he did not document the discussion he had with the nurse about Pt 1’s requests for food or drink. PCT 1 stated, he believes documenting would be expected. PCT 1 stated he “just assumed [Pt 1’s requests] would be brought to the doctor’s attention by the RN.” SO 1 stated he works at both hospital locations and at the behavioral health center. SO 1 stated differences he has noticed is they have more help there (behavioral health), clinical are staff trained differently, they have the de-escalation and CPI trainings, and other trainings (defensive tactics, classes for safe patient and staff handling). SO 1 stated behavioral health has psych techs (a healthcare professional who provides direct care to individuals with mental health conditions) who monitor the halls. PCT and SO 1 confirmed this event seemed “pretty normal” and they did not see anything of concern. During an interview and video surveillance review (sound present) on 6/9/25 at 2:48 p.m. with ERD, and DRM, ERD stated if a patient refuses to change out (from street clothes into paper scrubs) the ED has an established process in place to accommodate the patient request. ERD explained Pt 1 could have been allowed to stay in a hallway, with an assigned patient observer for safety, if Pt 1 did not want to take off her necklace. ERD stated they do not employ psych techs in the ED/SCU. DRM stated an investigation into Pt 1’s sexual abuse allegation was complete. DRM stated the investigation determined the sexual abuse allegation did not occur after a review of the archived video. DRM confirmed that an investigation and/or Root Cause Analysis (RCA- a problem-solving method used to identify the underlying reasons why a problem or event occurred) related to the concern for use of excessive force had not been conducted because the focus was on Pt 1’s sexual abuse allegation. During an interview and surveillance video (audio present) review on 6/9/25 at 5:14 p.m. with SO 2, DRM, and SOM 1, SO 2 stated he watched the video, earlier on 6/9/25. SO 2 explained he remembered the event involving Pt 1. SO 2 stated the PO told him Pt 1 had pulled the badge reader in the SCU from the wall and was holding it in her hand. SO 2 stated upon entering the SCU by door 1, he saw Pt 1 still had the badge reader in her hand. SO 2 stated he directed Pt 1 to “relax calm down, let go of the badge reader.” SO 2’s directive to Pt 1 was not heard on the video. It was not clear on video review if Pt 1 tried to run past the staff or if staff ran into Pt 1. SO 2 stated he pressed his panic button, right as they entered and began to grab Pt 1. SO 2 explained the panic button will dispatch additional help to the officer’s location once pressed; dispatch sent more help. SO 2 stated RN 1 came in with restraints, he did not know who gave order for restraints but RN 1 told [them] she had an order for restraints . On the surveillance video, Pt 1 was held down on the gurney by SO 1, SO 2 and RN 1 with PCT 1 and PCT 2 entering to help get Pt 1 into the 4-point restraints; there was no dialogue heard until Pt 1 said [SO2] was hurting her. SO 2 explained “we were at an awkward angle;” and were not able to not able to pull the gurney out away from the wall so the process was less smooth. SO 2 was heard speaking to Pt 1 at minute marker 6:29 p.m. the on the video (was seen and heard) telling Pt 1 he would let her out of restraints as soon as possible. SO 2 said he does not recall the nurse speaking to the patient. Staff were not heard to respond to Pt 1’s complaint that staff were hurting her on the surveillance video. SO 2 stated once the medication was given all hands came off Pt 1. Staff were not heard providing directives, and/or reassuring and therapeutic emotional support to Pt 1 on the surveillance video. SO 2 stated it did not seem Pt 1 understood what staff were telling her. SO 2 stated Pt 1 had not been in the SCU before and he felt Pt 1 was scared. SO 2 stated he remembered before the take down, Pt 1 repeatedly asked to see a doctor and had requested something to eat and drink. SO 2 stated he thought the nursing staff addressed Pt 1’s requests. SO 2 stated he could not recall if Pt 1 saw the doctor. SO 2 explained security staff attend an in-person course in Crisis Prevention Intervention (CPI) training, where he was learned to recognize a situation for what it is, and how to resolve the problem. SO 2 stated staff must recognize when to go into to the patient in the SCU to them we are not trying to hurt them. SO 2 stated once Pt 1 became physical, hitting the window with the badge reader, Pt 1 was “going to fight.” SO 2 stated, normally he assesses risks prior to reacting, but there was no time to de-escalate Pt 1 “she was going to fight; she charged to the door.” SO 2 stated in this situation we “had to go hands on.” SO 2 stated he did not know what patient rights were taken away when a patient is placed on a 1799 or a 5150 hold (an involuntary 72-hour psychiatric hold for individuals experiencing a mental health crisis who are deemed a danger to themselves or others). SO 2 stated one difference he has noticed when he works in the SCU versus at the behavioral health center, is that staff at the behavioral center are more hands on; they call security with the expectation that SO’s follow clinical staff lead. During an interview and video surveillance review on 6/9/25 at 6:00 p.m., with SOM 1 and DRM, SOM 1 explained a copy of the physical take down portion of Pt 1’s SCU stay was available because the Risk Management team was investigating Pt 1’s allegation of sexual abuse and requested video review. SOM 1 explained normally, video is stored on a DVR on a first in and first out rotation; once maximum capacity is reached and/or 10 days have passed, the DVR is overwritten. DRM stated although it is possible to save an encounter, in its entirety, staff may have decided to keep only the portion relevant to their investigation. SO 5 stated the difference between the hospital and the behavioral health center are in the hospital the SO applies restraint going into the room first, when has worked at the behavioral health center, has noticed there are more interactions with patients, here (SCU) the patients are sealed off.” Staff at the behavioral health are a little more hands on; with patients often already deescalated. During an interview and video surveillance review (sound present) on 6/10/25 at 2:42 p.m., with SOM 1 and SO 3, SO 3 stated his role is to deescalate and place hands on patients as needed observing policy in how to properly restrain, without causing further incident to the patient. SO 3 stated he has noted differences in the care of patients who are in the SCU versus patients at the behavioral health center. Some differences are in the SCU, it is like a holding tank, patients are medicated and observed, and can move if they need to use bathroom. At the behavioral health center, patients are provided with recreation and bathroom; staff are hands on and more patient focused. SO 3 stated in the SCU security is more at the forefront in SCU and act as the patient advocate, because the clinical staff is too busy. SO 3 stated patients on a hold, do not have the right to leave unit, cannot have cell phones. SO 3 stated, “no” he does not consult with clinical staff prior to entering the room or prior to engaging hands on. SO 3 stated he has watched the video of the situation with Pt 1. SO 3 explained on 5/9/25 at 6:27 p.m., he clocked in from lunch and was directed to help with restraint application. SO 3 stated when he got there, he waited for medical staff, but when he looked into the SCU and saw the activity, he ran in. SO 3 stated he “wasn’t here to determine how I could help. She (pt) was in RN 1’s face, best thing I could do was push down her forehead to assist with the restraint [application], SO 3 stated, “I did not speak to the patient at all.” SO 3 stated after an event, they call their watch commander (shift supervisor) and report what happened by giving them details. SO 3 stated a debriefing may be done and could involve a review of the video. SO 3 stated these debriefings are done with the security team involved, clinical staff do not attend. During an interview and video surveillance review (sound present) on 6/10/25 at 3:12 p.m., with SOM 1 and SO 4, SO 4 stated some differences between his shifts at the hospital versus the behavioral health center are in SCU it is more they are coming in from being outside, everything is going be scary for them, going through something coming off drugs. More unexpected of what could happen. Have tried to de-escalation in past. Usually we notify additional officers for restraints, usually 3, I would be primary as the SCU. Usually dispatch has eyes on camera, if officers are having trouble maintaining control dispatch will send additional officers. SO 4 explained at the behavioral health center, security is called to prevent and to deescalate; there security makes sure patients are not harming selves or others, taking clothes off or standing next to a patient in another bed. CBHC clinical staff restrain first, here in SCU SO restrain first. SO 4 stated it is a clinical call not a security call for application of restraints or administration of chemical restraints. Sometimes patients have sitters in hallways, SCU is green (part of the green zone) and SOs are aware where they are at. SO 4 stated when he entered the SCU at 6:29 p.m., Pt 1 was yelling and screaming. SO 4 stated as the 7th person in the room, he grabbed Pt 1’s left arm, to help SO 2 place the last restrain. SO 4 stated Pt 1 was calm by 6:29 p.m. SO 4 stated the nursing staff make the determination about what type of restraint (chemical, physical or both) is used. SO 4 stated the RN will order medications when they see patients pacing or something. SO 4 stated all [security] does is assist nursing staff when they ask. SO 4 stated when a patient is placed on a hold, they are not able to leave. Can’t keep any belongings on them. Can use bathroom, have meals, water, make phone calls, if they are in SCU. If they are on a hold in the hallway no visitors are allowed to stay with them. During an interview and record review, via telephone, on 6/10/25 at 4:15 p.m., with Patient Observer (PO) 1, and DRM, PO 1 stated her role is to continuously monitor SCU patient activity via video surveillance cameras and document what the patient does. PO 1 stated they log patient activity directly into the patient’s Electronic Medical Record (EMR) using a codified system (letters for activity, ex: “K” means lying down; “M” is quiet). PO 1 stated Pt 1’s behavior changed quickly, seemingly without provocation. PO 1 stated she did not call a code assessment, this is normally done by the nurse. After reviewing the “observation sheet,” PO 1 agrees with her documentation which indicated [on 5/9/25] at 1751 (5:51 p.m.) changing out into paper scrubs with security... (6:00 p.m.) talking w staff...1815 (6:15 p.m.) ambulating and talking with staff...1824 (6:24 p.m.) awake, ambulating yelling, shouting screaming at staff, pt took off the badge reader and started hitting the door with it...” PO 1 stated Pt 1 changed out without incident or would have documented it [incident]. PO 1 stated Pt 1 spoke with SOs by phone. During an interview, via telephone, on 6/10/25 at 4:46 p.m., with MD 2 and DRM, MD 2 stated she could not see the chart but her practice is to “do my signature below my note with details about the provider I sign out to” as it was not clear which provider had written the note due to addendums listed. MD 2 stated she could not recall generally when she gets alerts via secure chat application or “code assessments (overhead page alerting provider to the need for them to respond in person to the patient’s room). MD 2 she was with another patient while Pt 1 was restrained, was informed Pt 1 was kicking staff so she said she was “fine with it [restraint application].” MD 2 stated she recommended Pt 1 be roomed in the SCU, referring to the bizarre statements as “delusions, was worried she was having a psychotic break.” MD 2 stated when she told Pt 1 about being moved to the SCU, “she seemed ok with it. If there was something that agitated her, I wasn’t made aware. I am not sure what made her switch [become combative].” During an interview and video surveillance review (sound present) on 6/11/25 at 9:09 a.m., with ANM 4, ANM 4 she may have been rounding in the ED and was in the SCU area, when Pt 1’s behavior escalated and she was aware that RN 1 was waiting for medications to be verified. ANM 4 stated SO’s knew going in [to SCU] that medication had been ordered and needed to be given. ANM 4 stated she assisted in getting the lorazepam ordered by drawing it up at the SO desk/station. ANM stated she bypassed barcode scanning (a technology used to positively identify patients, medications, and specimens by scanning barcodes, typically on wristbands, medication packaging, and lab samples) due to the situation. The surveillance video showed ANM 4 was handling a single syringe; ANM 4 stated she could not recall if the syringe contained one or all of the medications ordered (lorazepam, haloperidol, and diphenhydramine). ANM 4 explained it is her normal practice to separate each medication into a separate syringe, so she felt confident the syringe only contained lorazepam. ANM 4 stated in this situation, she told RN 1 what she had drawn up (lorazepam). ANM 4 stated “no” she did not label the syringe. ANM 4 stated she handed the unlabeled syringe to RN 1 and scanned the medication later which documented the medication was given in Pt 1’s medication administration record. ANM 4 stated, it is ideal to barcode scan and administer the medication at (patient) bedside because the nurse can verify the “5 rights (used to ensure safe and accurate medication administration- right patient, drug, dose, route, time) “ and inform the patient what will be administered. ANM 4 explained her understanding of patient’s rights and involuntary holds is a 1799 is a 24-hour hold and a 5150 is a 72-hour hold placed to keep the patient safe. ANM 4 stated if a patient is at the point of being held by the security guard and being restrained, the medication can be given. ANM 4 stated “I don’t think she [a patient] can refuse” because of the hold order. “I know we can give a medication, especially if it was ordered by the doctor; the patient can’t refuse.” ANM 4 stated Pt 1 had the right to refuse to change out, and had a right to say no. ANM 4 stated staff should allow patient requests made if they can be accommodated, as long as staff, patients, and visitors are safe. ANM 4 stated her expectation is that staff would address any patient request for food or water by following doctor’s orders; if there is no order call the doctor to get one. ANM 4 stated it is her expectation that if a patient is refusing medication, the nurse would explain to the patient why the doctor ordered it. If the patient continues to refuse, the nurse would notify the doctor and document the notice in the patient’s EHR. ANM 4, stated it is expected staff would try to deescalate the situation by: talking to the patient, engaging them in conversation and redirecting them if they refuse to comply. ANM 4 stated listening, keeping your distance, and watching for cues that the patient may be escalating (pacing, threatening gestures, etc.) are some examples of de-escalation techniques. ANM 4 stated if a patient is on violent restraints, it is her expectation that staff reassess the patient on violent restraints every 15 minutes for patient activity, behaviors, skin check, and readiness to liberate from restraints. ANM 4 stated her expectation if a chemical restraint has been administered, the RN should be checking within 30 minutes after the medication was given reassessing, at minimum the patient’s response to the medication, vital signs (heart rate, blood pressure, respirations, etc.) and if the medication was effective (patient is calm/redirectable and/or has had any reaction to the medication). ANM 4 stated she expects the RN and PO to document what they see, with their observations of patient behaviors matching. ANM 4 stated on reflection, after viewing the video, she felt she could have stayed with RN 1 longer to support her during the event. During a concurrent interview, video surveillance (with sound) and record review on 6/11/25 at 11:14 a.m., with RN 1, EDM 1, and SOM 1, RN 1 stated she had not viewed the surveillance video until today, and confirmed this was after our interview on 6/5/25. RN 1 stated after viewing the surveillance video today, “watching it back, wow that’s a lot that happens, I probably could have said more to the patient.” RN 1 explained on assuming care of Pt 1 near the end of her shift, she remembered explaining to Pt 1 the “concept [of the hold];” RN 1 stated she told Pt 1 “we wanted to keep her to have psych (psychiatrist) see her, but get her medically cleared first. RN 1 stated she told Pt 1 then a SW will step in and do their assessments, they will then put her on a hold and transfer to inpatient care if needed.” RN 1 explained she usually informs SCU patients there is a phone in there (SCU) you can use to communicate, or you can knock on the window. RN 1 stated patients in the SCU can be heard through the windows without use of the telephone, it is preferred to use the phone. RN 1 stated if the patient does not use the phone, she will use it on her end and gesture, through the windows, for the patient to pick up the receiver. Surveillance video is started. RN 1 stated when Pt 1 hit the window, twice and said, “I need to feed my Guinee pigs, RN 1 responded something to the effect “how did you get that in your hand?” RN 1 stated Pt 1 responded “it came out.” RN 1 stated she (Pt 1) tapped on window again, and said I need to feed my Guinee pigs again. (Pt 1 can be heard). RN 1 stated she gestured to Pt 1 to move away from the door (this gesturing is not visualized on the surveillance video, view is obstructed), Pt 1 said “no I’m not going to bed (can be heard).” RN 1 stated prior to this exchange and before the time the surveillance video archive began, there was nothing to indicate Pt 1’s was at risk of becoming combative. RN 1 explained after voluntarily changing out, as Pt 1 was being escorted into the SCU, RN 1 told Pt 1 this is where she was going to be. RN 1 stated it seemed the reality of the situation registered in Pt 1’s mind. RN 1 stated Pt 1 tried to grab it [personal belongings bag] from him [SO 1] a couple of times; requiring SO 2 to come back in and help grab the belongings bag from Pt 1. RN 1 stated “I don’t know what I said exactly but 1 told Pt 1 her belongings would be locked up, stating “security puts your things in the lockers.” RN1 stated Pt 1 mentioned she didn’t trust or like law enforcement. RN 1 stated she tried explaining to Pt 1 that they are not law enforcement, she is a nurse and they are SOs. Surveillance video review resumes. RN 1 stated due to Pt 1’s unpredictable behavior SO went in first. RN 1 stated she left the room to go out to the desk and grab locking restraints. RN 1 stated did so under the premise “we are potentially going to need them. RN 1 stated “wasn’t going to put them on her at this point in time” but when Pt 1 kicked the SO, it was decided to apply the restraints. RN 1 stated PCT 1 and PCT 2 were watching what was happening through the windows and had been positioned to help as needed. Dialogue between Pt 1 and staff (heard on the video) indicated Pt 1 denied kicking staff and RN 1 responding “you can’t kick them.” Continued audio indicated at 6:27 p.m., Pt 1 declared “you are hurting me” to which SO 2 responded “lay down.” RN 1 is heard stating “I gave you a chance.” RN 1 clarified the statement of giving Pt 1 a chance meant when Pt 1 was seated on the gurney. RN 1 stated Pt 1 was not told verbally she was going to be placed in restraints and, “yes,” they should have and “yes,” potentially less restrictive interventions may have worked. RN 1 is heard responding to Pt 1 “it’s hurting you because you are not relaxing.” RN 1 stated she did not recall if she adjusted the restraints, or if she called a code assessment. RN 1 stated she did not draw up the medication ordered (lorazepam), and “no” the syringe was not labeled. RN 1 stated ANM 4 handed her the unlabeled syringe but told her what was in the syringe. RN 1 stated, “Usually, I draw my meds and give my own meds.” RN 1 stated her practice is to prepare medications in the med room, go to pts area, scans and then administer the medication. RN 1 stated ANM 4 could have given the medication. Pt 1 appeared to be lying calmly on the gurney in 4-point restraints on the surveillance video. RN 1 agreed Pt 1 seemed to calm down after being placed in restraints. RN 1 stated it is possible that Pt 1 may have remained calm, but a chemical restraint is the professional standard to ensure the patient returns to “an acceptable level of behavior” and that is why she followed the locking restraints with a chemical restraint (administration of lorazepam). physical restraints followed by a chemical [restraint], is what Pt 1’s behavior, presentation and clinical research recommends as professional standard of practice to return the patient to an “acceptable level of behavior.” RN 1 stated the lorazepam was administered against Pt 1’s wishes because RN 1 stated patients on a hold “don’t have the ability to refuse.” Pt 1 clearly stated (heard on video) “just give me the pill [expletive], I don’t take shots.” RN 1 explained the IM route would work better and quicker. RN 1 acknowledged Pt 1 had been restrained both physically and chemically. RN 1 stated she was aware that Pt 1 had requested something to eat and drink, but she could not eat or drink until imaging results came back. RN 1 stated, “no,” there was no active NPO (nothing by mouth) order and she did not speak with the doctor about it. RN 1 stated the RN is responsible for checks every 2 hours for comfort, nurses assess if restraints are too tight, and patient readiness to be liberated from restraints. RN 1 stated because lorazepam was not given for pain, Pt 1 did not need to be reassessed earlier than the 2-hours re-assessment requirement. RN 1 stated patients in the SCU are monitored by the PO continuously with documentation every 15 minutes to see how the patient is behaving. When asked which least restrictive interventions RN 1 used to de-escalate Pt 1’s behavior RN 1 referred to a didactic class on the management of SCU patients which she developed and presented to ED staff. EDM 2 stated the ED leadership approved the content of the didactic. This presentation was reviewed with RN 1. RN 1 stated prior to chemical restraints, she spoke with Pt 1 twice; on the phone. RN 1 stated, “no” she did not speak to Pt 1 at the bedside, about her multiple requests to speak with the doctor. RN 1 stated used the telephone. RN 1 stated nurses, PCTs, POs and SOs can enter the SCU in response to a patient’s requests. RN 1 stated Pt 1 requested, “multiple times” wanting to speak with the doctor. RN 1 stated she believes she messaged the doctor using the hospital approved secure messaging application, and did not recall if she documented this message in Pt 1’s EHR. RN 1 stated the doctor did not come to see Pt 1 but gave an order for lorazepam when RN 1 reported Pt 1 may not be able to complete imaging ordered due to some pacing and visible anxiety. RN 1 clarified, near the end of the concurrent interview and surveillance video review she had identified that she could have used some or more of the de-escalation techniques she has learned, used successfully with other SCU patients and in training other ED staff. During an interview and record review via telephone on 6/12/25 at 10:00 a.m., with ERD and RN 21, RN 21 stated she recalled the event on 5/9/25 involving Pt 1. RN 21 stated on assuming care at the beginning of her shift, Pt 1’s hold was upgraded to a 5150 hold. RN 21 described Pt 1 was a little agitated, upset, and asking why she was in restraints. RN 21 stated Pt 1 was communicating really well. RN 21 stated she let Pt 1 know liberation (removal) criteria for restraints. RN 21 explained she told Pt 1 she would give her 30 minutes to settle a bit explaining that she would then reassess [Pt 1’s] readiness to liberate with Pt 1 verbalizing understanding. RN 21 stated after reassessing, Pt 1 was ready for restraint removal. RN 21 stated she explained to Pt 1 it was important for her to remain calm, for both patient and staff safety. RN 21 stated if a patient refuses medication, her practice is to provide the patient with education about the medication and if they take it great, if they are kicking or hurting staff the nurse communicates with the behavior to the doctor and awaits doctor orders. RN 21 stated when a patient is on a 1779 or 5150 hold, they [patient] do not have the right to leave the facility because they are on a hold. RN 21 stated if medication is ordered emergently, and/or there is a concern for safety (staff or patients/visitors), the patient is put in restraints and the nurse gives the medication. RN 21 stated de-escalation techniques are important, no one wants to be on a hold, not a fun situation, in crisis, how they mentally process is different, keep in mind that they don’t want to be there. RN 21 stated she provides reassurance by explaining that [staff] are there to help them, explain process and all next steps. When they are escalating, feeling a little uneasy, offer what you can. RN 21 stated some cues to escalating behavior is pacing. RN 21 stated she spent a lot of time in the SCU with Pt 1, building a rapport. RN 21 stated after the restraints were removed Pt 1 was calm, RN 21 stated she thinks it Pt 1 did well because of the significant amount of time she spent with Pt 1. RN 21 stated any medication a patient refuses requires the nurse to educate the patient, if the patient continues to refuse, the doctor should be notified. RN 21 stated if a patient becomes violent in the SCU, they always use violent restraints plus a chemical restraint due to risks for harm if they [patients] are fighting. RN 21 stated once the patient falls asleep or becomes drowsy and/or calmer the restraints are removed. RN 21 stated she defines an acceptable level of behavior as the patient no longer displays harm to self or others. RN 21 stated signs a patient has returned to an acceptable level of behavior are the patient can verbalize understanding why they were in restraints, can state they are not going to harm themselves or others, return to appropriate language and calm body language. ERD stated in reviewing the video, she equated the acute psychiatric event to a patient having a seizure (medical emergency). ERD stated the goal is to treat and keep the patient safe while helping them to return to a safe place. ERD stated when Pt 1 pulled the badge reader, the situation became emergent. ERD acknowledged this investigation showed surveillance video review was beneficial for team learning and identified opportunities for improvement. During a review of hospital P&P titled “Use of Force,” dated 3/5/25, the P&P indicated “...I. PURPOSE The purpose of this policy is to provide security officers with guidelines for the legal and proper use of physical force where required to protect the safety of patients, staff, visitors, others and property. II POLICY... Security officers may also use reasonable force if necessary to: A. Stop a patient on a 5150/1799 hold from leaving the facility... he decision to use reasonable force requires careful attention to the facts and circumstances of each particular incident, including the nature of the relationship of the person posing a threat to CHS (e.g., patient, visitor, trespasser), severity of the incident at issue, whether the suspect poses an immediate threat to themselves, the safety of the security officer or others, an immediate threat to CHS property, and whether the force to be used is objectively reasonable to defend against the danger... III. DEFINITIONS...C. Reasonable Force - The amount of force that a reasonable security officer in the same situation would believe is necessary to protect against the imminent danger of bodily injury or unlawful touching, or damage to CMC property... IV. USE OF FORCE CONTINUUM The use of force continuum is a system used by this department to determine the reasonable force in a given situation. If the subject continues to rise in hostility, it may be necessary for the security officer to raise the level of force to counter the actions of the subject for self-defense and/or defense of another and/or defense of property. The possible security officer response levels are as follows: A. Level 1: Officer presence (examples: physical appearance, professional bearing) B. Level 2: Verbal commands (examples: clear and deliberate) C. Level 3: Soft techniques (examples: physical control tactics/wrist locks) D. Level 4: Hard techniques (examples: Tasers/strike points/impact weapons/OC Spray)V. USE OF FORCE FACTORS...A. 1. Whether the patient is attempting to leave the facility, but is on an active hold under Health and Safety Code section 1799 or Welfare and Institutions Code 5150 which would limit his/her freedom to leave. In such cases, the use of physical force should be limited to only that amount of physical force necessary in stopping the individual from leaving the facility...B. The following factors and circumstances should be taken into consideration when using physical force on a suspect (non-patient): 1. Seriousness of the act or crime 2. Size, age and weight of the subject 3. Apparent physical ability of the subject 4. Weapons possessed by or available to the subject 5. Known history of violence by the subject... VI. PROCEDURES A. De-escalation...B . Use of Force General Provisions...3. Reasonable use of force should be discontinued when the danger ceases or when the incident is under control. 4. Physical force shall not be used against individuals in restraints, except as objectively reasonable to prevent a patient on a lawful hold from leaving the facility... or to prevent imminent bodily injury to the individual, the security officer, or another person. In these situations, only the minimal amount of force necessary to control the situation shall be used...” During an interview on 6/12/25 at 9:32 a.m., with the Chief Nursing Officer (CNO), CNO stated when you quoted the abuse information [from the State Operations Manual (SOM- a federal document, issued by Centers for Medicare and Medicaid Services (CMS), containing survey and certification rules and guidance)] “it is very concerning.” CNO stated she expects the RN is in charge with Security responding to the RN’s direction in an assistive capacity. CNO stated the hospital does not currently conduct mock patient take-down drills. CNO stated her expectation was that staff would be communicating with the patient throughout the encounter to ensure the patient understood the plan for care. CNO stated her expectation is that staff would communicate patient requests and needs to the doctor and obtain orders as needed to meet patient needs and requests. CNO stated staff should have been able to provide Pt 1 access to the restroom. CNO stated she expected the nurse to have contacted the doctor and let the doctor know Pt 1 did not have a diet ordered and Pt 1 was hungry and thirsty. CNO stated when Pt 1 stated she did not want the shot, the RN should have discussed Pt 1’s refusal with the doctor for alternatives. CNO stated we [hospital] are always looking to improve. CNO stated the investigation into the events of Pt 1’s SCU visit has shown there are opportunities for process improvement, staff training, and documentation for patients in SCU. During a review of hospital P&P titled “Restraint and Seclusion” dated 3/14/25, the P&P indicated “...”...I. PURPOSE A. To provide a standardized process in the use of restraints and seclusion while protecting and preserving patients’ rights, dignity, safety and well-being. B. To meet and comply with regulatory requirements... II. DEFINITIONS... B. Chemical Restraint: A drug used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. C. Violent Behaviors: Patient is hitting, kicking, being aggressive and/or is a threat to staff or others safety. Any movement intended to harm others. Does not include verbal abuse. D. Violent Restraint: A restraint applied to ensure the immediate physical safety of the patient, a staff member or others... H. Emergency: A situation where the patient’s behavior presents an immediate and serious danger to the safety of the patient, staff, or others... III. POLICY A. Restraint or seclusion should be used only as last resort when a patient has become a danger to self or others and the least restrictive intervention should be used at all possible times. B. Restraints must be discontinued at the earliest possible time once the unsafe situation ends. C. Only Community Behavioral Health Center (CBHC) practices seclusion outlined in this policy. D. Patient Rights 1. All patients have the right to be free from physical or mental abuse, and corporal punishment. 2. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. 3. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. E. Alternatives to the Use of Restraint and Seclusion 1. The use of restraint or seclusion is limited to those situations for which there is adequate and appropriate clinical justification. 2. The use of restraint or seclusion is based on the assessed needs of the patient. Restraint or seclusion may only be used when less restrictive interventions or alternatives have been determined to be ineffective to protect the patient a staff member or others from harm. 3. ... F. Prohibitions on the Use of Restraint or Seclusion 1. The use of restraint or seclusion for the following reasons is prohibited: a. Coercion, discipline, convenience, or staff retaliation b. Solely on the patient’s history of dangerous behavior, if any... IV. PROCEDURE... C.... 3. All patients in restraints are monitored continuously (ongoing, without disruption) through face-to-face observation directly observed one-to-one... 5. Ongoing Monitoring and Assessment Requirements (non-[behavioral health center])...b. Assessment conducted by a licensed RN that has been educated and has documented competency. i. Frequency for violent restraints is at least every two hours. It may be done more frequently based on the individual needs of the patient. ii. Elements: I. Patient’s hydration and circulation. II. Skin assessment for injury at site of restraint. III. Patient’s general care needs including eating, toileting, and range of motion. IV. Patient’s continued need for restraint.... VI. PATIENT & FAMILY EDUCATION A. Patient Teaching...2...Violent and non-violent Restraints... i. Patient education regarding restraints and discontinuation criteria once per shift...” During a review of hospital P&P titled “Patient’s Rights and Responsibilities” dated 3/14/25, the P&P indicated “...I. PURPOSE To define the rights and responsibilities of patients who receive services at [hospital system]...III. POLICY... C. [hospital system] respects the rights of the patient, recognizes that each patient is an individual with unique health care needs, and, because of the importance of respecting each patient’s personal dignity, provides considerate, respectful care focused upon the patient’s individual needs. D. Each hospital affirms the patient’s right to make decisions regarding his/her medical care, including the decision to discontinue treatment, to the extent permitted by law... V. PATIENT RIGHTS... the hospital shall provide processes to support the following patient rights: ... 2. To receive considerate and respectful care, be made comfortable and maintain dignity in a safe setting, free from verbal or physical abuse or harassment... 7. To make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as the patient may need in order to give informed consent or to refuse this course of treatment... 11. To receive confidential treatment of all communications and clinical records pertaining to the care and the stay in the hospital... 12. To be free of unnecessary restraints and seclusion used in the provision of acute medical and surgical care. Restraints are never to be used as means of coercion, discipline, convenience or retaliation by staff. 13. To receive reasonable responses to any reasonable requests made for service... 26. To be free from neglect; exploitation or harassment; and verbal, mental, physical, sexual abuse and corporal punishment... XI. PATIENT TEACHING Inform patients of their rights and responsibilities at time of admission or pre-admission...” During a review of hospital P&P titled “Behavioral Patients in the Emergency Department” dated 9/10/24, the P&P indicated “...I. PURPOSE: A. To assist the Emergency Department staff with the proper management of patients experiencing acute psychiatric disturbances, patients suspected of being under the influence of alcohol and/or drugs, attempted physical harm to self or gravely disabled (“Gravely disabled” means a condition in which a person, as a result of a mental disorder, is unable to provide for their basic personal needs for food, clothing, and shelter... due to psychiatric condition... III. POLICY...D. Patients classified as mental health holds will be placed in a patient care area with adequate supervision depending on medical condition.. F. The provider/licensed staff or Social Worker is responsible for ensuring notification of patients and/or responsible parties unless contraindicated by an order... PATIENT EDUCATION: A. Explain procedures to patient as appropriate...” During a review of hospital P&P titled “Involuntary Detention of Mentally Disordered Persons - 5150/1799 Process,” dated 2/25/22, the P&P indicated “...I. PURPOSE A. To provide the staff at Community Behavioral Health Center (CBHC), Community Regional Medical Center (CRMC), Clovis Community Medical Center(CCMC) and Fresno Heart & Surgical Hospital (FHSH) with guidelines for compliance with the Welfare and Institutions Code (WIC) 5150 guidelines (commonly referred to as the “5150 Process”) as well as the Health and Safety Code (H&S) 1799.111, (commonly referred to as the “1799 Process”)... II. ...F. Emergency: Means “a condition or situation in which an individual has a need for immediate medical attention, or where the potential for such need is perceived by emergency medical personnel or a public safety agency.” (Cal. Health and Safety Code section 1797.70.)... III. POLICY A. The basic tenets of consent law state that all patients have the right to refuse medical treatment independent of whether they are on a psychiatric hold. Thus, if the treating doctor believes such a patient has capacity (i.e., is able to make and understand the implications of this decision...), they may refuse medical treatment. A patient may be involuntarily held according to the 5150 or 1799 provisions for psychiatric care and placement. For patients on a psychiatric hold who lack the capacity to give informed consent for their medical care or have emergent/life threatening conditions, treatment is allowed under the “Emergency Treatment Exception” referenced below found in state consent law.... G. If the individual does not have a mental disorder or does not meet the criteria 5150 process and the 1799 process do not apply and should not be utilized to involuntarily detain the person, regardless of whether the person is a danger to him/herself, danger to others or are gravely disabled....H. It is important to keep in mind with consent to treat medically, the 5150 Process and the 1799 Process do not help you. While you may hold someone against their will under the 5150 statute, this is solely to have them evaluated for the need for a 72 hour hold to evaluate and treat their psychiatric condition. It does not allow you to treat them medically or to medicate them against their will. During a review of the hospital “Standard of Practice for Emergency Department” policy and procedure (P&P) dated 9/23/24, the P&P indicated “...PURPOSE: These Standards of Practice are necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive by the Emergency Departments...of the [hospital system]... POLICY: A. The patient in the ED will receive care in accordance with the Standard of Practice for the ED area. The Standard of Practice categories are adopted by [hospital system’, which the Licensed Nurse must address when caring for each patient. B. Standards of Practice are to form the basis for monitoring and evaluating patient care in the ED... PROCEDURE: A. STANDARD OF PRACTICE: ... The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: ... 2. Adhere to all established [hospital] policies/procedures. 3. Intervene appropriately to correct unsafe situations... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and doctor order. a. Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs. i. Data will incorporate age-specific needs of the patient through the life span. ii. Assessment will reflect the cultural tradition/values of the patient/family. b. The data collection process for assessment is systematic, ongoing, and updated prior to transfer to another level of care and/or home... Evaluate all patients in a timely manner... d. A system specific assessment at the onset of patient treatment with ongoing assessment dependent upon patient condition and response to treatment. e. The data is to include a health history and physical assessment to determine patient’s capabilities, limitations, nutritional, physiological, psychosocial, cultural, and environmental needs/problems... Total intake/output monitored based on order or warranted by condition... 2. Advise the doctor of any alterations in the patient’s psychological and/or physiological condition and any abnormal lab results. 3. Nursing intervention is to be administered in accordance with individual needs of the patient and include other disciplines, private doctor, specialty doctors, social services, special programs, clinics or referral services as warranted... F. STANDARD OF PRACTICE: Skin integrity...Patient Rights... 1. The patient will be involved as actively as possible in planning interventions to maximize health capabilities. The RN will: a. Follow established policies/procedures of [the hospital] when implementing nursing care. b. Implement doctor orders. c. Follow the recommendations for wound management as described in the Corporate Patient Care Policy Manual. d. Maintain and/or improve skin integrity during hospitalization through appropriate nursing interventions. Promote patient comfort, cleanliness, and sense of wellbeing by assisting with activities of daily living (ADL’s- [toileting, dressing, etc.]). e. Reposition patient every 2 hour or more frequently, as needed. f. Obtain a doctor’s order for the use of pressure relieving devices when warranted. g. Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device... Document the nursing interventions/patient responses in the medical record...” According to Celofiga A, Kores Plesnicar B, Koprivsek J, Moskon M, Benkovic D, Gregoric Kumperscak H. Effectiveness of De-Escalation in Reducing Aggression and Coercion in Acute Psychiatric Units. A Cluster Randomized Study. Front Psychiatry. 2022 Apr 7;13:856153. doi: 10.3389/fpsyt.2022.856153. PMID: 35463507; PMCID: PMC9021532, electronically retrieved from https://pubmed.ncbi.nlm.nih.gov/35463507/ on 6/18/25 the article indicated “...Objective: Most guidelines for the management of aggressive behavior in acute psychiatric patients describe the use of de-escalation as the first-choice method, but the evidence for its effectiveness is inconsistent. The aim of the study was to assess the effect of verbal and non-verbal de-escalation on the incidence and severity of aggression and the use of physical restraints in acute psychiatric wards... Results: In the baseline study period, there were no significant differences in the incidence of aggressive behavior and physical restraints between the experimental and control groups. The incidence rates of aggressive events, severe aggressive events, and physical restraints per 100 treatment days decreased significantly after the intervention. Compared to the control group, the incidence rate of aggressive events was 73% lower in the experimental group (IRR = 0.268, 95% CI [0.221; 0.342]), while the rate of severe events was 86% lower (IRR = 0.142, 95% CI [0.107; 0.189]). During the intervention period, the incidence rate of physical restraints due to aggression in the experimental group decreased to 30% of the rate in the control group (IRR = 0.304, 95% CI [0.238; 0.386]). No reduction in the incidence of restraint used for reasons unrelated to aggression was observed. After the intervention, a statistically significant decrease in the severity of aggressive incidents (p < 0.001) was observed, while the average duration of restraint episodes did not decrease ...”Conclusion: De-escalation training is effective in reducing the incidence and severity of aggression and the use of physical restraints in acute psychiatric units. ...” 2. During a concurrent interview and record review on 6/6/25 at 10:17 a.m. with the Emergency Room Director (ERD) the Electronic Medical Record for Pt 6 was opened and reviewed. The document titled “History and Physical, dated 6/1/25 at 5:31 p.m. indicated Pt 6 is a 78-year old woman who came to the hospital on 6/1/25 at 2:30 p.m. with an injury and swelling to her right leg after a fall on 5/27/25. Pt 6 had been seen previously for her leg injury and had been prescribed antibiotics. Pt 6 also had venous insufficiency (not enough blood flowing to her legs) diabetes, and kidney problems. The ERD then opened the hospital document titled “ADT” (Admission, Discharge, and Transfers) which shows where Pt 6 was within the ED during her stay. The ADT indicated Pt 6 was first placed on a gurney at 2:45 p.m. for her initial treatment, then was placed in the hallway at 3:25 p.m. Pt 6 stayed on a gurney in the hallway from 6/1/25 at 3:25 p.m. until 6/3/25 at 6:25 p.m. for a total of 51 hours on a gurney in the hallway. The ERD reviewed documents and stated Pt 6 had an order written on 6/1/25 at 5:19 for inpatient care. was not on a “waffle” - a special overlay that sits on top of the bed to help relieve pain and prevent pressure injuries (bed sores.) The document titled “Pain monitoring” indicated on 6/1/25 at 10:54 p.m. Pt 6 reported her pain level was 10 (on a scale of 1-10, with 10 being the worst pain.) Pt 6 was given a tablet of hydromorphone and acetaminophen (a powerful pain medication) and her pain level came down to 1. On 6/2/25 at 5:22 a.m. Pt 6 had a pain level of 9, which she indicated was in her lower back rather than her leg. Pt 6 was given hydromorphone and acetaminophen again, and this time the reassessment said her pain was “better” but didn’t give a number indicating how sever the pain was. On 6/2/25 at 8:42 a.m. Pt 6 reported her pain level was 8 and no interventions (medication, repositioning, ice, etc) were documented. At 12:40 p.m. Pt 6 had a pain level of 8, this time Pt 6 indicated her pain was in her hip. Pt 6 was again given hydromorphone and acetaminophen, and at 1:20 p.m. her pain level was 5, with no further interventions. The ERD stated if Pt 6 had been in a room instead of the hallway, she may have had more focused attention on her pain, since she reported pain in her leg, back, and hip. DED stated a regular hospital bed may have been more comfortable and she might not have had as much pain. During an interview on 6/12/24 at 9:25 a.m. with Pt 6, Pt 6 stated she was in several different locations in hallways within the ED during her stay. Pt 6 stated she remained on a gurney until she was transferred to a room, and the ED was “very crowded.” Pt 6 stated she felt the nurses were doing the best they could, given the crowded conditions, and that they tried to protect her privacy and dignity while she was in the hallway of the crowded ED. Pt 6 stated she was more comfortable once she was in a room in an actual hospital bed. During a concurrent interview and record review on 6/6/25 at 9:15 a.m. with the Emergency Room Director (ERD) the Electronic Medical Record for Pt 10 was opened and reviewed. The document titled “History and Physical, dated 6/1/25 at 5:31 p.m. indicated Pt 10 was a woman with a history of high blood pressure who had been working in her yard when she got dizzy. She was brought to the hospital by ambulance and found to be dehydrated. She continued to feel dizzy and did not want to open her eyes. On 6/2/25 at 10:08 a.m. an order was written to admit Pt 6 as an inpatient. The ERD then opened the hospital document titled “ADT” The ADT indicated Pt 6 was first placed on a gurney on 6/1/25 at 3:04 p.m. and remained on the gurney until 6/3/25 at 1:27 a.m. for a total of over 33 hours on a hospital gurney. During this time, Pt 10 was in the hallway with lights on above her. The document titled, “Hospitalist History and Physical,” dated 6/2/25 at 4:20 a.m. indicated, “ ...General appearance: Sleepy and Oriented to time, place and person, able to speak in full sentences. Eyes: Not wanting to open her eyes ...” During an interview on 6/10/24 at 2:48 p.m. with Pt 10, Pt 10 stated didn’t remember much about her stay in the ED, but it was crowded, noisy, and the lights were bright. She stated she stayed out in the sun for too long and was dehydrated. Pt 10 stated she felt better once she was in a room where it was quiet, and she could have the lights off. During a concurrent observation, interview, and record review on 6/5/25 at 10:00 a.m. with RN 10 in the ED, Pt 50 was observed in a room inside the ED. RN 10 stated she was assigned 5 patients currently, 2 cardiac progressive care unit patients (CPCU) and 3 medical surgical (m/s) patients. RN 10 opened the EMR for Pt 50 and reviewed the record. The EMR indicated Pt 50 arrived in the ED on 6/3/25 t 2:44 p.m. with flank pain and difficulty urinating, and the order to admit her to the inpatient M/S was received on 6/3/25 at 11:43 a.m. Pt 50 had a history of lung cancer. RN 10 stated that the nearest bathroom to Pt 50 was outside her room, approximately 30-35 feet away, and she could walk to the bathroom using her walker. The document titled “ED Pt Care Timeline indicated, “Mobility: Very limited.” The hospital document titled ADT indicated Pt 50 was on a gurney in the hallway from 6/3/25 at 3:27 p.m. to 6/4/25 at 10:04 p.m., for over 30 hours, before being placed in a room in the ED. The order to admit Pt 50 RN 10 stated while patients are in hallway beds, they have a privacy screen that partially blocks them from view from people walking by. RN 10 stated. “We try our best, but it isn’t ideal. The lights are bright, and it can get noisy. We try to protect their privacy as best we can, but obviously they would be more comfortable if they were on the unit where they could be in a private room receiving more specialized care.” During a concurrent observation, interview, and record review on 6/5/25 at 10:14 a.m. with RN 10 in the ED, Pt 51 was observed lying on a gurney in the hallway with a free-standing divider partially blocking the view of the patient from passersby. RN 10 opened the EMR and stated Pt 51 came into the ED on 6/4/25 at 9:53 a.m. and has “probably been on the same gurney since then (about 24 hours.) The order to admit to M/S was received 6/4/25 at 10:06 a.m. RN 10 stated Pt 51 has an order for a diabetic diet, and she needs encouragement and assistance with eating, which is provided by nursing assistants. RN 51 stated Pt 51 wears a disposable brief (diaper) and needs assistance with cleaning herself. RN 10 stated folding screens are used when they need to change a patient’s brief, and that this was not ideal for privacy. RN 10 stated the lights in the hallway above the gurney cannot be dimmed without dimming all the lights in the ED, and there is a lot of noise in the ED that they can’t do anything about. During a concurrent observation, interview, and record review on 6/5/25 at 10:24 a.m. with RN 10 in the ED, Pt 52 was observed lying on a gurney in the hallway with a free-standing divider partially blocking the view of the patient from passersby. RN 10 opened the EMR and stated Pt 52 came into the ED on 6/4/25 at 9:07 p.m. and “has been on a gurney in the hallway since 1:30 a.m.” HRN 10 stated Pt 52 was a 36 year old man with an infected knee who was admitted as an inpatient for the M/S unit on 6/5/25 at 3:19 a.m. to receive intravenous antibiotics (liquid antibiotic medicine given directly into the vein) for his infection. RN 10 stated Pt 52 can use a urinal by himself and can get to the bathroom with assistance. The nearest bathroom to his gurney is approximately 30 feet away. RN 10 stated it isn’t ideal to have a patient in the hallway where there are bright lights and noise, and only a screen to protect their privacy. RN 10 stated “we do our best, but they would obviously be more comfortable on an actual bed on an inpatient unit.” During an interview with Pt 52 on 6/10/25 at 2:28 p.m., Pt 52 stated “overall, I understand that a lot of patients there were sicker than me. I was on that gurney in the hallway for about 24 hours. It wasn’t comfortable, but I understand. I thought they were going to drain my knee, but they sent me home and told me to follow up as an outpatient. It was noisy, I mean, you can’t really sleep.” Pt 52 stated he plans to do his follow-up care at a different hospital. During a concurrent observation, interview, and record review on 6/5/25 at 10:35 a.m. with RN 10 in the ED, Pt 67 was observed lying on a gurney in the hallway with a free-standing divider partially blocking the view of the patient from passersby. RN 10 opened the EMR and stated Pt 52 was an 89 year old woman who came into the ED on 6/3/25 at 9:01 a.m. for chest pain and high blood pressure and was admitted as an inpatient assigned to CPCU on 6/3/25 at 8:19 p.m. RN 10 stated Pt 67 is alert and can feed herself and can get up from the gurney and go to the bathroom by herself with assistance from staff or family. The nearest bathroom was approximately 40 feet away from the gurney. RN 10 stated Pt 67 doesn’t have as much privacy as she would if she was on the CPCU floor where the physician’s order indicated. RN 10 stated the lights cannot be dimmed above the gurney, and the noise level can get make it hard for patients to relax and sleep. During an interview on 6/10/25 at 3:19 with the daughter of Pt 67, daughter stated she was with her mother, Pt 67 during her stay in the ED. Daughter stated, “Honesty, the care was awful. My mother came in with high blood pressure, and they stuck her on a gurney in a hallway in between two patients who were yelling. The ED was super crowded, and I was worried about germs. It was very chaotic and upsetting. The environment did nothing to help with her high blood pressure.” During a review of the hospital “Standard of Practice for Emergency Department” policy and procedure (P&P) dated 9/23/24, the P&P indicated “...PURPOSE: These Standards of Practice are necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive by the Emergency Departments...of the [hospital system]... POLICY: A. The patient in the ED will receive care in accordance with the Standard of Practice for the ED area. The Standard of Practice categories are adopted by [hospital system’, which the Licensed Nurse must address when caring for each patient. B. Standards of Practice are to form the basis for monitoring and evaluating patient care in the ED... PROCEDURE: A. STANDARD OF PRACTICE: ... The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: ... 2. Adhere to all established [hospital] policies/procedures. 3. Intervene appropriately to correct unsafe situations... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order. a. Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs. i. Data will incorporate age-specific needs of the patient through the life span. ii. Assessment will reflect the cultural tradition/values of the patient/family. b. The data collection process for assessment is systematic, ongoing, and updated prior to transfer to another level of care and/or home... Evaluate all patients in a timely manner... d. A system specific assessment at the onset of patient treatment with ongoing assessment dependent upon patient condition and response to treatment. e. The data is to include a health history and physical assessment to determine patient’s capabilities, limitations, nutritional, physiological, psychosocial, cultural, and environmental needs/problems... Total intake/output monitored based on order or warranted by condition... 2. Advise the physician of any alterations in the patient’s psychological and/or physiological condition and any abnormal lab results. 3. Nursing intervention is to be administered in accordance with individual needs of the patient and include other disciplines, private physician, specialty physicians, social services, special programs, clinics or referral services as warranted... F. STANDARD OF PRACTICE: Skin integrity...Patient Rights... 1. The patient will be involved as actively as possible in planning interventions to maximize health capabilities. The RN will: a. Follow established policies/procedures of [the hospital] when implementing nursing care. b. Implement physician orders. c. Follow the recommendations for wound management as described in the Corporate Patient Care Policy Manual. d. Maintain and/or improve skin integrity during hospitalization through appropriate nursing interventions. Promote patient comfort, cleanliness, and sense of wellbeing by assisting with activities of daily living (ADL’s- [toileting, dressing, etc.]). e. Reposition patient every 2 hour or more frequently, as needed. f. Obtain a physician’s order for the use of pressure relieving devices when warranted. g. Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device... Document the nursing interventions/patient responses in the medical record...” During a review of the hospital “Standards of Practice - Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” P&P dated 9/25/24, the P&P indicated “...PURPOSE These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in the Critical Care, Step-Down/Progressive Care, Telemetry, and Medical/Surgical units...POLICY A. Licensed professionals are accountable for assigned patient care until end of shift, physical transfer, hand-off to another licensed staff member, or patient discharge.... B. If there is a difference between the physician order and the standards below, the one that is stricter will be followed (e.g. physician orders intake and outputs measured every 12 hours, but unit standard is every 8 hours; the unit standard will be followed)... E. Reposition patients who are unable to do so themselves every 2 hours or more frequently, while assessing the condition of the patient’s skin. F. Progressive mobility will be instituted utilizing the approved mobility assessment tool. G. Appropriate arrangements may be made to accommodate time outdoors for patients as clinically appropriate according to the patient’s stability level and plan of care... STANDARDS See Standards of Practice Documentation Grid...” The Joint Commission Journal on Quality and Patient Safety article titled, titled “No More Useless Band-aids that Fail to Solve America’s Emergency Department Boarding Crisis,” dated 12/2023 retrieved 6/24/25 from https://www.jointcommissionjournal.com/article/S1553-7250(23)00234-9/fulltext indicated, “The causes of boarding as well as many proposed solutions have been well described. However, the suggestions are band-aid solutions such as changing ED workflow, surgical schedule smoothing, and alternate care sites, and none of them will alleviate boarding and its harms. Boarding is the manifestation of a dysfunctional health care system with misaligned financial incentives. It is a direct consequence of the United States’ patchwork, profit-driven health care system, not attributable to any single hospital or health care organization. While daily admissions from the ED will vary somewhat, the typical number can be easily determined from the ED’s historical records. Beds could easily be reserved for these anticipated admissions, and remaining beds could be allocated to elective admissions. Predicting the daily admission needs for the ED to function and serve the community is not a difficult task. We lack the will to do this, not the ability to make it happen. The lack of will arises from hospital administrators having no incentive to reserve space for ED admissions when they can allocate beds to elective admissions that generate higher profit. In both for-profit and not-for-profit ...” hospitals-which account for the overwhelming majority of annual acute inpatient admissions in the United States-the C-suite is tasked with remaining fiscally solvent. To do so, they favor patients with the kinds of insurance and the kinds of medical conditions that provide lucrative reimbursement for short lengths of stay. In following this strategy, admitted ED patients are queued up in the ED, occupying rooms and halls that need to be available to the patients in the ED waiting room. Consequently, our healthcare system caters better to a regional patient in need of advanced oncology therapy, organ transplant, or complex surgery than a local community member who presents to the ED with pneumonia or congestive heart failure who may find that emergency medical services cannot take them to their preferred hospital because its ED is diverting due to saturation. Boarding is a driver of ambulance diversion and leads to further inequities and disparities.15-21 Our healthcare system does not value care of the most vulnerable.22 While many factors contribute to the lack of acute inpatient psychiatric stabilization beds, a reimbursement system that undervalues such care is a major factor.23 Individuals suffering a mental health crisis experience some of the most egregious prolonged boarding in EDs awaiting acute inpatient psychiatric beds 24-27. The American College of Emergency Physicians policy statement titled, “Boarding of Admitted and Intensive Care Patients in the Emergency Department,” revised February 2023, retrieved 6/24/25 from https://www.acep.org/siteassets/new-pdfs/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department.pdf, indicated, “ ... Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Once admitted, patient care is most effectively and safely delivered on inpatient units. Boarding of admitted patients in the ED represents a hospital-wide failure and contributes to lower quality of care, decreased patient safety, reduced timeliness of care, reduced patient satisfaction, an increased number of patients leaving without being seen, and increased mortality. Additionally, it directly contributes to ED crowding due to the resultant loss of bed and resource capacity. ED crowding and its negative impacts on patients are due to misaligned health care economics and financial pressures on hospitals ...” The Journal of Academic Emergency Medicine article titled, “The Association Between Length of Emergency Department Boarding and Mortality” retrieved 6/24/25 from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2011.01236.x, indicated, “ ...ED boarding occurs when insufficient hospital capacity is available for admitted patients to be transferred to inpatient beds. The result is that admitted patients remain in the ED, sometimes for long periods. The concern is that due to competing demands by other patients and general system overload, boarders do not receive the same level of care that they would in inpatient beds. Several recent articles have identified safety issues with boarding, including adverse events, higher rates of ventilator-associated pneumonia, higher mortality rates for intensive care unit (ICU) patients per se, and for admissions overall. There are also higher rates of medication errors and preventable adverse events ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 40644 Based on interview and record review, the hospital failed to recognize, investigate, and set clear expectations regarding the inappropriate use of excessive force on one (1) of seventy-two (72) sampled patients (Pt) 1, when Pt 1 was admitted to the special care unit (SCU- a locked unit within the Emergency Department), for evaluation for unusual verbal statements. Pt 1 was calm and was not physically aggressive when Emergency Department (ED- a hospital outpatient department that provides immediate medical care to patients with urgent or life-threatening conditions) staff and hospital Security Officers (SOs) performed a physical takedown (a physical maneuver or intervention to restrain or control a person, often in a potentially violent or combative situation) to restraint and administered medication against Pt 1’s verbal refusal. The interventions was not in accordance with the hospitals policies and procedures. The hospital did not conduct an investigation into the use of excessive force and no preventative measures were implemented. This failure resulted in the hospital’s inability to recognize the inappropriate use of force, analyze the underlying causes of the incident, and implement necessary corrective actions and oversight to prevent reoccurrence and placed patients in the ED’s behavioral unit at continued risk for harm from improper use of force or restraint. Findings: During a review of an Entity Reported Incident (ERI) submitted to the California Department of Public Health (CDPH) on 5/13/25, the ERI indicated “...Date of Alleged Event: 5/9/25... Description of Event and additional details: During chart review on 5/12/25, documentation by ED Registered Nurse (RN) on 5/10/25 found in the chart that stated the following: patient had confided in staff member that during episode when she was placed in restraints an officer had touched her breast inappropriately three times.” Pt discharged on 5/11/25...” During an interview and video surveillance review on 6/9/25 at 2:04 p.m., with Patient Care Technician (PCT) 1 and SO 1, a video dated 5/9/25 at 6:23 p.m. was reviewed. The footage was from the ED SCU, specifically area 5. The surveillance video showed Pt 1, who was not exhibiting violent physical behavior, was subjected to significant physical force when security officers forcibly grabbed her by the arms, dragged her to a gurney, and, with the help of additional staff, held her down to apply wrist and ankle restraints; despite her continued resistance and verbal objection, Pt 1 was then administered medication, all without clear evidence of de-escalation efforts from staff. SO 1 stated he was assigned to the SCU on 5/9/25, and SO 2 came to help while checking the ED. SO 1 stated that the role of security in the SCU was to calm patients down and get them to follow directions, using techniques from there crisis prevention intervention (CPI) training. SO 1 stated Pt 1 started to act aggressively, but he could not remember exactly what Pt 1 was saying. SO 1 stated Pt 1 did not want to sit down and had just finish changing her clothes. SO 1 stated he thought Pt 1 got upset because she was not allowed to keep her necklace in the SCU, and her belongings were locked away. SO 1 stated as soon as he and SO 2 opened the interior door, Pt 1 tried to rush through it. SO 1 stated he may have said something to Pt 1 like “calm down” or “relax” but the video did not capture any of this as no therapeutic communication could be heard on the audio. PCT 1 stated his job on 5/9/25 was to help nurses with patient care in the SCU. PCT 1 stated he was new to working in the ED and not yet familiar with de-escalation techniques. PCT 1 stated he had received some training from Registered Nurse (RN) 1 on how to care for SCU patients, but he had not completed the CPI course. SO 1 stated things are different when working at the ED SCU compared to the hospital’s Behavioral Health Center Facility. SO 1 stated at the Behavioral Health Center Facility, there’s more support; clinical staff had more training in de-escalation and CPI, and they also have their own defensive tactics training. PCT 1 and SO 1 stated in their own opinion, the incident with Pt 1 seemed routine, and they did not see anything that concerned them. During an interview and review of surveillance video on 6/9/25 at 2:48 p.m. with the Emergency Room Director (ERD) and the Director of Risk Management (DRM), the ERD stated the hospital had completed the investigation into Pt 1’s sexual abuse allegation, and the review of the video footage showed that no sexual abuse occurred. The DRM stated no investigation or root cause analysis (RCA- It’s a structured method used to investigate adverse events or near misses in healthcare to identify the underlying causes and prevent recurrence) was done regarding the concern of excessive force used on Pt 1. The DRM stated the hospital’s investigation focused only on the sexual abuse allegation and did not address the use of physical force during the incident. During an interview on 6/11/25 at 9 a.m., with the quality assurance and performance improvement (QAPI) review meeting with the Interim Vice President of Operations (IVPO), the Chief Nursing Officer (CNO), The Director of Quality Outcomes (DQO) and the Emergency Department Director (ERD), the CNO stated she did not watch the video of the incident until after the survey team raised concerns about possible use of excessive force to Pt 1. The ERD stated he had reviewed the video earlier, but her focus was on Pt 1’s complaint about inappropriate touching of her breast. The ERD stated the hospital determined that inappropriate touching did not occur. The ERD stated she did not initially notice the hospital staff might have use excessive force when trying to restraint Pt 1. During an interview on 6/12/25 at 9:32 a.m., with the chief nursing officer (CNO), the CNO stated the hospital was always looking to improve, and after learning more from the staff interviews, they need to review the video including the events before and after an incident to have the full context. The CNO stated The hospital does not currently run drills to prepare for situations like physical take downs. The CNO stated after reviewing the video, she saw many areas or the hospital could improve, such as better communication with patients, and how staff handled the situations. The CNO stated there are clear opportunities to improve staff training on de-escalation techniques in the SCU. During a review of hospital document titled, “Quality Performance Excellence Plan Fiscal Year 2025,” the document indicated, “ ...[hospital] aims to deliver exceptional healthcare to our patients through staff engagement, a commitment to continuous improvement, and performance excellence ...Leadership commitment, promoting a culture of safety, and application of robust performance improvement... the goals are in alignment with quality assurance performance improvement (QAPI) program, which includes, but not limited to : b. patient safety strategies ... Attachment B ...In order for an organization to become a HRO, the organization must incorporate a commitment to continuous performance improvement into its culture and operations ... Attachment C Root Cause Analysis: An RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process gives you a way to identify system vulnerabilities so that they can be eliminated or mitigated. The purpose is to find out what happened, why it happened, and determine what changes need to be made ...””

“PROVIDING ADEQUATE RESOURCES CFR(s): 482.21(e)(4) [The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following:] (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital’s performance and reducing risk to patients. This Standard is not met as evidenced by: 40644 Based on observation, interview and record review, the hospital failed to have an effective Quality Assurance and Improvement Program (QAPI-a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in healthcare settings) to resolve the long-standing problem of the hospital practice to provide care to inpatients in the Emergency Department (ED-an outpatient hospital department that provides immediate medical care to patients with urgent or life-threatening conditions). The QAPI program has not implemented actions to sustain improvement. This failure resulted in 1,217 patients receiving all of their inpatient care in the ED between 1/1/25 and 5/31/25 and had the potential to not meet the physician ordered inpatient needs and the comfort needs of the patients. Findings: During an interview on 6/11/25 at 9 a.m. with the Interim Vice President of Operations (IVPO), the Chief Nursing Officer (CNO), The Director of Quality Outcomes (DQO) and the Emergency Department Director (ERD), the QAPI goals was discussed. The IVPO stated he was ultimately responsible for the QAPI goals of reducing the number of patients who have to wait in the ED for a hospital bed after being admitted- these are called “boarding patients”. The IVPO stated the goal was to have patients wait no more than eight-hours in the ED after the admission order was given. The IVPO stated the current ED average wait time for an inpatient bed was 25.4 hours after the admission orders had been received. The IVPO stated meeting the eight-hour goal for all patients could take 12 to 18 months. The CNO stated the hospital does not plan to add more beds but instead plans to meet the goal by making their current process more efficient. During a review of a document titled, “18-Month Plan to Reduce ED Boarding to Under Eight Hours” provided by the IVPO on 6/12/25, the document indicated, “Goal: Reduce average ED boarding time from 25.4 hours to under 8 hours by December 2026, with a primary focus on throughput optimization, clinical workflow redesign, and real-time operational accountability.” During a review of a document titled, “Percent of Patients Boarded in [hospital name] ED for less than 8 hours” provided on 6/12/25, the document indicated for the month of May 2025, 18% of patients were boarding for less than 8 hours (82% of boarding patients exceeding 8 hours) in the ED. The document indicated, “January 1, 2025 - May 31, 2025: ED Discharges: 1,217.” This document indicated it was prepared by the Interim Vice President of Operations.”

“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: 45929 Based on observations, interviews, and record reviews, the hospital failed to develop and maintain individualized care plans (CP-a document that outlines a patient’s health conditions, treatments and other information to guide their care and ensure continuity) for patient six and patient 15 that accurately reflect their specific needs as required by hospital policy when: 1. Pt 6’s CP did not include important details about her pain location, effective medications, or other pain management interventions. This failure could potentially result in poor pain control and delayed treatment. 2. Pt 15’s CP did not identify her as non-English speaker or address her communication needs to ensure she fully understands her care. This failure could potentially lead to miscommunication, misunderstanding about treatment, medications errors and reduced patient safety. Findings: 1. During a concurrent interview and record review on 6/6/25 at 10:17 a.m. with the Emergency Room Director (ERD), Pt 6’s Electronic Medical Record (EMR) was reviewed. The document titled “History and Physical (H&P),” dated 6/1/25 at 5:31 p.m. indicated Pt 6 was a 78-year-old female who came to the hospital on 6/1/25 at 2:30 p.m. with an injury and swelling to her right leg after a fall on 5/27/25. Pt 6 had been seen previously for her leg injury and had been prescribed antibiotics. Pt 6 also had other health issues, including venous insufficiency (not enough blood flowing to her legs) diabetes (a disease where the body has trouble regulating blood sugar levels), and kidney problems (any condition where the kidneys are damaged or not functioning properly). The ERD stated Pt 6 had a physician order on 6/1/25 at 5:19 for inpatient care. The ERD reviewed Pt 6’s document titled “Pain monitoring”. The pain monitoring dated 6/1/25 at 10:54 p.m. indicated Pt 6 reported a pain level of 10 (on a scale of 1-10, with 10 being the worst pain) on her lower legs. Pt 6 was given a tablet of hydromorphone and acetaminophen (a powerful pain medication) and her pain level dropped to a one. On 6/2/25 at 5:22 a.m. Pt 6 reported a pain level of 9, this time in her lower back. Pt 6 was given hydromorphone and acetaminophen, and her pain reassessment was noted as “better” but no number was recorded indicating how sever the pain was. On 6/2/25 at 8:42 a.m. Pt 6 reported her pain level was 8 and no treatments were documented. At 12:40 p.m. Pt 6 reported a pain level of 8, now on her hip. Pt 6 was given hydromorphone and acetaminophen, and at 1:20 p.m. her pain level was 5, with no further interventions. The ERD reviewed Pt 6’s pain management CP titled, “Control of Acute Pain” and “Reduced Pain Sensation” started on 6/2/25 at 6:11 a.m., the care plan did not indicate where the pain was located, what medications help, or if any other treatments were used. The ERD stated there should have been more detailed information for Pt 6’s pain, especially since she reported pain in different areas. The ERD stated the CP should be individualized and focused on Pt 6’s specific needs. During an interview on 6/12/24 at 9:25 a.m. with Pt 6, Pt 6 stated she was in a lot of pain while she was in the hospital, mainly in her leg, but her back also hurt. Pt 6 stated she was given pain medication, which helped with the pain. 2. During a concurrent interview and record review on 6/6/25 at 10:32 a.m. with Emergency Department Manager (EDM) 1, Pt 15’s EMR was reviewed. The EMR indicated Pt 15 spoke Spanish and needed an interpreter. EDM 1 stated Spanish was considered a communication barrier for Pt 15. Pt 15’s CP dated 6/2/25 to 6/3/25, was reviewed. EDM 1 stated Pt 15’s CP did not indicate any communication barrier. During a concurrent observation and interview on 6/6/25 at 1:16 p.m. in Pt 15’s room, Pt 15 was alert and sitting up in bed. Pt 15 was asked in Spanish if she speaks and understands English. Pt 15 shook her head “no”. During an interview on 6/12/25 at 9:30 a.m. with the Chief Nursing Officer (CNO), the CNO stated it was important to identify and address communication barriers so staff could properly explained care to patients. During a review the hospital policy & procedure (P&P) titled, “Interpreters/Translation: Non-English/limited English Proficient & Deaf/Hearing Impaired”, dated 6/14/24, the P&P indicated, “ ... Providing care/service to the patient requiring interpreter services ... Incorporate the communication barrier on the patient’s plan of care ...”. During a review of a professional reference titled, “Safety first: The importance of interpreters & translated documents in preventing patient harm”, the reference indicated, “ ... When used effectively, interpreters and translated documents not only enable providers to communicate with their LEP [limited English proficiency] and NEP [non-English proficiency] patients, but also help promote patient safety by preventing medical errors and patient harm, which will minimize health disparities within this population ... open communication channels with their provider allows these patients to truly be in the center of their care ...”. During a review of the hospital’s Policy and Procedure (P&P) titled, “Interdisciplinary Plan of Care”, dated 10/12/23, the “P&P indicated, “ ... PURPOSE ... C. To promote interdisciplinary collaboration in order to develop a Plan of Care that is individualized, age and developmentally appropriate, and takes into consideration the physical, psychosocial, spiritual, and cultural needs of the patient and their family ... PROCEDURE ... 3. Initiate the Plan of Care based on the patient’s comprehensive assessment and medical care of the provider responsible for the patient ... Document the Interdisciplinary/Nursing Interventions when identified ... Activate interventions for the problems identified based on patient assessment ... For outcomes not met, develop and document an action plan such as notification of provider, change in interventions, or new orders ...”.”

“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: 40644 Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital’s policies and procedures (P&P), when: 1. The nursing staff failed to do a head-to-toe assessment (HTTA-thoroughly examine the body) for one of 10 patients (Pt 3) when Pt 3 was brought to the emergency department (ED- provides immediate medical care to patients with urgent or life-threatening conditions) by ambulance after a motorcycle accident and the nurse did not remove his clothing to check for injuries and did not listen to his heart, lungs, and abdominal (stomach area) sounds (an assessment using a stethoscope [a device used to listen to sounds inside the body] helps the nurse listen to the heart, lungs, and stomach to check if the body is working normally). This failure had the potential to result in Pt 3 not receiving prompt care for his broken wrists, broken clavicle (collar bone) and scrapes on his body from contact with the pavement and had the potential to delay treatment of major injuries that could be hidden under his clothing. 2. Three of three patients (Patient (Pt) 2, Pt 21 and Pt 22) did not have their skin assessed and documented each shift by ED nursing staff, and Pt 21 did not have a dual nurse skin assessment when transferred to another patient care area per hospital P&P titled, “Pressure Injury Risk Assessment, Prevention, Staging and Treatment”, “Admission & Ongoing Assessment - Nursing (Acute Care)”, and “Documentation in the Health Record”. These failures placed Pt 2, Pt 21, and Pt 22’s skin at risk for further breakdown, and was the potential cause for Pt 2’s hospital acquired (developed during hospital stay) stage 3 (full thickness) pressure injury (PI -damage to the skin and underlying tissue caused by prolonged pressure) to the coccyx (tailbone). 3. One of 10 patients (Pt 22) admitted as an inpatient and held in the ED, did not have a head-to-toe assessment completed by ED nursing staff after being admitted as an inpatient, according to hospital P&P titled, “Admission & Ongoing Assessment - Nursing (Acute Care)”. This failure placed Pt 22 at risk for nursing staff to miss a change of condition by not having a baseline assessment. 4. Two out of 10 sampled patients (Pt 2 and Pt 21) admitted as inpatients to the hospital and held in the Emergency Department (ED) were not provided hygiene care while in the ED according to hospital Policy and Procedure (P&P) titled “Oral Care”, and the “Patient Care Tech 1 Job Description”. These failures had the potential to increase Pt 2 and Pt 21’s risk of infection, and risk for skin breakdown. Theses failure also had the potential to decrease Pt 2 and Pt 21’s self-esteem, and sense of dignity (self-worth). 5. One out of 10 sampled patients (Pt 2) did not receive a meal or snacks while admitted and held in the ED on 3/27/25 according to physician order. This failure had the potential to cause weakness, weight loss, and compromise his immune system leading to an increased risk of infections. 6. For two of twelve patients (Pt 2 and Pt 21) a nutritional risk screening was not completed or was not completed accurately by nursing staff within 24 hours of admission according to the hospital’s P&P titled, “Nutritional Care and Documentation in the EHR [Electronic Health Record].” These failures had the potential to delay a Registered Dietitian (RD) for medical nutrition therapy for Pt 2 and Pt 21. This delay could lead to a range of serious consequences, including delayed illness recovery, poor wound healing and weight loss. 7. The hospital failed to ensure an enteral feeding (a method of providing nutrition directly into the gastrointestinal tract through a tube) was labeled with the date and time of change for one of two patients (Patient 65) in accordance with hospital P&P. This failure had the potential to result in the use of expired or contaminated formula, increasing the risk for infection or compromised nutritional support. Findings: 1. During an interview on 6/2/25 at 8:45 a.m. with the mother of Pt 3 (M3), M3 stated she was called to the scene of the motorcycle accident on 5/9/25 and arrived in the ED soon after the ambulance that brought Pt 3 to the ED. M3 stated she is a registered nurse at a different hospital, and she was in the ED with Pt 3 while he was waiting for treatment. M3 stated at no time did any nurse listen to Pt 3’s heart, lungs, or abdomen, nor did anyone ask him to remove his clothing so his body could be examined. During an interview on 6/4/25 at 2:38 p.m. with Emergency Department Manager (EDM) 1, EDM 1 opened the Electronic Medical Record (EMR- is a digital version of a patient’s paper chart, containing medical history, diagnosis, and medication) for Pt 3. EDM 1 stated the chart indicated Pt 3 arrived in the ED on 5/9/25 at 5:17 p.m. with multiple fractures (many broken bones), ESI level of 2 (Emergency Severity Index (ESI) is a tool used in emergency departments to determine how sick or injured a patient is, with level one (1) being the most critical and level 5 being not very sick or injured at all.) EDM 1 stated the EMR indicated Pt 3 had been in a motorcycle accident. EDM 1 was unable to find documentation of a physical assessment, including no documentation that a nurse listens to Pt 3’s heart, lungs, or abdomen, or removed his clothing to look for other injuries. EDM 1 stated, “it looks like we didn’t do a physical assessment. “We didn’t strip him and flip him.” EDM 1 explained this as the standard process of removing all clothing from a patient’s body and checking the entire body for injuries, which she would expect for a patient who had been in a motorcycle accident. During an interview on 6/5/25 at 8:05 a.m. with RN 16, RN 16 stated she was the first nurse assigned to Pt 3 after triage (a system for quickly assessing a patient upon arrival to determine the severity of their condition and priority of their care). RN 16 stated her shift on 5/9/25 started at 7 a.m. and would end after she gave report to the oncoming nurse between 7 p.m. and 7:30 p.m. RN 16 stated she was assigned to care for Pt 3 “towards the end of her shift.” RN 16 stated Pt 3 was alert and walking around, “if I had tried to put him in a gown, I think he would have refused.” RN 16 stated she did not recall asking Pt 3 to remove his clothing to allow her to do a more thorough examination. RN 16 stated Pt 3 had an intravenous line (is a small tube put into a vein to give medicine or fluids directly into the body), which was placed by the ambulance staff prior to arrival in the ED. RN 16 stated Pt 3’s mother was with him in the ED and asked to speak with the doctor. RN 16 stated she contacted Medical Doctor (MD) 1, who was assigned to Pt 3. MD 1 ordered pain medication for Pt 3 but did not come to see Pt 3 immediately. During a concurrent interview and record review on 6/10/25 at 7:30 a.m. with Registered Nurse (RN) 15, RN 15 accessed and reviewed her own notes in the EMR. RN 15 stated she was assigned to care for Pt 3 when her shift started on 5/9/25 at 7 p.m. RN 15 stated she was assigned in the “Red Zone” which she described as the area where critically ill patients are placed. RN 15 stated this was an appropriate location within the ED for Pt 3 because he had been in a motorcycle accident, and he had an ESI of 2. RN 15 could not find documentation to indicate she had done a physical assessment to check for other injuries to Pt 3. RN 15 stated she did not listen to Pt 3’s heart, lungs, or abdomen, and did not remove Pt 3’s clothing to examine him. RN 15 stated her documentation showed she first saw Pt 3 on 5/9/25 at 7:35 p.m. During an interview on 6/10/25 at 11:30 with MD 1, MD 1 stated he had recently reviewed the EMR for Pt 3 and remembered the patient. MD 1 stated he started the medical screening exam right after the ambulance brought Pt 3 at the hospital. MD 1 stated he remembered Pt 3 was alert, oriented, and able to speak clearly and described his accident. MD 1 stated Pt 3 was not having any difficulty breathing, his abdomen felt soft, and his head and neck could move normally, so he wasn’t concerned of getting an immediate image of Pt 3’s head and neck. MD 1 stated he remembered Pt 3 had tenderness to his wrists, so he ordered an x-ray of the wrists. MD 1 stated he received a call from the RN caring for Pt 3 asking him to come and talk with Pt 3’s mother, but at the same time, the ED had a “code white” (a baby wasn’t breathing) with another patient. MD 1 stated he ordered pain medication for Pt 3 and told the nurse he would come to check on Pt 3 as soon as possible. During a review of hospital document titled “Physician Emergency - ED Provider Note,” signed by MD 1 dated 5/9/25 at 5:43 p.m., the note indicated, “35 y.o. (year old) male brought in by ambulance for complaints of multiple abrasions (scrapes), bilateral (both sides) wrist pain, R (right) clavicle (collar bone) pain with deformity (misshaped due to break), and mid back pain s/p (after) solo motorcycle accident this evening. States he was the solo rider driving approximately 10 MPH when he lost control of the motorcycle. He was lay the bike onto the road. Denies loss of consciousness (didn’t pass out). He was wearing a helmet. No shortness of breath, nausea, or vomiting. During a review of hospital policy titled, “Standard of Practice for Emergency Department,” dated 0/23/24, the policy indicated, “ ... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order, a. Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs. During a review of hospital policy titled “Triage,” dated 9/20/24, the document indicated, “ ...PURPOSE: A. To promptly identify patients with an emergency medical condition at [name of hospital]. B. To determine the appropriate area for treatment. C. To facilitate patient flow through the Emergency Department (ED). D. To provide initial assessment of arriving patients. E. To decrease door to provider times. F. To facilitate the treatment of patients within the ED. During a review of hospital policy titled, “Emergency Severity Index Policy” dated 9/10/24, the document indicated, “PURPOSE: To provide guidelines for all patients presenting to the Emergency Department. All patients presenting to the Emergency Department will undergo an Emergency Severity Index Assessment by the triage nurse to initiate a Medical Screening Examination and determine the timing, urgency and appropriate location in the ED for completion of the Medical Screening examination and disposition of the patient. DEFINITION: Emergency Severity Index (ESI): The ESI is a 5-level Emergency Department Triage algorithm that sorts patients into 5 groups from 1 (Immediate) to 5 (non-urgent) based on predicted acuity and resource needs. POLICY: Patients will have the Emergency Severity Index (ESI) assessment at the Triage area of the Emergency Department or within the treatment area of the Emergency Department. PROCEDURE: The triage nurse will categorize the patient into one of the following five (5) ESI Levels. The levels will be determined by using the following: Index Level Definitions, Data Base, and ESI algorithm. Index Level Definitions: ESI Level 1 - Immediate; ESI Level 2 - Emergent ...” The California Code of Regulations, Title 22, Section 70215 states “a registered nurse shall directly provide: ongoing patient assessment as defined in the Business and Professions Code, Section 2725(d). Such assessments shall be performed, and the findings documented in the patient’s medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area.” The California Nursing Practice Act, Business and Professions Code Chapter 6, Section 2725(d), defines an assessment as an observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. 49884 2. During a concurrent interview and record review on 6/5/25 at 11:15 a.m. with Nurse Manager (NM) 3, NM 3 opened Pt 2’s EMR and stated, Pt 2 arrived in the ED on 3/27/25 at 5:53 a.m., with a complaint of being unable to urinate (pee). Pt 2’s hospital document titled, “History and Physical (H&P-an assessment from physician including medical history and exam),” dated 3/27/25, was reviewed. The “H&P” indicated Pt 2 had a complaint of scrotal (the sack of skin and muscle that holds the testicles outside the body) swelling the size of a grapefruit and urinary retention (unable to urinate). NM 3 stated Pt 2 had a past medical history (PMH) of benign prostatic hyperplasia (BPH-the prostate gland [walnut-sized gland located in the male reproductive system, just below the bladder] enlarges). NM 3 stated Pt 2 was admitted to the hospital as an inpatient for a perianal fistula (an abnormal tunnel-like connection between the anal canal and the skin surrounding the anus) and urinary tract infection (UTI- a bacterial infection that occurs when bacteria enter the urinary tract and multiply). NM 3 reviewed Pt 2’s hospital document titled, “Admit Discharge Transfer Log (ADT)”, which showed where Pt 2 was moved throughout his hospital stay. NM 3 stated Pt 2 was moved to the inpatient Medical Surgical (MS) Unit (patients with a variety of medical and surgical conditions receive care) on 3/28/25 at 2:55 p.m. The “ADT” indicated, Pt 2 had physician inpatient admit orders but stayed in the ED for 27 hours and 31 minutes before transferred to the MS unit. NM 3 reviewed Pt 2’s hospital document titled “Skin Integrity Accordion [SIA],” dated 3/27/25 to 4/3/25. The “SIA” indicated, Pt 2 did not receive a complete skin assessment, including, “skin integrity [healthy and intact state of skin]”, “activity”, “Braden Scale [an assessment tool used in healthcare to determine risk of developing PI [pressure injury] scored from 6-23 lower number indicates higher risk]”, and “Hygiene”, until Pt 2 was moved to the inpatient MS unit on 3/28/25. The “SIA” indicated, ED RNs did not perform an admission skin assessment on 3/27/25. NM 3 stated the night shift ED RNs on 3/27/25, and the day shift ED RNs on 3/28/25 did not perform a complete skin assessment. NM 3 stated the ED RNs should have performed a complete skin assessment during admission assessment and every shift. NM 3 stated on 3/28/25 at 3:30 p.m. the MS nurses documented Pt 2 had a discoloration to coccyx and swelling to the scrotum. NM 3 stated no photos were taken of the coccyx discoloration because nurses usually do not take photos of discoloration. NM 3 stated on 4/2/25 at 9 p.m. the MS nurses discovered a stage 3 PI on Pt 2’s coccyx. The “SIA” indicated “intact” skin and scrotum swelling from 3/29/25 to 3/31/25. NM 3 stated, MS nurses documented an incision to the scrotum and penis on 3/31/25. NM 3 stated Pt 2 had a darker pigmented skin tone, which may have made it harder to spot early signs of deep tissue injury (DTI - a type of PI where damage occurs to underlying tissues, but the skin may appear intact or only slightly discolored and can progress into a full thickness wound if not addressed promptly) on Pt 2’s coccyx. NM 3 stated the DTI may have developed to a stage 3 PI. NM 3 stated Pt 2 was able to walk and shift positions but was reluctant to do so because of pain and swelling to the scrotum. NM 3 stated nursing notes indicated staff often found Pt 2 in the same position during rounds (when medical staff check on patients). NM 3 stated Pt 2’s stage 3 PI was preventable and a full skin assessment in the ED could have started early prevention interventions which was not done. NM 3 stated MS nurses knew Pt 2 was not walking much or shifting his weight in bed but did not adjust care plan interventions to prevent the PI from progressing or catch signs of the PI getting worse. NM 3 stated Pt 2 should have been placed on a specialty bed designed to prevent bed sores or PI but was not. NM 3 stated on 4/3/25 Pt 2 was provided a specialty bed. During a concurrent interview and record review on 6/9/25 at 9:30 a.m. with Emergency Department Manager (EDM) 2, Pt 2’s hospital document titled “Emergency Department Timeline [EDT]”. The “EDT” indicated, on 3/27/25 at 7:45 p.m. a HTTA was completed but no comprehensive skin assessment was documented. EDM 2 stated Pt 2 had a Braden Scale Score (Scores are from 6 to 23, lower number indicates higher risk) completed without a documented skin assessment. EDM 2 stated he was unable to find a documented skin assessment for Pt 2 while in the ED. EDM 2 stated there should been a skin assessment documented in Pt 2’s Medical Record at the time of admission on 3/27/25, and one for the night on 3/27/25 and the morning shift of 3/28/25. EDM 2 stated a comprehensive skin assessment in the ED was important to have a baseline and identify any wounds or skin issues early, to initiate appropriate wound care interventions. EDM 2 stated skin assessment should have been done every shift in the ED but was not. During a concurrent interview and record review on 6/5/25 at 2:56 p.m. with NM 2, Pt 21’s EMR was reviewed. NM 2 stated, Pt 21 arrived in the ED by ambulance from a Skilled Nursing Facility (SNF-a type of healthcare facility that provides 24-hour skilled nursing care and rehabilitation services to individuals who require medical care and support after a hospital stay, but do not need the intensive level of care provided in a hospital) on 5/24/25 at 3:50 p.m. NM 2 reviewed Pt 21’s hospital document titled, “H&P”, dated, 5/25/25, NM 2 stated Pt 21 was a 74-year-old admitted with altered mental status (AMS- confusion or changes in thinking or behavior) and Failure to Thrive (FTT -a serious decline in physical and mental function with weight loss, poor appetite, and reduced activity levels), chronic hypoxic respiratory failure (a condition where the lungs don’t properly oxygenate the blood) on home oxygen, diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), and was bedbound (confined to bed) with weakness of lower legs. NM 2 stated Pt 21 had physician’s inpatient admit orders on 5/25/25 at 12:55 a.m. and was transferred to the Stepdown Unit (a unit bridging the gap between the intensive care unit (ICU) and the general MS floor) on 5/26/25 at 4:30 p.m. NM 2 reviewed Pt 21’s “SIA”, and stated, ED RNs did not document a nightshift skin assessment on 5/25/25. NM 2 stated, the Stepdown RNs did not document a two-person skin assessment on 5/26/25, as required by the hospital policy. NM 2 stated RN 2 admitted Pt 21 to the Stepdown Unit on 5/26/25 at 4:41 p.m. but did not document a skin assessment. NM 2 stated RN 2 should have completed a two-person skin assessment with another nurse upon admission to the unit. NM 2 stated a two-person skin assessment allowed nurses to have a second set of eyes to look for skin breakdown on patients. NM 2 stated the first documented skin assessment in the Stepdown unit was completed later that night on 5/26/25 at 8 p.m. and showed redness on Pt 21’s right heel, not documented in the ED. NM 2 stated Pt 21 had had a Braden Score of 12 indicating a high risk of PI and needed pressure reduction interventions put in place for skin protection. During a concurrent observation and interview on 6/ 6/25 at 9:45 a.m., Pt 21 was seen lying in her hospital bed on her back with the head of the bed raised to a 30° angle. Pt 21 had a nasal oxygen tube, a pressure relief boot on her left foot, and a pillow under her right heel to keep it elevated. Pt 21 was watching TV and agreed to be interviewed. Pt 21 stated she had been in the hospital for a few weeks and the nurses were treating wounds on her heels and bottom. Patient 21 stated she was feeling better compared to when she first arrived. During an interview on 6/6/25 at 9:48 a.m. with RN 4, RN 4 stated she was Pt 21’s primary nurse for the day. RN 4 stated Pt 21 had a DTI on her left heel and was wearing a protective boot to help prevent PI. RN 4 stated she has received patients from the ED before who had wounds that were not documented. RN 4 stated when patients were admitted to the unit, a full head to toe assessment and a two-nurse skin checked are required. RN 4 stated she usually does the skin check and assessment when she takes the first set of vital signs. RN 4 stated skin assessment should be done every shift. During a concurrent interview and record review on 6/9/25 at 9:41 a.m. with EDM 2, Pt 21’s “ADT,” dated, 5/24/25 to 5/26/25, and “SIA,” dated 5/24/25 to 5/28/25, were reviewed. EDM 2 verified in Pt 21’s “SIA” there was no skin assessment documented on 5/25/25 during the night shift. EDM 2 stated Pt 21 should have a skin assessment completed every shift. During a concurrent interview and record review on 6/12/25 at 8:35 a.m. with RN 2, Pt 21’s “SIA”, “Skin Photos” and “HTTA” dated 5/26/25 were reviewed. RN 2 stated he was Pt 21’s primary nurse on 5/26/25 when she was transferred from the ED to the Stepdown Unit. RN 2 stated he worked day shift on 5/26/25 from 7 a.m. to 7:30 p.m. RN 2 stated he remembered Pt 21 and confirmed he completed the HTTA assessment on 5/26/25 at 4:42 p.m. RN 2 stated dual nurse skin checks was required by hospital policy. RN 2 stated he took four photos of Pt 21’s skin issues, including a wound on the coccyx, redness on the right heel, abrasion under breast, and a red mark to the leg, but admitted he forgot to document. RN 2 stated he should have documented Pt 21’s skin assessment to have a baseline for the care team to monitor. During a concurrent interview and record review on 6/9/25 at 9:54 a.m. with EDM 2, EDM 2 reviewed Pt 22’s EMR. EDM 2 stated Pt 22 arrived at the ED by ambulance on 5/9/25 at 2:47 p.m. for altered mental status. EDM 2 reviewed Pt 22’s H&P dated 5/9/25, the H&P indicated Pt 22 was 94 years old with a history of high blood pressure (a condition where the force of blood against the artery walls is consistently too high) and breast cancer (a disease when cells in the breast grow out of control, potentially forming tumors) The H&P also indicated redness and a possible open wound on the lower right leg, especially near the ankle, which was warm and tender to touch. EDM 2 stated Pt 22 22 was admitted as an inpatient later that night at 10:08 PM with a diagnosis of “likely metabolic encephalopathy [a brain dysfunction causing confusion] due to underlying sepsis [a life-threatening blood infection], [with] acute kidney injury [A sudden and often reversible decline in kidney function].” EDM 2 reviewed Pt 22’s hospital document titled, “EDT”, the EDT indicated Pt 22 stayed in the ED for 31 hours and 37 minutes before being moved to the inpatient Cardiac Progressive Care (care for patients with heart conditions) Unit on 5/11/25 at 5:45 p.m. EDM 2 reviewed Pt 22’s hospital document titled, “SIA” dated, 5/9/25 to 6/3/25, EDM 2 stated, there was no skin assessment documented skin assessment for the night shift on 5/10/25. The “SIA” indicated Pt 22 had wounds to her arm and ankle when transferred to the CPCU from the ED. EDM 2 stated full skin assessments should be completed upon admission to the unit, and every shift. During an interview on 5/12/25 at 9:41 a.m. with the Chief Nursing Officer (CNO), the CNO stated, her expectation was that skin assessments were completed and documented per policy, in any unit of the hospital. The CNO stated skin assessments should be ongoing and continuous. The CNO sated nursing should adjust the patient’s care plan interventions as the patient’s conditions changes based on assessments. During a review of the hospital’s P&P titled, “Pressure Injury Risk Assessment, Prevention, Staging and Treatment”, dated 5/19/25, indicated, “ ...All patients shall be assessed upon admission, then every shift, and with condition changes using the Braden Scale for Predicting Pressure Sore Risk [tool used by healthcare workers]. ...The initial skin assessment upon admission and/or transfer from another unit will be conducted by an RN and a secondary licensed staff member. ...Refine the assessment by including these additional risk factors: a. Fragile skin b. Existing pressure injury of any stage, including those injuries that have healed or are closed c. Impairments in blood flow to extremities from vascular [arteries and veins] disease, diabetes [high blood sugar] or tobacco use 4. Develop a plan of care based on the areas of risks, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, positioning, and the support surface. If the risk is from malnutrition, address this problem, etc. B. Prevention (All patients regardless of score) 1. Skin Care a. Inspect all of the skin following admission and document the assessment in the medical record within 24 hours of admission. b. Re-assess the skin routinely per the Standards of Practice Documentation Grid. c. Assess pressure points, including under equipment contact sites, and also over boney prominences [areas where bones are close to skin], such as the sacrum [area above tailbone on back], coccyx, buttocks, heels, ischium [hip bones], trochanters [upper part of thigh bone], elbows, and under medical devices. d. When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin. Moistening the skin assists in identifying changes in color ... Document initial skin assessment and Braden Scale score in the EHR [electronic health record] ...”. During a review of the hospital’s P&P titled, “Admission & Ongoing Assessment - Nursing (Acute Care)”, dated 5/19/25, indicated, “ ...Patients being admitted to the acute care facility through the Emergency Department (ED) will have the admission and assessment process initiated in the ED. The information gathered will be verified and completed as necessary by the RN in the inpatient receiving area ... A comprehensive nursing admission assessment using the nursing process will be initiated by the RN within two hours of the patient’s admission. Integumentary [skin] status. ...3. The comprehensive initial nursing admission assessment is to be documented by the RN and/or admission team completing the admission. Ongoing nursing assessment will be initiated by the RN or LVN at the beginning of every shift in accordance with their scope of practice ...”. During a review of the hospital’s P&P titled, “Documentation in the Health Record”, dated 6/14/18, indicated, “ ...All care providers caring for the patient are to document within their scope of practice/job description. B. All patient care and activities are to be documented at the time care is provided. ... EHR 1. Documentation of assessments, completion of notes from interviews and history taking, medication administration (bar coding), vital signs, intake and output collection are recorded at the patient’s bedside. 2. Documentation of care planning, completion of bedside educational modules, and result reviewing and graphing may be recorded outside the patient’s room ...”. During a professional reference review titled, “Nursing interventions in preventing pressure injuries in acute inpatient care: a cross-sectional national study”, dated 6/12/23, the professional reference indicated, “ ...Several nursing interventions for pressure injury prevention have been identified, including risk and skin status assessment. ... Preventing pressure injuries (PIs) is an important part of nurses’ work in hospitals and in communities. Pressure injuries arise from a failure of skin integrity due to unrelieved pressure and other forces, such as a bony area contacting external surfaces or a medical device causing pressure. ...Most importantly, PIs reduce the quality of life of patients, along with the quality of care. ...An earlier study identified that every tenth patient arriving at the hospital already had PIs or developed them within 36 h of admission. Thus, nurses and other health care personnel play a significant role in PI prevention. According to the International Guideline, pressure injuries stage I are a prognostic factor for higher stage PIs. Each patient should go through a comprehensive skin and tissue assessment after admission, or after being transferred to healthcare services as a part of the risk assessment. A skin assessment should also be implemented prior to being discharged from healthcare services. ...PI risk and skin status assessments are of high importance for HAPI prevention ...” 3. During a concurrent interview and record review on 6/6/25 at 10:34 p.m. with NM 1 and Assistant Nurse Manager (ANM) 1, NM 1 reviewed Pt 22’s EMR and stated Pt 22 arrived at the ED on 5/9/25 at 2:48 p.m., physician inpatient order was placed on 5/9/25 at 10:08 p.m. and Pt 22 was transferred on an inpatient bed in CPCU on 5/11/25 at 5:45 p.m. Pt 22 stayed in the ED for 43 hours and 37 minutes. NM 1 reviewed Pt 22’s document titled “HTTA”, from 5/9/25 to 5/13/25. NM 1 compared the HTTA both the ED and the CPCU, and stated the level of care should be the same in both areas. ANM 1 stated the ED nurses did not performed the NIH (National Institute of Health Stroke Scale) stroke scale (a widely used tool to assess the severity of stroke in patients. It’s a 11-item scale that evaluates neurological function and deficits, with scores ranging from 0 to 42, where higher scores indicate greater severity), HENT (a physical examination focusing on the Head, Eyes, Ears, Nose, and Throat), Respiratory assessment (a systematic evaluation of the breathing process and lung function to identify any potential problems or abnormalities), Edema assessment (the process of evaluating swelling, or edema, in the body), Neurovascular assessment (a clinical evaluation of a patient’s circulation and nerve function in a limb, typically an extremity, to detect any signs of impaired blood flow or nerve damage) Abdominal and Bowel sounds assessment ( is a physical exam of the abdomen to assess the condition of the digestive, GU assessment (genitourinary- a systemic evaluation of the urinary system, Mobility assessment (a process to evaluate a person’s ability to move), Psychosocial assessment (a comprehensive evaluation of an individual’s mental health, social well-being, and ability to function within their environment, and Fall risk assessment (a process used to identify individuals who are at increased risk of falling). During a concurrent interview and record review on 6/9/25 at 10:05 a.m. with EDM 2, EDM 2 reviewed Pt 22’s EMR and stated Pt 22 arrived at the ED on 5/9/25 at 2:48 p.m., physician inpatient order was placed on 5/9/25 at 10:08 p.m. EDM 2 reviewed Pt 22’s HTTA and stated the ED nurses did not document a HTTA at the time of admission or once per shift as required. EDM 2 stated it was important to complete a HTTA to establish a baseline for Pt 22’ condition and identify changes in patient 22’s condition to provide appropriate care. During a review of the hospital’s P&P titled, “Admission & Ongoing Assessment - Nursing (Acute Care)”, dated 5/19/25, indicated, “ ...Patients being admitted to the acute care facility through the Emergency Department (ED) will have the admission and assessment process initiated in the ED. The information gathered will be verified and completed as necessary by the RN in the inpatient receiving area. ... A comprehensive nursing admission assessment using the nursing process will be initiated by the RN within two hours of the patient’s admission... While aspects of data collection may be delegated by the RN to other care providers within their scope of practice, job description, and in accordance with the policy, the RN is responsible for coordinating the patient’s plan of care and patient/family education (refer to Role-Based Patient Care by Scope of Practice policy). 2. A comprehensive initial assessment includes reviewing and/or establishing a baseline assessment including: a. Vital signs, weight, height and allergies. b. Neurological status. c. Sensory status. d. Psychological status. e. Cardiovascular status. f. Respiratory status. g. Gastrointestinal status. h. Nutritional status. ...genital. j. Pain assessment. k. Urinary status. l. Endocrine functioning. m. Integumentary [skin] status. n. Musculoskeletal status. o. Functional status. p. Developmental status. q. Discharge planning needs. 3. The comprehensive initial nursing admission assessment is to be documented by the RN and/or admission team completing the admission. Ongoing nursing assessment will be initiated by the RN or LVN at the beginning of every shift in accordance with their scope of practice...”. During a review of a professional reference titled, “Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study,” dated 2/16/23, the professional article indicated, “ ... Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information and patient care plans, such as professionals’ evaluation and judgement about the patients, evaluation charts, tests, reports, subjective notes or professionals’ reflections ... Documenting routine practices is essential for the continuity of patient care, ... communication among healthcare professionals and better patient diagnoses and treatments ... it should be patient-focused, accurate, relevant, clear, permanent, confidential and timely ... Poor documentation practice affects patient management, continuity of patient care and medicolegal issues, which arise from incomplete and inadequate documentation, lack of accuracy and poor quality. It leads to adverse patient outcomes, medication errors and patient deaths. Distorted health information may influence health professionals’ decision-making capabilities due to inappropriate and misleading documentation practices...”. During a professional reference review titled, “Nursing Admission Assessment and Examination”, dated 8/28/23, the professional reference indicated, “ ... The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. This concept of precision education to tailor care based on an individual’s unique cultural, spiritual, and physical needs, rather than a trial by error, one size fits all approach results in a more favorable outcome. The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient. Subjective and objective data collection are an integral part of this process. Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care ...”. 4. During a concurrent interview and record review on 6/5/25 at 11:15 a.m. with NM 3, NM 3 opened Pt 2’s EMR and opened the hospital document titled “Daily Cares Flowsheet (DCF)”, dated 3/27/25 to 3/28/25 which showed Activities of Daily Living (bathing, eating, dressing, mobility, oral care) provided to Pt 2, NM 3 stated Pt 2 had no hygiene care documented in the ED. NM 3 stated Hygiene care began on MS Unit. NM 3 stated nursing staff should document when care was offered, and patients refused. NM 3 stated if Pt 2 received care it should be documented. During a concurrent interview and record review on 6/9/25 at 9:48 a.m. with EDM 2, EDM 2 opened Pt 2’s EMR and opened the hospital document titled “EDT” which showed the care Pt 2 received during his stay in the ED from 3/27/25 to 3/28/25. EDM 2 stated Pt 2 was admitted as an inpatient on 3/27/25 at 11:24 a.m. and held in the ED until moving to the inpatient MS Unit on 3/28/25 at 2:55 p.m. EDM 2 then opened the hospital document titled “DCF”, EDM 2 stated ED staff did not document any hygiene care for Pt 2 on 3/27/25 or 3/28/25. The “DCF” indicated Pt 2’s first documented hygiene was on 3/28/25 at 5:04 p.m. after transfer to the MS unit. EDM 2 stated Pt 2 should have been provided hygiene care in the ED, to follow up on skin assessments, reduce the risk of infection and to increase Pt 2’s overall morale (mental and emotional state). EDM 2 stated staff should document all patient hygiene provided or offered and refused in the medical record. During an interview on 6/12/25 at 9:45 a.m. with the CNO, the CNO stated her expectation was for hygiene to be offered to patients and to be documented by nursing staff. During a review of the hospital’s P&P titled, “Oral Care”, dated 2/15/22, indicated, “ ...Oral care should be encouraged for every patient in the hospital as it effectively decreases the risk of infection. Oral care will be done by trained staff or designee for patients who are unable to perform their own oral care. Oral assessments and care should be done at least every shift and more frequently if indicated ...”. During a review of the hospital’s document titled, “Patient Care Tech 1 Job Description”, dated 11/13/24, indicated, “ ... Job Summary ... Under the direction of a licensed clinical staff member, the Patient Care Tech 1 (PCT1) provides both basic patient care and clerical support using defined procedures and standards in accordance with the goals of the unit ... Essential Accountabilities ... job’s main responsibilities ... Under the direction of the RN/L LVN delivers basic patient care. Performs and assists with elemental aspects of patient care such as bed scale weights, 1/0, hygiene, dressing, turning and ambulation. Safely performs/assists with inpatient lifts/transfers, moves, positioning and ambulation in coordination with the patient care team. Records vital signs, height, weight and 1/0. Collects and records data as assigned and reports information to RN ...”. During a review of professional reference titled, “Assisting Patients with Personal Hygiene,” (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK563155/) dated 9/26/22, the professional reference indicated, “ ... Preventing the spread of contamination from the medical provider to the patient and vice versa is essential ... A lack of hygiene can result in many adverse effects, such as hospital-acquired infections ... Basic adult hygiene includes oral hygiene, bathing, eliminating, shaving, brushing, and styling hair ... These may seem like basic procedures but are vital to maintaining the patient’s health ... The inability to properly maintain hygienic conditions for patients can lead to many adverse effects ... Bathing patients regularly, ... can help prevent ... infections ... Bathing helps the patient feel clean and gain a sense of normalcy, removes dirt, perspiration, bacteria, and dead skin, and promotes blood circulation ... Regular nail care can remove bacteria underneath the fingernails to help prevent infections ...”. 5. During a concurrent interview and record review on 6/5/25 at 11:17 a.m. with NM 3, NM 3 opened Pt 2’s EMR and opened the hospital document titled “DCF” dated 3/27/25 to 3/28/25 to review nutrition provided to Pt 2. NM 3 stated the “DCF” had no documented meal until 3/28/25 at 9 a.m. when 25% was documented. NM 3 stated, “I would imagine they would have charted it if he did eat”. NM 3 stated the expectation was for meal or snack intake to be documented. During a concurrent interview and record review on 6/9/25 at 9:55 a.m. with EDM 2, EDM 2 opened Pt 2’s EMR then opened the hospital document titled, “Provider Orders (PO)”, dated 3/27/25 at 3:17 p.m., EDM 2 stated Pt 2 was on a regular diet while admitted and held in the ED. EDM 2 “DCF” for the ED admission dates of 3/27/25 to 3/28/25 to review nutrition (meal or snack) intake documentation for Pt 2. EDM 2 opened the hospital document titled “Intake and Output”, dated 3/27/25 and 3/28/25. EDM 2 stated he was unable to find any nutrition intake documentation in Pt 2’s EMR before 3/28/25 at 9 a.m. EDM 2 stated documentation of nutrition intake was important because what goes in must come out, tells us volume, metabolism, allows communication other staff to know what’s working for them etc. During a review of the hospital’s P&P titled, “Documentation in the Health Record”, dated 6/14/18, indicated, “ ...All care providers caring for the patient are to document within their scope of practice/job description. B. All patient care and activities are to be documented at the time care is provided. ... EHR 1. Documentation of assessments, completion of notes from interviews and history taking, ... intake and output collection are recorded at the patient’s bedside ...”. 6. During a concurrent interview and record review on 6/5/25 at 11:15 a.m. with Nurse Manager (NM) 3, the Electronic Medical Record (EMR) for Pt 2 was opened and reviewed. The hospital document titled “History and Physical [H&P-an assessment from physician including medical history and exam],” dated 3/27/25, was reviewed. The “H&P” indicated Pt 2 arrived in the Emergency Department (ED) on 3/24/25 with complaint of scrotal (the sack of skin and muscle that holds the testicles outside the body) swelling the size of a grapefruit and was unable to urinate. Pt 2 had past medical history (PMH) of benign prostatic hyperplasia (BPH-the prostate gland [walnut-sized gland located in the male reproductive system, just below the bladder] enlarges. NM 3 stated Pt 2 was admitted for a perianal fistula (an abnormal tunnel-like connection between the anal canal and the skin surrounding the anus) and urinary tract infection (UTI- a bacterial infection that occurs when bacteria enter the urinary tract and multiply). NM 3 then opened the hospital document “Admit, Discharge, Transfers [ADT]” which showed where Pt 2 was held and moved during his stay. NM 3 stated Pt 2 was admitted as an inpatient on 3/27/25 at 11:24 a.m. and held in the ED until moving to the to the inpatient Medical Surgical (MS) Unit (patients with a variety of medical and surgical conditions receive care) on 3/28/25 at 2:55 p.m. NM 3 then opened the hospital document “Nursing Navigators Admission Nutrition” Screening for review. NM 3 stated nursing staff should have documented a nutrition screening upon admission and did not. During a concurrent interview and record review on 6/5/25 at 9:30 a.m. with Emergency Department Manager (EDM) 3, Pt 2’s “Emergency Department Timeline [EDT]”, dated 3/27/25 to 3/28/25, was reviewed. EDM 3 stated some people use the flowsheets to look at the information, but he preferred looking at the “EDT” because all the patient’s ED care was listed in one place. EDM 3 stated Pt 2 was admitted as an inpatient on 3/27/25 at 11:24 a.m. and moved to the Medical Surgical (MS) Unit (patients with a variety of medical and surgical conditions receive care) on 3/28/25 at 2:55 p.m. EDM 3 stated Pt 2 did not have a nutritional risk screening completed by nursing staff during the time he was admitted and held in the ED and should have. Pt 2 was admitted and held in the ED for 27 hours and 31 minutes before transfer to the MS unit. During a concurrent interview and record review on 6/4/25 at 1:51 p.m. with NM 2 opened Pt 21’s EMR and stated Pt 21 was admitted as an inpatient on 5/25/25 at 12:55 a.m. and held in the ED until 5/25/25 at 4:30 p.m., when she was moved to the Stepdown Unit (a unit bridging the gap between the intensive care unit (ICU) and the general MS floor). NM 2 opened the document titled, “Nutrition Screening” and stated it was completed by an ED RN on 5/25/25 at 9:19 a.m. NM 2 stated the ED RN documented Pt 21 had no nutritional deficits. NM 2 stated, she would expect to see a nursing note from the ED RN describing where they got their information for the nutrition screen. NM 2 acknowledged the nutrition screen did not look accurate. NM 2 stated RNs could get information to complete the screening from the patient, from family if present, or from the information sent from the patient’s SNF. NM 2 stated she was unsure where the RN got the information from when completing the screening questionnaire, since no other notes were in the EMR. NM 2 then opened the hospital document titled, “H&P” dated 5/25/25 at 1:01 a.m., NM 2 stated the ED RN that completed Pt 21’s screening had access to the “H&P” to review and should have been aware of Pt 21’s chief complaint, Failure to Thrive (FTT-decline in an adults physical and mental process function, weight loss, poor appetite, and decreased activity). NM 2 opened the document titled “SIA” and stated on 5/24/25 at 11:19 p.m. RNs documented a PI wound Pt 21’s coccyx. NM 2 stated both the chief complaint, and the PI would have changed the nutrition screen results. NM 2 stated both documents were completed and available for review prior to the nutrition screening. During a review of Pt 21’s “Nutrition Screen with Choices [NSWC]”, dated 6/9/25, the “NSWC” indicated, “ ... Have you lost weight recently without trying? [responses are scored 0-4] 0=No, 1=Yes 1-13 lbs. [pounds - a unit of weight measurement], 2=Yes 14-23 lbs. or Unsure, 4=Yes >33 lbs. ...”. Nursing staff documented, 0. Have you been eating poorly because of a decreased appetite? ...1=Yes, 0=No ...”. Nursing staff documented, 0. The computer calculated a “Malnutrition Score” with the entered data (0-5), zero = no malnutrition, 5 = severe malnutrition. Pt 21’s calculated total was 0. The “NSWC” indicated, “ ...Pressure injury Stage two [partial thickness skin loss] or greater Yes / No”. Nursing staff documented, No. “ ...Tube Feeding [A method of providing nutrition through a tube inserted into the stomach or intestines], TPN [Total Parenteral Nutrition - complete nutrients directly into bloodstream through vein], or PPN [Partial Parenteral Nutrition - supplemental nutrition directly into blood steam through vein]”. Nursing staff documented, No. “ ...Body surface burn greater than 20%. (18 years or older) ...”. Nursing staff documented, No. During an interview on 6/5/25 at 2:52 p.m. with NM 3, NM 3 stated, when nursing documented a nutrition screening with a full thickness skin loss (Stage 3) Pressure Injury (PI- damage to the skin and underlying tissue caused by prolonged pressure) the computer would automatically send a referral to an RD for a nutritional assessment. During a concurrent interview and record review on 6/4/25 at 2:22 p.m. with Nurse Educator (NE) 2, NE 2 opened Pt 21’s EMR and stated the expectation was for RNs to put in a note in the record when they did the nutrition risk screen, to know where the RN got the information from. NE 2 stated maybe the RN who completed the nutrition screening was in training, because the other admission assessment documents completed during Pt 21’s admission were completed by a different nurse. During a concurrent interview and record review on 6/5/25 at 2:56 p.m. with NM 3, NM 3 opened Pt 21’s EMR, NM 3 then opened the hospital document “Nursing Navigators Admission Nutrition” Screening for review. NM 3 stated Pt 21’s nutrition screening was documented on 5/25/25 at 9:19 a.m. NM 3 stated Pt 21’s malnutrition screen score was zero, indicating no nutritional deficits. When asked if the score of zero for malnutrition was accurate, due to the chief complaint of decreased appetite and poor food intake, NM 3 stated, the nurse may not have been aware of the chief complaint and the patient may have said she did not have a poor appetite. NM 3 then opened the hospital document titled “Head to Toe Assessment [HTA]” from 5/24/25 at 11:19 p.m. and nursing staff documented Pt 21 had a “wound” to her coccyx (tailbone). NM 3 then opened the hospital documents “Skin Photos” for review. NM 3 stated a photo from 5/26/25 showed a full thickness skin loss (stage 3) pressure injury. NM 3 stated the nurse completing the “HTA” was a different nurse from the nutrition screening nurse, and NM 3 did not know why the nurse answered “no” to the choice for no wounds. NM 3 stated there were no photos taken of the wound on 5/24/25 when the “HTA” was completed and there should have been. During an interview on 6/6/25 at 9:48 a.m. with RN 4, RN 4 stated she was Pt 21’s primary nurse for the day. RN 4 stated Pt 21 had a DTI to her left heel and had a boot on to protect the heel. RN 4 stated the admitting nutrition screen was supposed to be completed upon admission and her practice was to complete the screening when patients arrived in the unit. RN 4 stated the EMR auto sent a nutrition consult for wounds stage 2 or greater, and a malnutrition score of two or greater. RN 4 stated proper nutrition helped with healing. During an interview on 6/12/25 at 9:45 a.m. with the Chief Nursing Officer (CNO), the CNO stated nutrition screening should be completed per policy and be accurate to the state of the patient. During a review of the hospital’s P&P titled, “Nutritional Care and Documentation in the EHR”, dated 2/10/25, indicated, “ ... To ensure that an initial assessment program is implemented that identifies patients who may require medical nutrition therapy and that these patients are further assessed and receive nutrition assessment and reassessment when applicable. To standardize nutritional care practices and written documentation within the EHR. ...Nursing Responsibilities Initial screening will be performed by a Registered Nurse (RN) during the admission process per the Patient Assessment policy. All patients will be screened for nutritional risk within 24 hours of admission. The following indicators will generate a referral to the RD: 1. a. Adult Patients: ...malnutrition (not getting enough nutrition) score > 2 based on Malnutrition Screening Tool (MST) ...nutrition support (TF [Tube Feeding: A method of providing nutrition through a tube inserted into the stomach or intestines], TPN [Total Parenteral Nutrition - complete nutrients directly into bloodstream through vein], or PPN [Partial Parenteral Nutrition - supplemental nutrition directly into blood steam through vein]) ...pressure injury [damage to the skin and underlying tissue caused by prolonged pressure) stage II [partial thickness skin loss] or greater ...major burn >20% Total Body Surface Area ...”. During a professional reference review titled, “Nutritional Care: Nurses’ Critical Role in Improving Patient Outcomes”, dated Jul-Sep 2024, the professional reference indicated, “ ...Nutrition is an essential component of general health and well-being. ... In the clinical environment, the multidisciplinary [define] team plays a fundamental role in meeting patients’ nutritional requirements. Of these professionals, nurses hold a great position because they are continually present at the bedside with the patient, directly engage with the patients, and spend hours interacting with them. ...For instance, nurses are the first to clinically identify patients’ nutrition problems. A wide range of assessment tools and methods is used when a nurse assesses a patient’s nutritional status. While doing a routine assessment of the patient’s vital signs, a nurse may notice changes in weight and diet that may indicate some malnutrition. Nurses can systematically identify those at risk of malnutrition and intervene early by implementing standardized nutrition screening tools such as the subjective global assessment or the Malnutrition Universal Screening Tool...”. 43258 7. During a concurrent interview and observation on 6/4/25 at 10:17 a.m. with NM 3 in Pt 65’s room, a container of [name of enteral formula] unlabeled with the date and time of change was observed being administered to Pt 65. NM 3 stated he did not know when the tube feeding was changed. During a concurrent observation and interview on 6/5/25 at 1:38 p.m. with RN 17, RN 17 reviewed the manufacturer’s product labeling for the enteral feeding and stated once it was punctured it was to be used within 24 hours. During a concurrent observation and interview on 6/5/25 at 2:21 p.m. with Clinical Dietician 1 (CD 1) and NM 2, the manufacturer’s labeling for [name of enteral formula] was reviewed. CD 1 stated it was nursing staff who would know about hanging and dating of the container once punctured. NM 2 stated it was expected for nursing staff to document on the enteral feeding bottle the date and time it was hung. During a concurrent interview and record review on 6/5/25 at 2:37 p.m. with NM 3, the hospital’s policy and procedure (P&P) titled, “Enteral Tube Feeding- Patients 14 and Older,” dated 12/19/23 was reviewed. The P&P indicated, “IV. Guidelines A. Maintenance of Enteral Feeding Tube ... 5. Change equipment (e.g. Irrigation syringe) and label with date and time every 24 hours if using an open system. If using a closed system, change bag and tubing every 48 hours or per manufacturer guidelines; label with date and time of change...”. NM 3 stated the [name of enteral formula] had nothing written on it (for Pt 65 observed on 6/4/25) and the nurse who hung the feeding did not follow the P&P. He stated the container needed to be labeled with the date so nursing staff knew when to change it.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 43258 Based on observation, interview, and record review, the hospital failed to administer medications in accordance with physician orders, hospital policies, and acceptable standards of practice for three of 72 sampled patients (Patient 1, Patient 12, and Patient 16) when: 1. Nursing staff did not administer intravenous (IV, into the vein) magnesium at the ordered time and rate and did not administer PRN (as needed) intravenous blood pressure medication according to physician’s orders for Patient 12; 2. The hospital did not administer IV vancomycin (an antibiotic to treat infection) at the scheduled time for Patient 16; and 3. An intramuscular (IM, into the muscle) medication administered to Patient 1 was prepared by one LN (ANM 4, Assistant Nursing Manager 4) and administered by another LN (Registered Nurse 1) and the LNs did not follow acceptable standards of safe medication administration. These failures resulted in the hospital not ensuring safe and accurate administration of medications, preventable medication errors, delays in treatment, and potential for subtherapeutic and/or adverse clinical outcomes. Findings: 1a. A review of Patient 12’s History & Physical (H&P - comprehensive patient assessment) indicated he presented to the Emergency Department (ED) on 6/2/25 with a complaint of shortness of breath. The Assessment & Plan indicated, “Atrial fibrillation with RVR (rapid ventricular response, a condition where the heart is beating irregularly and faster than normal, potentially causing symptoms like palpitations, dizziness, or shortness of breath) ... keep K (potassium > [greater than] 4, Mg (magnesium) > [greater than] 2 ...” A review of Patient 12’s medical record indicated the following physician’s orders: - Magnesium sulfate 1 gram/100 milliliter (g/mL, a unit of measurement) infusion (administered through the vein): 1 g IV every hour administered over one hour, scheduled start and end 6/2/25 at 6:21 a.m. after two doses were administered. During a concurrent interview and record review on 6/11/25 at 2:16 p.m. with Nurse Manager 2 (NM 2), Patient 12’s physician’s orders and Medication Administration Record (MAR) for the magnesium infusion were reviewed. NM 2 confirmed the order for magnesium was for two doses to be administered every hour, and each to be infused over one hour. NM 2 reviewed the MAR and confirmed the first dose was administered on 6/2/25 at 4:50 a.m. and the second dose was administered at 5:21 a.m., only 31 minutes apart. NM 2 reviewed Patient 12’s record and confirmed Patient 12 only had one IV (intravenous, into the vein) line when the magnesium was administered. During a review of the hospital’s P&P titled, “Medications- Orders, Administration, Storage, Documentation,” dated 12/19/23, the P&P indicated, “III. Policy ... B. Medication Administration ... 11. Timing of Medication Administration a. The timing of medication administration is based on the nature of the medication and its clinical application to ensure safe and timely administration ... 17. It is the responsibility of the person administering the medication to verify the following ... d. The right time ... V. PROCEDURE ... K. Review administration instructions on MAR ...” 1b. A review of Patient 12’s History & Physical indicated he presented to the Emergency Department (ED) on 6/2/25 with a complaint of shortness of breath. The Assessment & Plan indicated, “Atrial fibrillation with RVR.” A review of Patient 12’s medical record indicated the following physician’s orders: - Metoprolol (medication to slow heart rate) injection 5 milligrams (mg, a unit of measurement): 5 mg IV every 6 hours PRN (as needed) for HR (heart rate) > 110 bpm (beats per minutes), scheduled start date 6/2/25 at 12:13 a.m. During a concurrent interview and record review on 6/12/25 at 11:19 a.m. with NM 2, Patient 12’s vitals dated 6/3/25 were reviewed. NM 2 confirmed Patient 12’s heart rate was documented at 117 bpm on 6/3/25 at 7:59 a.m. She confirmed metoprolol was not administered to Patient 12 and stated if the heart rate was greater than 110 bpm, the nurse should have administered it per the doctor’s orders. During a review of the hospital’s P&P titled, “Medications- Orders, Administration, Storage, Documentation,” dated 12/19/23, the P&P indicated, “III. Policy ... B. Medication Administration ... 11. Timing of Medication Administration a. The timing of medication administration is based on the nature of the medication and its clinical application to ensure safe and timely administration ... 17. It is the responsibility of the person administering the medication to verify the following ... d. The right dose e. The right time F. The right route ... V. PROCEDURE ... K. Review administration instructions on MAR ...” 2. A review of Patient 16’s H&P indicated he presented to the ED on 6/2/25 with complaints of swelling, redness and pain in his lower right extremity. The Assessment and Plan indicated, “Sepsis (an infection in the blood) ... Start Zosyn (an antibiotic to treat infection) and vancomycin empirically ... Cellulitis (a skin infection) and abscess (a pus-filled pocket that forms in the body due to an infection) of lower extremity ... Start Zosyn and vancomycin empirically ...” A review of Patient 16’s medical record indicated physician’s orders for the following antibiotics (medication to treat infection): - Vancomycin (an antibiotic to treat infection) 1.5 g/500 milliliters (g/mL, a unit of measurement): 1,500 mg IV 3 times per day, administered over 120 minutes, scheduled start date 6/2/25 at 1 p.m. - Zosyn (antibiotic to treat infection) 3.375 g/mL: 3.375 g IV 3 times per day, scheduled start date 6/2/25 at 8:23 a.m. During a concurrent interview and record review on 6/11/25 at 3:07 p.m. with Director of Pharmacy (DOP), Patient 16’s MAR was reviewed. The DOP confirmed the MAR indicated vancomycin scheduled for 6/2/25 at 1 p.m. was not administered to Patient 16 until 5:02 p.m. that day, approximately 4 hours later than scheduled. During an interview on 6/12/25 at 8:33 a.m. with DOP, DOP stated Patient 16 was administered the vancomycin later than scheduled because the patient only had one IV line at the time. During an interview on 6/12/25 at 9:10 a.m. with NM 2, Patient 16’s medical record was reviewed. NM 2 confirmed Patient 16 only had one IV line at the time vancomycin was scheduled to be administered. NM 2 reviewed Patient 16’s record and confirmed there was no documentation of a second IV line. NM 2 stated if a patient had multiple medications schedule to be administered at or around the same time, nursing staff were expected to contact pharmacy and work with the pharmacist to plan how to administer them. She stated she was not sure contacted the pharmacy and stated sometimes it was documented and other times it was not. During a review of the hospital’s P&P titled, “Medications- Orders, Administration, Storage, Documentation,” dated 12/19/23, the P&P indicated, “III. Policy ... B. Medication Administration ... 11. Timing of Medication Administration a. The timing of medication administration is based on the nature of the medication and its clinical application to ensure safe and timely administration. These medications are classified as either not eligible for scheduled dosing times or eligible for scheduled dosing times ... ii. Medications eligible for scheduled dosing times are prescribed on a repeated cycle of frequency ... Medications eligible for scheduled dosing times may be classified as time critical or non-time critical scheduled medications; I. Time critical A. Maintain total one-hour administration window where administration may occur up to 30 minutes before or after scheduled time. Examples of time critical scheduled medications include but may not be limited to: 1. Antibiotics ... 17. It is the responsibility of the person administering the medication to verify the following ... d. The right dose e. The right time F. The right route ... V. PROCEDURE ... K. Review administration instructions on MAR ... M. Each person administering medications or treatment is required to check the medication against the MAR or original written order ... prior to medication administration.” 3. During an interview and video surveillance review on 6/9/24 at 11:10 a.m., with Security Operations Manager (SOM) 1, and Vice President (VP) of Regulatory, Risk, and Medical Affairs (VPR), RN 1 was observed at Pt 1’s bedside in the Special Care Unit (SCU- locked and monitored area where mental behavioral health patients are placed) in the Emergency Department (ED) when Assistant Nurse Manager (ANM) 4 was observed to hand an unlabeled syringe to RN 1. RN 1 administered the medication to Pt 1 while she was being physically restrained by Security Offices (SOs) who were in the process of applying four-point locking restraints (the physical restraint of a patient’s limbs using restraints on all four limbs simultaneously) to Pt 1’s wrists and ankles. During a review of Pt 1’s “Face Sheet (FS)” dated 5/9/25, the FS indicated, “... [Pt 1] arrived at the ED on 5/9/25 at 17:27 (5:27 p.m.) ... Discharge Date/Time: 5/11/25 at 21:40 (9:40 p.m.) ...” During a review of Pt 1’s “ED Provider Notes (ED Note)” dated 5/9/25, the ED Note indicated, “[Pt 1] ...54-year-old ...presents to the ED for evaluation s/p (status/post- after) alleged assault today. Patient has complaints of headache and nausea... Patient states while she was at the rental property she was allegedly assaulted by her tenants... patient alleges “police came and hit the backside of my car. ...denies SI (Suicidal Ideation- thoughts of harming self), HI (Homicidal Ideation- thoughts of harming others), visual hallucinations, or auditory hallucinations. ...Discussion...a past medical history of generalized anxiety disorder (worrying constantly and can’t control it) ...Patient reporting abdominal pain and recent diagnosis of pregnancy. Patient appears to have delusions... Patient was placed on a 1799 hold (a short-term, 24-hour psychiatric detention used in California hospitals for gravely disabled (a condition in which a person: as a result of a mental health disorder, impairment by chronic alcoholism, severe substance use disorder, or a co-occurring mental health disorder and severe substance use disorder, is unable to provide for their basic personal needs for food, clothing, shelter, personal safety, or necessary medical care)... Patient attempted to elope from the SCU area and would not respond to verbal redirection requiring 4-point restraints, diphenhydramine/haloperidol/lorazepam (antianxiety medication). Patient was seen by psychiatric liaison who recommended lifting 1799 hold... The patient currently appears clinically sober, without evidence of ingestion or withdrawal. At this time, is medically clear. Awaiting psych recs (recommendations)...” During a review of Pt 1’s Medication Administration Record (MAR) dated 6/10/25 for dates 5/8/25 through 5/11/25, the MAR indicated “...Lorazepam (brand name) injection 2 mg (milligrams- unit of measure) Dose: 2 mg Freq. ONCE Route: IM Start 5/9/25 18:36 (6:36 p.m.) ...5/9/25...18:32 (6:32 p.m.) (2mg)-$Given...” During an interview and video surveillance review on 6/11/25 at 9:09 a.m., with Assistant Nurse Manager (ANM) 4, ANM 4 stated she responded to assist with an agitated patient in the SCU. ANM 4 stated lorazepam was already ordered with haloperidol and diphenhydramine ordered later. ANM 4 stated she obtained the lorazepam vial, drew up the medication into a syringe, applied the needle and handed it to RN 1 to administer the medication. ANM 4 stated the bar code scanning step in the medication administration process was bypassed due to the situation. ANM 4 stated she entered the SCU and handed the pre-filled syringe to the RN 1. ANM 4 stated she verbally communicated to RN 1 that the syringe contained lorazepam. ANM 4 stated the syringe was not labeled. ANM stated she usually asks if she can help by giving the medication but did not this time. ANM 4 stated she scanned the vials [into Pt 1’s medical record] following the incident with Pt 1. ANM stated ideally, bar code scanning happens at bedside to ensure the patient’s 5 rights are upheld (for example: inform the patient, confirm the right route and then document). During an interview and video surveillance review on 6/11/25 at 1:15 p.m., with RN 1 and ED Manager (EDM) 1, RN 1 stated while attempting to prevent Pt 1 from leaving the SCU and then being placed in locking restraints to both wrists and ankles, ANM 4 responded to the event and offered to get the lorazepam ordered to help return Pt 1 to “an acceptable level of behavior.” RN 1 stated ANM 4 returned and handed the prepared syringe to her for administration. RN 1 stated ANM 4 verbalized that the syringe contained lorazepam. RN 1 stated she administered the medication through paper scrubs and into Pt 1’s right leg. RN 1 stated she did not witness ANM 4 draw up the lorazepam from its original container but administered it because she felt the situation was emergent. EDM 1 stated it is a nursing professional standard that if you prepare the medication, you administer the medication. During an interview on 6/12/25 at 9:53 a.m., with Chief Nursing Officer (CNO), CNO stated the medication administration policy indicated nursing staff could draw up medications in an “emergency” without labeling the syringe and hand it to another nurse to inject. Stated the policy was uploaded (provided) and the area had been highlighted. During a review of the hospital P&P titled “Medications - Orders, Administration, Storage, Documentation” dated 12/19/23, the P&P indicated “ ... I. PURPOSE: To provide guidelines for the safe and accurate .... administration ... of medications ... II. DEFINITIONS ... D. Five Rights of Medication Administration 1. The right drug 2. The right patient 3. The right dose 4. The right time 5. The right route...III. POLICY: ...B. Medication Administration ... 8. Medications shall be administered using Bar Code Medication Administration (BCMA) in all areas that BCMA is implemented. Exceptions to this process are emergencies, scanner equipment not available at time of administration, and system not working, and when using approved EHR Narrators (e.g., sedation narrator).17. It is the responsibility of the person administering the medication to verify the following ... a. Drug allergies, b. The right drug, c. The right patient, d. The right dose, e. The right time, f. The right route ... V. PROCEDURE: ... F. Before administering any medications, verify that no contraindications to the medication exist and check drug allergies ...G. ... verify the medication label matches the Medication Administration Record (MAR) or prescriber’s order ... J. ... 3 ... a. ... I. Containers used to transfer medication and solutions from the original packaging include such things as syringes ... ii. An immediately administered medication is one that an authorized staff member prepares or obtains, and administers directly to the patient without any break in the process, such as laying the syringe or container down for later use ... EXCEPTION: A medication that has been transferred from the original container and is immediately administered does not have to be labeled. NOTE: Pre-labeled empty syringes or containers are not acceptable ... b. The new label on the transfer container or syringe contains the following information: i. Name of solution or medication ... ii. Strength and amount ... iii. Volume ... vi. Date prepared ... c. If the person preparing the medication or solution is not the person administering it, verify the information on the new label, both verbally and visually, between two individuals qualified to participate in the procedure. Verify information on the label against the original medication or solution container ... L. On patient care areas using the point of care BCMA scanning system to administer medications:... f. When the patient’s condition necessitates quick actions and/or the scanning of medications/IVs would impede the ability of staff to deliver medications in an emergent situation, staff must complete the five rights of medication administration check before administration. The documentation of the administration of the medications/IVs is completed in the EHR when the patient is stabilized...” According to the National Institutes of Health (NIH)’s National Library of Medicine, “Nursing Rights of Medication Administration” by Hanson A, Haddad LM. Nursing Rights of Medication Administration. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Electronically retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 11/13/24 the article indicated “ ...Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration ... According to the Joint Commission’s “National Patient Safety Goals® Effective January 2024 for the Hospital Program” dated 10/4/24, the article indicated “...Goal 3. Improve the safety of using medications. NPSG.03.04.01 Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins...Rationale for NPSG.03.04.01 Medications or other solutions in unlabeled containers are unidentifiable. Errors, sometimes tragic, have resulted from medications and other solutions removed from their original containers and placed into unlabeled containers. This unsafe practice neglects basic principles of safe medication management, yet it is routine in many organizations. The labeling of all medications, medication containers’, and other solutions is a risk-reduction activity consistent with safe medication management. This practice addresses a recognized risk point in the administration of medications in perioperative and other procedural settings...” According to the National Institutes of Health (NIH)’s National Library of Medicine, “Medication Routes of Administration” by Kim J, De Jesus O. Medication Routes of Administration. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Electronically retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK568677/on 11/14/24 the article indicated “Five (5) Rights of Medication Use (the “five rights” are emphasized for the preparation of medication administration: right patient, right drug, right dose, right site, and right timing. It is essential to explain to patients how the medication will be administered, obtain consent for procedures when indicated (e.g., central venous catheter), and help prepare patients before they receive their medication. The site of application of the drug should be chosen based on its adequacy and indications. The label on the medication should be checked for its name, dose, and approved usage route.” According to the National Institutes of Health (NIH)’s National Library of Medicine “Medication Administration Safety and Quality: An Evidence-Based Handbook for Nurses” Hughes RG, Blegen MA. Medication Administration Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 37. Electronically retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK2656/ on 11/15/24 the article indicated “Medication errors occur in all settings5 and may or may not cause an adverse drug event (ADE). Medications with complex dosing regimens and those given in specialty areas (e.g., intensive care units, emergency departments, and diagnostic and interventional areas) are associated with increased risk of ADEs.6 Phillips and colleagues7 found that deaths (the most severe ADE) associated with medication errors involved central nervous system agents, antineoplastics, and cardiovascular drugs. Most of the common types of errors resulting in patient death involved the wrong dose (40.9 percent), the wrong drug (16 percent), and the wrong route of administration (9.5 percent). The causes of these deaths were categorized as oral and written miscommunication, name confusion (e.g., names that look or sound alike), similar or misleading container labeling, performance or knowledge deficits, and inappropriate packaging or device design.””

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 43258 Based on observation, interview, and record review, the hospital failed to demonstrate current and accurate records were kept for the receipt and disposition for all scheduled drugs, including patient’s own medications (POM, personal belongings) categorized as controlled substances (drugs regulated by the government due to potential for abuse, misuse, or health risks) for one of one patient, Patient (Pt 71) in accordance with professional standards when staff stored Pt 71’s POM and were not able to determine whether the POM contained controlled substances. The pharmacy did not have a system in place to accurately record receipt and disposition of POM stored in the pharmacy. These failures had the potential for inadequate oversight for controlled substances accountability for 325 patients, preventable loss of patient’s property, inadequate hospital measures to prevent drug diversion (illegal distribution of controlled substances not intended by the prescriber), and impaired (under the influence) staff providing patient care. Findings: During an interview on 6/3/25 at 11:28 a.m. with Director of Pharmacy (DOP), DOP stated the hospital followed ASHP (American Society of Health System - a professional organization) standards of practice for hospital pharmacy services. During a concurrent observation and interview on 6/3/25 at 2:03 p.m. with the Pharmacy Manager/Pharmacist-in-Charge (PM/PIC), an inspection of the locked cabinet designated for POM without active medication orders to be dispensed in the hospital was conducted. Inside the cabinet was a red plastic bin labeled, “PATIENTS’ OWN MEDICATIONS. CONTROLLED. TO BE DESTROYED.” Two sealed plastic bags labeled “8952046” and “8952047” were observed stapled together inside the red bin. The bags were prelabeled with “Patient’s Medicine Inventory” with spaces for staff to fill out which included the patient’s name and inventory of what medications were placed in the bag. Outside of the bag labeled “8952046” was a pink sticker labeled “DISCHARGED DATE: 3/26/25 DESTRUCTION DATE: 4/26/25.” Inside of the bags were Patient 71’s medications along with papers and a pill box that contained various pills. PM/PIC stated staff visually inspected the medications placed in the bag to know if any of them were controlled substances. She stated that in this case it was difficult to know what was in the bag since it was not filled out appropriately and it was difficult to visually inspect with unlabeled pills in the pill box and papers stuffed in the bag. PM/PIC stated since they could not verify what was in the bag, they were treating the contents as though they were controlled substances. During an interview on 6/6/25 at 10:15 a.m. with PM/PIC, PM/PIC stated to verify the contents of the bags containing Patient 71’s medications, it would have had to be opened and inspected but they did not do that because it would have compromised the security seal. PM/PIC confirmed the bags came from the Emergency Department (ED) and stated they do not open the bag unless they receive authorization or give it back to nursing staff to take to the patient to open it. The PM/PIC stated the hospital has received controlled substances of POM in the past to store in the Pharmacy Department and the hospital has potential in the future to receive controlled substances of POM to store in the Pharmacy Department. During a concurrent interview and record review on 6/6/25 at 1:33 p.m. with DOP, PM/PIC and Pharmacy Manager/Quality & Education (PM/QE), hospital policies on patient’s home medications and controlled substances were reviewed. PM/QE stated the hospital’s policy on POM would address storage of POM CS. Review of the policies titled, “Medication from Home,” dated 3/14/25, and “Controlled Substance- Surveillance System,” dated 6/27/24 did not contain policies or procedures regarding narcotic accountability for POM categorized as controlled substances. During a review of “ASHP [American Society of Health System - a professional organization] Guidelines on Preventing Diversion of Controlled Substances,” dated 2022, the section titled “Purpose” indicated, “Controlled Substances (CS) diversion in health systems can lead to serious patient safety issues, harm to the diverter, and significant liability risk to the organization. Diversion puts patients at risk of harm, directly or indirectly.” The section titled “Patient’s Own Medications, Medical Cannabis [plant], Marijuana [substance with mind-altering effects], and Illicit [not permitted] Substances,” indicated “Healthcare organization should develop procedures for the disposition of patients CS ...brought into a facility.” The section titled “CS Brought into the Hospital by Patients,” indicated “Procedures are established that address special circumstances to ensure controls are in place to secure CS and prevent diversion of CS brought into the organization by patients. Patients should be encouraged to return their own medications to home via a household member or authorized agent when possible. Alternatively, patients or their authorized agent may be provided with an envelope to mail prescriptions to their home or directed to a collection receptacle for disposal ...CS should only be allowed when they are to be administered to the patient pursuant to a medication order, on behalf of the patient, and with their consent. These medications should be inventoried and stored in a secure location. When a patient is not able to maintain security of their own medications due to loss of competence or death, or when medications are abandoned, documentation of the patient’s home medications, quantity [physical count] inventoried, and signature of two verifying HCWs [licensed health care workers] should be recorded in the medical record upon receipt of the medications, and arrangements made as soon as possible for appropriate disposition.” During a review of “ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals,” dated 2013, the section titled “Purpose” indicated, “The following minimum standard guidelines are intended to serve as a basic guide for the provision of pharmacy services in hospitals.” The section titled “Controlled Substances” indicated, “There shall be policies and procedures to ensure control of the distribution and use of controlled substances and other medications with a potential for abuse. These policies and procedures shall be consistent with applicable laws and regulations and shall include methods for preventing and detecting diversion.” The section titled “Patient’s Own Medications” indicated, “Drug products and related devices brought into the hospital by patients shall be identified by the pharmacy and documented in the patient’s medical record if the medications are to be used during hospitalization. They shall be administered only pursuant to a prescriber’s order and according to hospital policies and procedures, which should ensure the pharmacist’s identification and validation of medication integrity as well as the secure and appropriate storage and management of such medications.” During a review of the hospital’s policy and procedure titled, “Medication from Home,” dated 3/14/25, the P&P indicated, “IV. Procedure A Storage of a Patient’s Home Medication ... 2. Emergency Department a. If no one is available to take the patient’s medication home, the Licensed Nurse obtains a ‘Patient’s Medicine Inventory’ bag from the unit supply shelf or from the Stockroom. b. Licensed Nurse completed the Inventory section on the bag by listing the patient’s medication and places the medication in the bag. c. Licensed Nurse places the patient’s label on the front of the bag in the section asking for the patient information and on the tear-off receipt at the top of the bag. d. Licensed Nurse seals the bag. e. Licensed Nurse to record patient’s home medication in the EHR under Patient Stored Medications section ...” During a review of the hospital’s policy and procedure titled, “Patient Valuables and Personal Property,” dated 5/3/23, the P&P indicated, “ IV. PROCEDURE ...B. Medications from Home ... 2. If no one is available to take the medications home, the medications are listed on the patient’s medicine inventory bag and placed in this plastic bag in the presence of the patient if possible, and sent to Pharmacy for storage.” During a review of the hospital’s policy and procedure titled, “Controlled Substances - Surveillance System,” dated 6/27/24, the P&P indicated, “Purpose. To ensure compliance with California and Federal laws pertaining to accountability of controlled substances ...Policy ... The Pharmacy Managers and/or PICs must have risk mitigation strategies employed to reduce the risk of controlled substance theft or significant loss.” During a review of the hospital’s policy and procedure titled, “Controlled Substances - Storage,” dated 12/6/24, the P&P indicated, “Purpose. To ensure that all Drug Enforcement Administration (DEA - federal law enforcement agency) defined controlled substances are managed in compliance with State and Federal laws pertaining to proper storage of controlled substances within the hospital ... Policy ... It is the responsibility of the Pharmacy Manager/designee to abide by the State and Federal Laws pertaining to proper storage of controlled substances.””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 43258 Based on interview and record review, the hospital failed to provide patient safety for medication use for three of 72 sampled patients (Patient 6, Patient 9, and Patient 16) when: 1. Patient 16’s vancomycin (an antibiotic to treat infection) trough (a blood level to measure the amount of antibiotic in the body) levels were not obtained in accordance with professional standards to guide dosing and monitor safety, despite Patient 16 receiving multiple doses of the antibiotic; 2. Multiple incomplete and unclear PRN (as needed) pain medication orders were not clarified for indication for use (e.g. mild, moderate, or severe pain) prior to administration (Patients 6 and 9); and 3. A pain assessment was not completed before an opioid pain medication (a class of medication identified as high-risk/high-alert medications - drugs that bear a heightened risk of causing significant patient harm when used in error) was administered to Patient 9. These failures had the potential to result in inappropriate medication administration, preventable medication errors, unmonitored antibiotic use, suboptimal therapeutic outcomes, increased risk of adverse drug events including vancomycin-related toxicity (kidney and ear damage) and oversedation, and patient harm or death. Findings: 1. A review of Patient 16’s History & Physical (H&P, comprehensive patient assessment) indicated he presented to the ED on 6/2/25 with complaint of swelling, redness and pain in his lower right extremity. The Assessment and Plan indicated, “Sepsis (an infection in the blood) ... Start Zosyn (an antibiotic to treat infection) and vancomycin empirically ... Cellulitis (a skin infection) and abscess (a pus-filled pocket that forms in the body due to an infection) of lower extremity ... Start Zosyn and vancomycin empirically ...” A review of Patient 16’s medical record indicated a loading dose (an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose) of vancomycin 2 grams/500 ml (g/ml, a unit of measurement) ordered on 6/2/25 and administered at 7:54 a.m. Following the loading dose, Patient 16 was ordered vancomycin 1.5 g/500 ml, administered 3 times per day, dated 6/2/25 and administered on the following dates and times: 6/2/25 at 5:02 p.m., 6/2/25 at 10:02 p.m., 6/3/25 at 4:29 a.m., 6/3/25 at 1:35 p.m., 6/4/25 at 12:26 a.m., and 6/4/25 at 8:26 a.m. This was a total of seven vancomycin doses over the span of three days. A review of Patient 16’s pharmacy progress notes titled, “Clinical Pharmacy- Vancomycin Consult Initiation,” dated 6/2/25 at 8:42 a.m., the note indicated, “3. Pharmacy will order trough level as clinically appropriate ... 5. Pharmacy will continue to monitor patient and adjust vancomycin therapy as clinically indicated ...” A review of Patient 16’s Initial Dose Comment documented by the pharmacist for vancomycin, dated 6/3/25, the document indicated, “ ...Vancomycin may take some time to accumulate. Will check trough tomorrow.” During an interview on 6/3/25 at 11:28 a.m., with Director of Pharmacy (DOP), DOP stated the hospital followed ASHP (American Society of Health-System Pharmacists - a professional pharmacy organization) standards of practice for hospital pharmacy services. A review of Patient 16’s Nursing Reminder task indicated an order dated 6/4/25 at 12:30 p.m. for the first vancomycin trough after the seventh administered dose (instead of around third or fourth vancomycin dose). During a concurrent interview and record review on 6/11/25 at 3:07 p.m. with MSC 1, Patient 16’s labs were reviewed. MSC 1 confirmed there were no vancomycin trough levels drawn for Patient 16. During a concurrent interview and record review on 6/12/25 at 8:33 a.m. with DOP, Patient 16’s labs were reviewed. DOP confirmed vancomycin trough levels had not been completed for Patient 16. DOP stated the order for trough levels to be drawn was on 6/4/25 but the medication had been discontinued before it was due. DOP stated the reason trough levels were not ordered to be drawn sooner was because Patient 16 was obese. According to Micromedex (a comprehensive, evidence-based online database that provides drug, disease, and toxicology information for healthcare professionals), the half life of vancomycin in an adult with normal kidney function is four to six hours. This range indicates vancomycin trough levels should be completed between 12 and 30 hours after initiating therapy. Review of the section titled “Medication Safety” indicated, “Perform early and frequent therapeutic monitoring of AUC [area under the serum curve, method for monitoring vancomycin therapy] exposure in obese patients for dose adjustments; obtain peak and trough concentrations if possible.” A review of “Therapeutic Monitoring of Vancomycin in Adult Patients: A Consensus Review of the American Society of Health-System Pharmacists [ASHP], the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists,” dated 2009, indicated, “Vancomycin has long been considered a nephrotoxic (toxic to the kidneys) and ototoxic (toxic to the ears) agent. Excessive serum (blood) drug concentrations have been implicated, and it was assumed that monitoring of serum concentrations would allow interventions that decrease toxicity... All patients receiving prolonged courses of vancomycin should have at least one steady-state trough concentration obtained (just before the fourth dose).” During a review of the facility’s procedure titled, “Adult Vancomycin and Aminoglycoside Dosing Guidelines,” dated 11/23/21, the procedure indicated, “I. Purpose: To establish adult pharmacokinetic (PK) dosing guidelines for parenterally (through the vein) administered aminoglycosides and vancomycin to be used by [the hospital system’s] clinical pharmacists ... III. Policy: These guidelines will be used to dose and monitor the use of aminoglycosides or vancomycin therapy by [the hospital system’s] clinical pharmacists in patients 18 years of age or greater ... C. Vancomycin Dosing Guidelines ... 7. Monitoring ... b. Trough levels are obtained after the patient has reached steady-state if vancomycin therapy is expected to continue for greater than 3 days (a minimum of 3 to 5 half lives [the time it takes for the amount of a drug’s active substance in your body to reduce by half] ... around the 3rd or 4th maintenance dose) ...” 2a. A review of Patient 9’s History & Physical (H&P) indicated he was admitted to the emergency department (ED) on 6/1/25 with suspected diagnoses which included sepsis (a life-threatening condition that arises when the body’s response to an infection spirals out of control, causing widespread inflammation and potentially damaging organs) and a history of chronic back pain. A review of Patient 9’s medical record indicated physician’s orders for the following: - Hydrocodone/APAP (an opioid pain medication) 10/325 milligrams (mg, a unit of measurement for dose): 1 tablet every 6 hours PRN for pain (for unspecified pain level, where is 0/10 is no pain and 10/10 is severe pain), scheduled start date 6/1/25 at 11:50 p.m. and “End Date/Time” on 6/3/25 at 1:24 p.m. - Acetaminophen (medication to treat pain and fever) 650 mg: 1 tablet every 6 hours PRN for mild pain (for numeric score 1-3/10), fever, for temperature greater than 39 degrees Celsius, scheduled start date 6/1/25 at 10:41 p.m. and “End Date/Time” on 6/4/25 at 12:03 a.m. During a concurrent interview and record review on 6/12/25 at 9:06 a.m. with Director of Pharmacy (DOP), Patient 9’s orders for pain medication were reviewed. DOP stated there was a role for pharmacy to clarify overlapping orders indicated for pain, such as Resident 9’s orders for Hydrocodone/APAP and acetaminophen, to clarify with the prescriber when each medication was indicated. DOP reviewed Patient 9’s medical record and confirmed pharmacy did not seek clarification for the above-mentioned orders. During a concurrent interview and record review on 6/12/25 at 9:35 a.m. with Nurse Manager 2 (NM 2), Patient 9’s orders for pain medication were reviewed. NM 2 stated it was the expectation of nursing staff to obtain clarification if a patient had multiple as-needed pain medication orders. 2b. A review of Patient 6’s H&P indicated she was admitted to the ED on 6/1/25 with suspected diagnoses which included cellulitis (an infection caused by bacteria spreading through a break in the skin) of the right leg and swelling of both legs. A review of Patient 6’s medical record indicated physician’s orders for the following: - Hydrocodone/APAP 5/325 mg: 1 tablet every 4 hours PRN for pain (for unspecified pain level), scheduled start date 6/1/25 at 2:47 p.m. and “End Date/Time” of 6/1/25 at 5:19 p.m. - Hydrocodone/APAP 5/325 mg: 1 tablet every 6 hours PRN for pain (for unspecified pain level), modified time of 6/1/25 at 5:19 p.m., and “End Date/Time” of 6/5/25 at 9:30 p.m. - Acetaminophen 650 mg: 1 tablet every 6 hours PRN for mild pain (for numeric score 1-3/10), fever, for temperature greater than 39 degrees Celsius, scheduled start date 6/1/25 at 5:19 p.m. and “End Date/Time” for 6/5/25 at 9:30 p.m. During a concurrent interview and record review on 6/12/25 at 9:08 a.m. with DOP, Patient 6’s orders for pain medication were reviewed. DOP confirmed it was expected for pharmacy to get clarification of duplicate orders and acknowledged that it was not done. During a review of the hospital’s policy and procedure (P&P) titled, “Medication Orders- Pharmacist Order Review Process,” dated 12/3/24, the P&P indicated, “II. Policy: The Pharmacist will review all medication orders to assure that appropriate medication prescribing (dose, route, drug) is performed for the purposes of accuracy and patient safety ... If there are questions and/or concerns, the prescriber will be contacted to discuss these concerns ...” During a review of the hospital’s P&P titled, “Medications- Orders, Administration, Storage, Documentation,” dated 12/19/23, the P&P indicated, “III. Policy A. Medication Orders ... 4. Any orders for medications that are illegible, incomplete, and/or unclear will require clarification ... b. If an illegible, incomplete, and/or unclear order is received in the Pharmacy, the Pharmacist will contact the ordering prescriber and will clarify using the telephone/verbal order process ... Pharmacy will communicate the changes to the patient’s RN (registered nurse) ...” During a review of the hospital’s P&P titled, “Pain Assessment & Management- Patients 14 and Older,” dated 1/15/25, the P&P indicated, “IV. Procedure ...B. Data Collection and Assessment ...6. Pain management scales utilizing the 0-10 descriptors, will be assessed as a pain rating of 0=no pain, 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain. Patients denial of pain will be interpreted as 0 ... D. Implementation 1. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider.” 3. A review of Patient 9’s H&P indicated he was admitted to the ED on 6/1/25 with suspected diagnoses which included severe sepsis and acute kidney failure. A review of Patient 9’s medical record indicated a physician’s order for fentanyl (an opioid medication to treat severe pain) injection 25 micrograms (mcg, a unit of measurement), every hour PRN for moderate pain, severe pain, scheduled start date 6/3/25 at 1:10 p.m. Fentanyl belongs to a class of drugs called opioids. IV opioids work in the brain to produce a variety of effects including pain relief. IV opioids are potent and potentially dangerous medications due to their potential to cause adverse events, such as over sedation, respiratory depression, and death in some cases. During a concurrent interview and record review on 6/11/25 at 1 p.m. with NM2, Patient 9’s Pain Monitoring dated 6/3/25 and Medication Administration Record (MAR) for fentanyl were reviewed. NM 2 confirmed Patient 9’s MAR indicated he was administered fentanyl 25 mcg on 6/4/25 at 3:51 a.m. NM 2 reviewed the Pain Monitoring on 6/4/25 and confirmed she did not see a pain assessment completed prior to the administration. She stated she did not see any documentation between 2:21 a.m. and 4:21 p.m. regarding pain. NM 2 stated it was expected for nursing staff to do an assessment using a scale prior to pain medication administration, then look at the medications in a patient’s chart to see which one would be deemed appropriate for the pain. American Society of Health-System Pharmacists (ASHP), the largest professional association of pharmacists in the United States, has identified minimum standard guidelines intended to serve as a basic guide for the provision of pharmacy services in hospitals. The “ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals,” dated 4/13/12, indicated, “Medication therapy monitoring includes a proactive assessment of patient problems and an assessment of the following: a. The therapeutic appropriateness of the patient’s medication regimen ... c. The appropriateness of the dose of the medication, as well as the route, method, and frequency of administration of the medication ... e. Medication-medication, medication-food, medication-dietary supplement, medication-laboratory test, and medication-disease interactions. f. Adverse drug reactions and other undesired effects ... h. Clinical and pharmacokinetic laboratory data to evaluate the efficacy and safety of medication therapy and to anticipate toxicity and adverse effects.” During a review of the hospital’s P&P titled, “Pain Assessment & Management- Patients 14 and Older,” dated 1/15/25, the P&P indicated, “IV. Procedure ... E. Monitor- Assessment/Reassessment of Pain Management and Adverse Effects 1. Assessment for pain so to be completed using the appropriate pain assessment tools during routine unit assessment times, prior to pain medication administration and as needed.””

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 28773 Based on staff interviews and review of hospital documents, the hospital failed to ensure food and nutrition services were organized effectively when the structure of the hospital policy and procedure regarding nutrition screening and assessment was not following current standards of practice according to the Academy of Nutrition and Dietetics. This failure has the potential to result in the delay of nutritional care and interventions for patients, which can worsen patient health outcomes. (Cross Reference A-0398) Findings: During the course of the full validation survey from 6/3/25 until 6/5/25, nine clinical records were reviewed for clinical nutrition care. Two clinical records (Patient 46 and 21) had inaccurate nursing admission nutrition risk assessments. Patient 46 was not appropriately assessed for nutrition risk and there was no referral to the Registered Dietitian when Patient 46’s admission history and physical (H&P) were performed by the physician, dated 5/31/25, indicated that Patient 46’s chief complaint was failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). The physician’s “H&P” also indicated Patient 46 had no appetite and had lost weight 1 week prior to the hospital admission. After the H&P was completed, the nurse did the Malnutrition Screening Tool (MST) to determine the patient’s nutrition risk by asking two questions: “have you lost weight recently without trying? No, have you been eating poorly because of a decreased appetite? No.” Within two hours of admission the nurse did a comprehensive nursing assessment and determined Patient 46 had nausea. Despite this Patient 46 received a score of 0 on the MST tool and a nutrition consult was not triggered. During a review of Patient 21’s history and physical completed by the physician, dated 5/25/25, indicated the patient was admitted to the hospital with a chief complaint of altered mental status (change in a person’s cognitive function, including alertness, attention, orientation, and memory) and failure to thrive per staff at the skilled nursing facility with decreased appetite and intake for two to three days. The nursing nutrition screen for the MST was scored as a 0 and answered No to the questions “have you lost weight recently without trying? And have you been eating poorly because of a decreased appetite?” (Cross Reference A-0398) During an interview with the Registered Dietitian (RD 1) on 6/04/2025 at 11:42 a.m. with a concurrent clinical nutrition chart review, RD 1 explained the process for seeing inpatients. RD 1 indicated patients are seen within 24 hours from a MD consult, within 36 hours of a nutrition support consult and within 48 hours from a nursing or education consult. The RD also indicated patients who are on clear liquids (CL) would be seen within 3 days and patients who are nothing by mouth (NPO). The remaining patients would be seen within 5 days of admission. RD 1 confirmed nursing does the nutrition admission screen within 24 hours. RD 1 stated an MST score of 2 or greater for poor nutrition, weight loss, wounds, enteral (EN) or parenteral nutrition (PN) (feeding by tube through the gut or vein), or burns. During a review of the hospital policy and procedures titled, “Nutritional Care and Documentation in the EHR”, dated 2/10/25, indicated Nursing is responsible for the initial screening during the admission process and all patients will be screened for nutrition risk within 24 hours of admission. The following indicators would generate a referral to the Registered Dietitian (RD). For Adult patients, a malnutrition score of greater than or equal to two on the Malnutrition Screening Tool, nutrition support (enteral or parental nutrition - feeding by the gut or vein), pressure injury stage II or greater or a major burn greater than 20% total body surface area. The policy indicated “The RD will perform a nutrition assessment for all patients a. within 24 hours of receiving an Inpatient Consult for all reasons except education. b. within 36 hours of initial nutrition support orders (unless patient’s nutrition support needs were already assessed and documented by RD). c. within 48 hours of receiving a Nursing Referral generated from the Nutrition Screening conducted on admission .... 3. Within 24 hours of consult for Calorie Count, the RD will initiate the Calorie Count ... 4. Within 48 hours of consult or referral for education, the RD will provide nutrition education within the parameters of the diet order or as specified within the Consult. 5. Unless previously consulted, the RD will perform a nutrition assessment for all adult patients ... b. within 5 days of admission at CCMC excluding perinatal patients. These patients are assessed within 7 days of admission .... 7. Unless previously consulted, the RD will perform a nutrition assessment for all patients a. with a diet order of NPO for 3 days. b. with diet orders of NPO and Clear Liquid for 5 days. c. with a diet order of Clear Liquid for 5 days.” During an interview with the Clinical Nutrition Manager (CNM) on 6/5/25 starting at 1:50 p.m., the CNM was asked to describe how they identify high risk nutrition patients, after admission, who have specialized diets s such as renal (kidnet health) diet or consistent carbohydrate diet orders. CNM stated the RDs use clinical judgement for malnutrition. The CNM also stated the RDs review the hospital census each morning and review diets such as NPO/CL and patients receiving EN/PN. The RD summarized a system, that unless a consult was ordered, all patients with therapeutic diets would be assessed within 5 days. The remaining patients would be assessed on the sixth day of admission. The CNM stated their policy, and procedure is based on the Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM). The CNM stated the RDs also get a list of patients on anticoagulant medications so they can educate them for food-drug interactions. CNM reviewed the AND NCM in conjunction with surveyors and acknowledged that the policy does not capture all the items listed in the AND NCM. During a review of the Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM indicated to have Screening for nutrition problems other than malnutrition that included obesity, patients with history of heart failure, presence of edema on admission, and need for sodium-restricted diet. It also indicated, “In adults undergoing dialysis, assessments are best obtained after treatment when body fluid compartment levels are more likely to be balanced.” The NCM referenced “KDOQI Clinical Practice Guideline for Nutrition in CKD (CPG)”, dated 2020, the CPG indicated, “. . .percent change in usual body weight (dry weight in maintenance dialysis patients) may be a more reliable measure.” Additionally the NCM indicated “the Academy of Nutrition and Dietetics Evidence Analysis Library (EAL) Type 1 and Type 2 Diabetes Evidence-Based Nutrition Practice Guidelines for Adults make the following recommendations regarding carbohydrate intake (Academy EAL, 2008) In persons on medical nutrition therapy alone, glucose-lowering medications, or fixed insulin doses, meal and snack carbohydrate intake should be kept consistent on a day-to-day basis ..... The amount of carbohydrate is determined by the RDN (Registered Dietitian Nutritionist) in consultation with the individual with diabetes.” It indicated the following amounts are often used as a starting point, for women it is three to four carbohydrate servings per meal and one if desired for a snack and for men it is four to five per meal and one if desired for snack. It further indicated the amounts can then be adjusted based on the individual’s determination of what is reasonable for him or her to follow long-term and on blood glucose monitoring results. The hospital policy and procedure did not reflect the current standard of practice. During a review of the hospital “Diet Manual”, dated revised 11/24, indicated the hospital had diets called diabetic diet and consistent carbohydrate diet. Both diets indicated they provided a consistent amount of carbohydrates during mealtimes and up to four (4) carbohydrates are provided at each meal and that an evening snack consisting of one (1) carbohydrate and 1 protein exchange would be provided upon physician’s order. It is unclear whether patients with Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) would get the appropriate amount of carbohydrate, based on their individualized nutritional needs, if the RD does not assess the patient in a timely manner while hospitalized.”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 28773 Based on staff interviews, review of clinical records and hospital documents, the hospital failed to ensure therapeutic diet orders were followed when the hospitals diet manual and the department’s policy and procedure for nutrition supplementation did not provide clear parameters when the Registered Dietitian initiated nutrition supplements. This failure could result in patients having an increase in adverse clinical status. Findings: During a review of clinical record for Patient 21 in the presence of the Registered Dietitian (RD 1) and Clinical Nutrition Manager (CNM), Patient 21 was admitted to the hospital with a chief complaint of altered mental status (change in a person’s cognitive function, including alertness, attention, orientation, and memory) and failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) per staff at the skilled nursing facility with decreased appetite and intake for two to three days. Review of physician orders dated 5/26/25, indicated a ground/minced diabetic diet. Review of diet orders, written by a Registered Dietitian, dated 5/29/25 at 10:51 a.m., initiated a nutrition supplement (Ensure Max protein) two times a day. During a concurrent interview with the clinical record review of Patient 21 with RD 1 on 6/4/25 at 12:10 p.m., RD 1 stated the hospital has a system for every diet order there is a mechanism for the physician to check a box as a “yes” to allow the RD to provide oral nutrition supplements. RD 1 acknowledged for Patient 21 that was not checked or marked as a “yes” in the current diet order. During an interview with RD 1 on 6/4/25 at 3:01 p.m., RD 1 stated if the diet order did not give the RD the ability initiate a nutrition supplement, then the RD needed to call the physician and get a telephone order. During a review of the diet order entry system in the electronic medical record, indicated “RD may individualize the dietary treatment plan within the parameters of the prescribed diet order as outlined in the diet manual? (Examples: may provide snacks, accommodate preferences, adjust portion sizes and provide oral nutrition supplements).” During a review of the hospital policy and procedure titled “Enteral Nutrition, Oral Nutrition Supplements, and Parenteral Nutrition” dated 1/5/23, indicated “ ...A. . B. A physician order is required for the provision of any food/beverage support for therapeutic diets, ONS, EN support and PN support. Orders are placed in the Electronic Health Record (EHR) .....D. A RD may individualize the patient’s nutritional or dietary treatment, when necessary, by modifying the distribution, type, or quantity of food and nutrients within the parameters of the diet order unless otherwise stated in the diet order by a patient’s provider. This includes the planning and provision of ONS and specified EN formulas which may be added, changed, or discontinued. Refer to the respective facility diet manual for approved nutritional interventions based on the prescribed diet.” During a review of the hospital’s Diet Manual and Enteral Nutrition Formulary 2025, dated revised November 2024, noted the section titled “approved nutritional interventions” was consistent with the hospital’s enteral, parenteral and oral nutritional supplement policy. that “all diet orders include the option of an Oral Nutrition Supplement (ONS). The diet manual also included a crosswalk that showed the different diets and what oral nutrition supplements were allowed. However, this portion of the diet manual die not include under what circumstances or parameters oral nutrition supplements could be added by the RD. During an interview with the CNM on 6/5/25 at 1:50 p.m., CNM acknowledged the policy and diet manual did not specify under which circumstances an ONS would be initiated and additionally lacked specific parameters such as frequency, duration and monitoring for effectiveness of the intervention.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45977 Based on observation, interview, and record review, the hospital’s infection prevention and control program (IPCP) failed to ensure a clean and sanitary environment in accordance with hospital policies and procedures and national standards of practice for infection control to prevent and control infections among patients, personnel, and visitors when: 1. In two of two sampled rooms (The Inpatient and Outpatient Sterile Processing Decontamination [SPD] rooms), SPD staff did not clean and maintain the floors and six of six washer conveyors (a sterile processing room conveyor system is a specialized material handling solution designed for healthcare environments like hospitals and surgical centers. Its main purpose is to automate the transportation of medical instruments and supplies throughout the sterile processing workflow, from decontamination to sterilization and storage.) in accordance with manufacturer’s instructions. A white substance was found on the floor in the Inpatient Decontamination room. In six of six conveyor systems, white residue and black debris was observed. 2. Staff failed to ensure a biohazardous waste container (a special container to dispose of items that might have germs, blood, needles, glass, medication, and sharp objects) was closed in an ultrasound (a test using soundwaves to make pictures of the body) treatment room (Ultrasound Room 2) that was not in use, and in accordance with the hospital’s policy and national guidelines. 3. Staff failed to ensure the hospitals policy for transporting contaminated (dirty or with germs that could make people sick) instruments was followed and there were no biohazardous labels or containers for contaminated vaginal ultrasound probe transportation. 4. Soiled adhesive from tape was left on the walls in in two of two sampled obstetric (OB - a branch of medicine that deals with pregnancy, childbirth) operating area rooms (C-Section 2 and Clean Supply Room) and should have been removed and cleaned in accordance with infection control standards. 5. Staff did not document the monitoring for cooling of potentially hazardous foods that were located in the hospital walk-in refrigerator in accordance with hospital policies and procedures and standards of practice. 6. Food items stored in a reach-in refrigerator in the hospital kitchen were greater than 41 degrees Fahrenheit (F) and not in accordance with standards of practice. 7. Areas of the kitchen and adjacent areas were not maintained in a sanitary manner in accordance with standards of practice. The cooks’ tool cabinet was disorganized and had food crumbs., The catering/doctors’ lounge cooking line had a build up of black grime and the cafeteria cooking line had a build-up of food on the floor under the equipment and under the counter refrigerators had food crumbs on the shelves. 8. In the NICU (neonatal intensive care unit), bottles were being washed in a handwashing sink and a sanitizer that is not food safe was being used to sanitize the bottle preparation counter and staff did not follow standards of practice for these items. 9. The hospital failed to ensure a single-use only syringe used to administer medications was discarded after use in accordance with hospital policy and procedure. As a result of these failures all patients and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: During an interview on 6/11/25 at 9:50 a.m., in the Imaging Department, with the Infection Prevention Director (IPD), the IPD stated the hospital followed nationally recognized guidelines: a. APIC - Association for Professionals in Infection Control b. AORN - Association of Perioperative Registered Nurses c. AAMI - Association for the Advancement of Medical Instrumentation d. ASHRAE - American Society of Heating, Refrigerating, and Air-Conditioning Engineers e. CDC - Center for Disease Control and Prevention f. OSHA - Occupational Safety and Health Administration 1. During a concurrent observation and interview, on 6/5/25, at 10:50 a.m., with the Sterile Processing Department (SPD) Manager (SPM), Director of Surgical Services (SSD), Surgical Services Nurse Educator (NE 1), SPD Supervisor (SPS), and Infection Preventionist (IP 1), on the first floor, in the Inpatient Sterile Processing decontamination room, between the cart washer and the conveyor system, the floor was observed with four inches of white substance or residue in the corner next to the floor sink. SPM stated, it appears to be salts left from hard water and the machine the cleaning staff use for the floor missed the corner. SPM stated, the staff should have manually cleaned the corner and made sure the floors were clean. SPM stated, it is expected the floors are terminally cleaned (thorough disinfection and cleaning) every day. During a concurrent observation and interview, on 6/5/25, at 10:55 a.m., with the SPM, SSD, NE 1, SPS and IP 1, on the first floor, in the Inpatient Sterile Processing decontamination room, the conveyor system was observed with white spots and white residue before four of four entrances to the washer/disinfectors. SPM stated, the white spots are water deposits and appear after the staff clean the conveyor system. SPM stated, a separate vendor has been used to clean the conveyors. SPM stated, the conveyor should be cleaned without any visible spots or debris. During a concurrent observation and interview, on 6/5/25, at 11:20 a.m., with the SPM, SSD, NE 1, IP 1 and Infection Preventionist Director (IPD), on the first floor, in the Outpatient Sterile Processing decontamination room, the conveyor system was observed with white spots and black residue before two of two entrances to the washer/disinfectors. The washers/disinfectors had not been used for the day. SPM stated, the conveyor should be cleaned daily so that no white spots or debris is in the conveyor system. During an interview, on 6/11/25, at 9:15 a.m., with the IP 1 and Infection Preventionist Director (IPD), IP 1 stated, the SPS decontamination rooms should be cleaned daily and there should be no water spots or debris on the floor. IP 1 stated, there should be no water spots on the equipment or conveyor system for any of the washers in SPS. IPD stated, he agrees with IP 1 and SPS should ensure that the equipment and floors are clean. During an interview, on 6/11/25, at 9:15 a.m., with the Chief Nursing Officer (CNO), the CNO stated, she expected the SPS decontamination rooms should be cleaned daily and her team would be looking into cleaning the equipment more often if needed. CNO stated, the SPS staff should follow the policies about cleaning and ensure the hard water spots are cleaned on the floor and equipment. During a review of the conveyor system manufacturers operator manual titled, “[BRAND NAME] Conveyor System”, dated 8/7/23, the manual indicated, “ ... 5.3 Routine Maintenance ... Maintenance procedures described in this section must be performed as required at the suggested frequency. The indicated frequencies are minimums and can be changed if use warrants ... Clean conveyor drip pan ... 1x [once]/day ... Clean motorized and/or non-motorized rollers ... 1x [once]/day ... Clean plastic side and corner guides ... 1x[once]/day ...” During a review of the facility policy and Procedure (P&P) titled, “Environmental Cleaning and Disinfection Policy”, dated 10/31/23, the record indicated, “ ... To reduce the risk of healthcare-associated infections (HAIs) by defining the general requirements for cleaning and disinfection performed by the environmental services department. ... Tasks sheets have been developed that detail the cleaning and disinfection requirements for designated areas. Tasks sheets also include general reminders about cleaning and disinfection, as wells as, a room checklist ... Department leadership will perform regular service quality checks ... “ According to the Centers for Disease Control (CDC), undated, retrieved 8/2/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, “ Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)” During a review of the document titled, “CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings” retrieved from, https://www.cdc.gov/infection-control/hcp/core-practices/index.html dated 4/12/24, “ ...standard precautions (basic level of infection control that is used in patient care) include: ...hand hygiene ...environmental cleaning and disinfection .. Reprocessing of reusable medical equipment between each patient or when soiled...” 2. During a concurrent observation and interview on 6/11/25 at 9:50 a.m., in Ultrasound Department Room 2 with the Manager of Imaging Department (MID), the Ultrasound Sonographer (US - person trained to use a machine to take pictures of the body using sound waves) 1, and the IPD, a red biohazardous sharps container was observed open while the room was not in use. The US validated the open container and stated the lid should be closed. The MID stated the container should be closed so others were not poked accidentally when handling the container, and it was a hospital policy that the container lid be closed when the room was not in use. The IPD stated an open biohazardous sharps container was an “infection control concern” and a potential for cross contamination (unintentional transfer of harmful germs from one person, object, or surface to another). During an interview on 6/12/25 at 9:30 a.m., with the Chief Nursing Officer (CNO), the CNO stated it was her expectation that staff follow all corporate policies. During a review of the hospital’s policy and procedure (P&P) titled, “Medical Waste Management”, dated 4/27/27, the P&P indicated “I. PURPOSE A. To prevent the contamination of patients, staff, equipment, and environment with medical waste ...V. PROCEDURE A. Waste Segregation ...3. Deposit Sharps into leak resistant, puncture resistant, rigid container which are taped or have tight lids ...” During a review of the hospital’s P&P titled, “Infection Prevention Plan - [Name of Hospital System], dated 2/27/27, the P&P indicated “III GOAL A. The goal of [Name of Hospital System] Infection Prevention Program is to minimize the risk of acquiring and transmitting healthcare associated infections (HAI)/infectious diseases to patients, employees, medical staff, residents, volunteers, contractors, students, and visitors. The overall goals of [Name of Hospital System] Infection Prevention program include ...2. Limited unprotected exposures to pathogens. 3. Limiting the transmission of infections associated with procedures. 4. Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. 5. Improving compliance with hand hygiene guidelines ...VIII. Responsibility A. Final responsibility for quality patient care resides with the Board of Trustees. Responsibility for infection prevention is delegated through the Medical Staff Office to the Infection Prevention Committee. The Infection Preventionist operate under direction of the Infection Prevention Committee and the Quality Management Department ...”. A review of OSHA’s regulatory requirement indicated the following, “...29 CFR 1910.1030(d)(4)(iii)(B)(1)(i), dated 08/09/2007 (August 9, 2007), requires that...Regulated waste shall be placed in containers which are...Closable...”. 3. During a concurrent observation and interview on 6/11/25 at 10:01 a.m., in Ultrasound Department Room 2, with the Director of Imaging (DID), MID, US 1, and the IPD, the US described how she transported a contaminated vaginal ultrasound probe from outside of the department for high level disinfection (the process used for the destruction of all germs except for low levels of bacterial spores). US 1 stated she transported a contaminated ultrasound probe by hand with plastic bag over the probe head, and the connection cord was uncovered. US 1 stated contaminated probes were not transported in a closed container with a biohazardous label. US 1 stated there were no designated containers for transporting contaminated ultrasound probes. The DID and MID validated the department did not have instrument containers and biohazardous labels for transport of contaminated instruments. The DID, MID, and US 1 were not aware of the hospital’s instrument transport policy for contaminated instruments. The IPD stated “ultrasound probes should be in a well-marked container for transport” so anyone in the hospital was aware there was a “potentially biohazardous instrument being transported”. During an interview on 6/12/25 at 9:30 a.m., with the CNO, the CNO stated it was her expectation that staff follow all corporate policies. During an interview on 6/12/25 at 10:50 a.m., with the IPD, the IPD stated there was a corporate policy for instrument transport and acknowledged the policy for instrument transport was not followed. The IPD stated contaminated instruments must be transported in a closed container and “clearly marked” as biohazardous to keep people safe. During a review of the hospital’s P&P titled, “Instrument Transport” dated 9/22, the P&P indicated “I. PURPOSE: To provide guidelines for cleaning, transporting instruments and medical devices to Sterile Processing other designated location for sterilization or disinfection to maintain infection prevention principles, safety, and facilitate optimal patient outcomes ...III. Policy ...C. Contaminated instruments must be contained during transport ...IV. Procedure H. Transport instruments to decontamination(to remove dangerous germs from objects so they are safe to handle or reuse) area ...in enclosed box that is: 1. Puncture resistant; ...a. Labeled with an indicator that indicates the contents are During a review of the hospital’s P&P titled, “Infection Prevention Plan - [Name of Hospital System], dated 2/27/27, the P&P indicated “III GOAL A. The goal of [Name of Hospital System] Infection Prevention Program is to minimize the risk of acquiring and transmitting healthcare associated infections (HAI)/infectious diseases to patients, employees, medical staff, residents, volunteers, contractors, students, and visitors. The overall goals of [Name of Hospital System] Infection Prevention program include ...2. Limited unprotected exposures to pathogens 3. Limiting the transmission of infections associated with procedures 4. Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies ...VIII. Responsibility A. Final responsibility for quality patient care resides with the Board of Trustees. Responsibility for infection prevention is delegated through the Medical Staff Office to the Infection Prevention Committee. The Infection Preventionist operate under direction of the Infection Prevention Committee and the Quality Management Department ...” During the review of ANSI/AAMI ST79::2017, Comprehensive guide to steam sterilization and sterility assurance in health care facilities, the guidelines indicated the following standard for hand transport of contaminated equipment “6 Handling, collection, and transport of contaminated items ...Procedures must be developed, with support from the infection prevention and control and hazardous materials personnel, to protect personnel, patients, and the environment from contamination and to comply with OSHA regulations ...6.5.4 Prior to transportation, items contaminated with blood and other potentially infectious materials should be placed in a container that is puncture=resistant, leak-proof on the bottoms and sides, labeled as biohazardous, and sealed. ...” 4. During a concurrent observation and interview on 6/11/25 at 10:18 a.m., in the OB operating room (OR) area with the Nurse Manager of OB (NM 5), and the IPD, in C-Section 2 room, and the clean supply room between C-Section 2 and C-Section 3, there was sticky brown and black residue on the walls. NM 5 stated the sticky substance on the walls was tape residue. NM 5 stated the nurses continue to use tape even after they have been trained not to. NM 5 stated tape residue created an infection control issue. The IPD stated sticky residue is harder to clean and tape residue can harbor infections in the OR. The IPD stated “tape is an IP no no”. During an interview on 6/11/25 at 10:32 a.m., with an environmental service staff member (EVSS)1, EVSS 1 stated she cleaned the C-section OR’s and supply area. EVSS 1 stated she received special training to work in the OR she was trained specifically to remove tape residue by using a special tool to scratch tape residue off and use adhesive remover. EVSS 1 was not aware there was tape residue in C-Section 2 and the clean supply room. During an interview on 6/12/25 at 9:30 a.m., with the CNO, the CNO stated it was her expectation that staff follow all corporate policies and sticker residue should have been removed. During a concurrent interview and document review on 6/12/25 at 10:25 a.m., with the IPD, the IDP shared a flyer titled “Did You Know”, dated June 2025. The document stated “Recent surveys and departmental audits have identified the need for increased attention to peeling or deteriorating stickers and labels across our facilities. Sticky residue from labels and tape can interfere with the effective cleaning and sterilization. These items must be fully removed, including all adhesive residue.” The IPD stated sticky tape residue was an infection control issue because sticky residue was “harder to clean and harbors infection”. The IPD stated the surface beneath the sticky residue cannot be effectively cleaned. During a review of the hospital’s P&P titled, “Procedural Area Terminal Cleaning”, dated 01/2024, the P&P indicated “ ...V. PROCEDURE ...D. Examine walls for visible soil and disinfect as needed ...” During a review of the hospital’s P&P titled, “Infection Prevention Plan - [Name of Hospital System], dated 2/27/27, the P&P indicated “III GOAL A. The goal of [Name of Hospital System] Infection Prevention Program is to minimize the risk of acquiring and transmitting healthcare associated infections (HAI)/infectious diseases to patients, employees, medical staff, residents, volunteers, contractors, students, and visitors. The overall goals of [Name of Hospital System] Infection Prevention program include ...2. Limited unprotected exposures to pathogens. 3. Limiting the transmission of infections associated with procedures. 4. Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. 5. Improving compliance with hand hygiene guidelines ...VIII. Responsibility A. Final responsibility for quality patient care resides with the Board of Trustees. Responsibility for infection prevention is delegated through the Medical Staff Office to the Infection Prevention Committee. The Infection Preventionist operate under direction of the Infection Prevention Committee and the Quality Management Department ...” A review of AORN “Guidelines for Environmental Cleaning”, dated January 2020 indicated “ ...terminal cleaning and disinfection of operating or procedure rooms be performed daily when these areas are in use. This process involves thorough cleaning of all surfaces and equipment to reduce the risk of infection ...” A review of OSHA requirements for bloodborne pathogens dated 8/9/2007, indicated the following: “... 29 CFR 1910.1030(d)(4)(ii): All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials. 29 CFR 1910.1030(d)(4)(ii)(A): Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning”. 5. Potentially hazardous foods (PHF) are those foods capable of supporting bacterial growth associated with foodborne illness. PHF includes foods like milk, meat, poultry, fish, eggs, and certain cooked foods like rice and pasta and require time and temperature control for food safety (Food and Drug Administration, FDA, Food Code, 2022). During the initial tour of the hospital kitchen on 6/3/25 starting at 10:59 a.m., in the hospital kitchen one of the walk-in refrigerators, there were multiple previously cooked foods that were located inside. There was a container of white-bean soup dated 6/1/25 and a hotel pan of white rice dated 6/1/25 use by 6/5/25. During an interview with the Executive Chef (EC) on 6/04/2025 at 10:41 a.m., EC stated the expectation is for foods that are cooled to go in the blast chiller and document on the cooling log. EC stated he was currently looking for cooling logs for 6/1 to see where the white bean soup and white rice were documented. During an interview with the Director of Food Services (DFS) on 6/05/2025 at 1:35 p.m., DFS stated they don’t have the cooling log for the white rice and the white bean soup. DFS stated it either got misplaced or not done. DFS stated she expects all items that are cooled to be on the cooling logs. During a review of the hospital policy and procedure titled “Food Cooling”, dated 12/8/24, indicated cooked PHF shall be cooled from 140 to 70 degrees F within 2 hours and to 41 degrees F within a total of six hours. It indicated under food cooling documentation, the cook will document the date, name of food item, temperature of food item and the time the cooling process started on the food cooling log. It indicated at 2 hours the cook will record the temperature of the food item on the food cooling log, at or before 6 hours, the cook will record the temperature of the food item on the food cooling log. It indicated once the cooling process is complete, the cook will cover, label and date the item and store appropriately. 6. During the initial tour of the hospital kitchen on 6/3/25 at 11:20 a.m.., in the hospital kitchen, an under-counter reach-in refrigerator located across from the cook line, there were multiple food items. There was previously cooked pasta that was dated 6/3/25 that was 43.2 degrees F, tuna salad dated 5/31/25 that was 42.4 degrees F. In the other under counter reach-in refrigerator located across from the cook line, there was a container of previously cooked pasta dated 6/3/25 that was 44.4 degrees F, ham dated 5/30 that was 42.6 degrees F, previously cooked beef dated 6/3 was 46.2 degrees, another container of previously cooked pasta dated 6/3 was 42.6 degrees F. During a concurrent interview with the EC on 6/3/25 at 11:30 a.m., EC took temperatures of the food items and acknowledged the temperatures were too high and stated that the reach-in refrigerators needed to be lowered. During a review of the hospital policy and procedures titled “Storage”, dated 11/13/24, indicated under refrigerated storage the prevailing air temperature of refrigeration units containing potentially hazardous foods must be cold enough to maintain them temperature of food stored therein at 41 degrees F or below. 7. During an observation and concurrent interview with the Food Service Director (FSD) on June 3, 2025, at 10:50 am, the chef’s tool cabinet, was disorganized and the drawers had food crumbs. A thermometer probe was sticky. Inside one of the cabinets there was a unknown black powder spill on the equipment inside, and on the shelf and on the door. The FSD stated the cabinet should be maintained clean and organized. During an observation in the kitchen on June 3, 2025, at 11:18 am, the catering and doctors’ lounge cooking line that included a flat top grill, a grill, larger flat top grill and a fryer, there was black grime build-up on the equipment, the storage drawers under the equipment had food crumbs and grease build-up. During an observation in the dish room and concurrent interview with Executive Chef (EC) on June 3, 2025 at 2:07 pm, staff are washing dishes using the high temperature dish machine (dishwashers that reach extremely high temperatures during their rinse cycles in order to sanitize dishes). EC put a temperature measuring disc into the machine at the rack level to determine the highest temperature reached. The temperature measuring device read 145 degrees Fahrenheit. EC stated the temperature should be 160 degrees Fahrenheit. EC put another temperature measuring device in the machine to get a second reading. This time the temperature was 141 degrees Fahrenheit. During an observation in the cafeteria kitchen on June 3, 2025, at 2:43 pm, the under the counter refrigerators had food and crumbs inside on the shelves. The floor under the equipment had a build-up of food and trash. During an interview with the Food Service Director (FSD), on June 5, 2025, at 1:35 pm, FSD stated there were some items that were not on the cleaning logs or that needed to be updated with more detail. FSD stated her expectation is that the catering and doctors lounge cooking line and the cafeteria cooking line should be maintained clean. She stated the cleaning log for the cook’s tool cabinet also needs to be updated to be cleaned more frequently. The FSD stated in regard to the dish machine, the temperature at the rack level should be 160 degrees. During a review of the nutrition and dining services facility policy titled, “Infection Prevention”, dated 04/16/2025, indicated “Cleaning: The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas. These duties are divided among Nutrition and Dining employees and outsourced as necessary.” During a review of the nutrition and dining services facility policy titled, “Infection Prevention”, dated 04/16/2025, indicated, “Dishwashing: 3. High temperature dish machine sanitizing occurs by use of the matrix of time and temperature. Dish machine temperatures maintained are: a. Wash: 150-165°F, b. Final Rinse: 180°F or above, c. Rack Level: 160°F or above.” 8. During an observation in the NICU (neonatal intensive care unit) (specialized area within a hospital that provides advanced care for newborns who need intensive medical attention) and concurrent record review on June 4, 2025, at 1:56 pm, Registered Nurse (RN 14) cleaned the counter top where she was going to prepare a baby bottle with [Company Name] germicidal disposable wipes (disinfecting wipes that use Quaternary ammonium (type of chemical that is used to kill bacteria, viruses, and mold) and isopropyl alcohol (is a clear, colorless, bitter liquid commonly found in “rubbing alcohol, Intoxication may occur through ingestion or inhalation of vapors, especially in infants) to kill microorganisms (germs). The label on the wipes indicated “this product is not to be used as a terminal sterilant/high level disinfectant on any surface or instrument that (1) is introduced directly into the human body, either into or in contact with the bloodstream or normally sterile areas of the body, or (2) contact intact mucous membranes (such as the nose, mouth, lungs, and stomach) but which does not ordinarily penetrate the blood barrier or otherwise enter normally sterile areas of the body.) During an interview with the Clinical Nutrition Manager (CNM) on June 5, 2025, at 11:41am, CNM stated the germicidal disposable wipes do not indicate that they are food safe. During an interview with the Infection Preventionist Director (IPD), on June 5, 2025, at 3:20 pm, IPD stated the instructions for use did not indicate that the product is food safe or not. During a review of the standard of practice by the Academy of Nutrition and Dietetics, titled “Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities”, Third Edition, dated 2019, indicated, “All work surfaces must be cleaned with an antimicrobial sanitizing solution that is appropriate for food contact surfaces.” During an observation in the NICU on June 4th, 2025, at 11:33 am, Registered Nurse 14 fed the baby a bottle of breast milk. After completing the feeding she took the bottle to the sink in a room next door and washed the bottle in the sink with [brand name] dish soup. During an interview with the Nurse Manager 6 (NM6) of the NICU, on June 4, 2025, at 2:15pm, the sink in the room where Registered Nurse 14 washed the bottle was in the isolation supply room and the sink was for nursing staff handwashing. During an interview with the Clinical Nutrition Manager (CNM), on June 5, 2025, at 11:41am, CNM stated there should be a separate sink for bottle washing. They should not be washing bottles in a handwashing sink. During a review of the FDA Federal Food Code, dated 2022, 2-301.15 indicated, “food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing, or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste.” In addition, “Effective handwashing is essential for minimizing the likelihood of the hands becoming a vehicle of cross contamination. It is important that handwashing be done only at a properly equipped handwashing facility in order to help ensure that food employees effectively clean their hands. Handwashing sinks are to be conveniently located, always accessible for handwashing, maintained so they provide proper water temperatures and pressure, and equipped with suitable hand cleansers, nail brushes, and disposable towels and waste containers, or hand dryers. It is inappropriate to wash hands in a food preparation sink since this may result in avoidable contamination of the sink and the food prepared therein. Service sinks may not be used for food employee handwashing since this practice may introduce additional hand contaminants because these sinks may be used for the disposal of mop water, toxic chemicals, and a variety of other liquid wastes. Such wastes may contain pathogens from cleaning the floors of food preparation areas and toilet rooms and discharges from ill persons.” 9. During a concurrent medication pass observation and interview on 6/4/25 at 8:59 a.m. with Registered Nurse 17 (RN 17), RN 17 was observed preparing and administering medications to Patient 64. RN 17 administered medications to Patient 64 through a [manufacturer] 60 milliliter (ml, a unit of measurement) sterile syringe attached to a G-tube (gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach when a person is unable to eat or drink adequately). After the medications were administered to Patient 64, RN 17 went to sink and washed the syringe with water then dried it with a paper towel. RN 17 then placed the syringe onto Patient 64’s bedside table. When asked if the syringe was multiple use, RN 17 looked at the package labeling and stated it was single-use and discarded the syringe into the trash bin. During a concurrent observation and interview on 6/4/25 at 10:23 a.m. with RN 18 and RN 19 in Patient 65’s room, an unwrapped 60 mL syringe covered with an orange-colored crusty substance was observed laying on top of a small, folded towel next to the sink. Next to the syringe on top of the same towel were two bottles of water, a stack of medication cups and a stack of plastic drinking cups. RN 19 stated RN 18 had used the syringe to administer medications to Patient 65 earlier that morning. RN 18 stated the syringe was no longer sterile after use but saved it to check with RN 19 on what to do after its use. During a concurrent observation and interview on 6/6/25 at 11:57 a.m. with Infection Prevention Director (IPD), the product labeling of the 60 ml syringe used to administer medications to Patient 64 and 65 was reviewed. The [manufacturer’s] product labeling indicated “STERILE, SINGLE USE ONLY.” IPD confirmed the manufacturer’s product labeling indicated the syringe was single use only. He stated it should have been discarded after use and staff were expected to follow manufacturer’s requirements. A review of the manufacturer’s labeling for [manufacturer], dated 2/3/21, indicated, “Warnings ... 2. The syringe is intended for one-time use. Each syringe should be used for one dispensing on one patient ... Instructions ... 9. Dispose of syringe as required by hospital protocols and local or national regulations.” During a review of the hospital’s plan titled, “Infection Prevention Plan [hospital systems name],” dated 2/27/25, the plan indicated “The goal of [the name of the hospital] Infection Prevention Program is to minimize the risk of acquiring [contacting] and transmitting healthcare-associated infections (HAI)/infectious diseases to patients.””

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 45929 Based on observation, interview and record review, the Condition of Participation (COP) Compliance with Federal, State, and Local laws and regulations related to the health and safety of patients was determined to be NOT MET when: 1. The hospital did not report a wrong side procedure within five days of detection (Refer to A-0022, item 1) 2a. The nurse-to-patient staffing ratios (refers to the number of patients a single nurse is responsible for at a given time) were 1:3 in the Intensive Care Unit (ICU- a hospital unit that provides specialized care for patients who are critically ill) on 12/30/24, 12/31/24, 1/1/25, and 1/13/25 (Refer to A-0022, item 2a) 2b. The nurse-to-patient ratio assignments for the Stepdown unit (SD- a unit providing patient care between intensive care and acute care levels) were 1:4 on 11/1/24, 12/11/24, 1/4/25, 1/11/25, 1/13/25, and 1/24/25 (Refer to A-0022, item 2b) 2c. The nurse-to-patient ratio assignments for the Cardiac Progressive Care Units (CPCU- (CPCU- a hospital unit that provides care for patients with cardiac issues on telemetry monitor [ medical device that continuously monitors and records patients heart rate, blood pressure, respiratory rate, and oxygen level]) patients were 1:5 on 11/1/24, 12/11/24, 1/4/25, 1/11/25, 1/13/25, 1/18/25, 1/24/25, and 1/29/25 (Refer to A-0022, item 2c) 2d. The nurse-to-patient ratio assignments for the Emergency Department (ED- hospital area for patients requiring immediate medical attention)) were 1:5 and 1:6 on 2/3/25 (Refer to A-0022, item 2d) The cumulative effect of this systemic failure resulted in the facility’s substantial noncompliance with federal, state and local laws (Refer A022).”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 49884 Based on observation, interview and record review, the hospital failed to have an effective Governing Body (GB) legally responsible for the conduct of the hospital when: 1. Resources and oversight were not provided to ensure the hospital followed State mandated nurse-to-patient staffing ratios in the Intensive Care Unit (ICU), the Stepdown unit (SD, a unit providing patient care between intensive care and acute care levels), the Cardiac Progressive Care Units (CPCU, a telemetry unit [where vital sign monitors that continuously transmit data, such as heart rate, breathing, and blood pressure to a nearby location] caring for patients with heart issues), and the Emergency Department (ED). (Refer to A020) 2. Resources and oversight were not provided to ensure the hospital addressed the rights of all inpatients holding in the ED the benefit, safety and quality of care to be placed in an inpatient unit. The GB was aware and did not redirect the hospital to utilize a 30-bed unit that was licensed for inpatient care and not utilized. (Refer to A115) 3. Resources and oversight were not provided to ensure the hospital maintained an effective, comprehensive, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI-is a systematic approach to improving the quality of care and services delivered to patients) program when the program did not effectively identify, collect data, track data, develop, or implement performance improvement activities consistent with their own Plans of Correction accepted by the California Department of Public Health (CDPH) on 12/10/24. Infection control deficiencies were not corrected or monitored for ongoing compliance, performance improvement projects were not developed to address high-volume, high-risk and problem-prone areas in the Emergency Department and other areas of the hospital to address safety and quality; and nurse-to-patient ratios were not addressed to comply with state-mandated ratios. (Refer to A263) 4. Resources and oversight were not provided to ensure the hospital’s nursing staff were appropriately trained and competent to provide care for inpatients holding in the ED. Eleven (11) of twelve (12) sampled Pts (Pt 2, Pt 3, Pt 4, Pt 7, Pt 8, Pt 9, Pt 38, Pt 39, Pt 40, Pt 41, and Pt 42) who had physician orders to provide a specific level of inpatient unit care and nursing staff did not implement effective and safe measures in accordance with hospital policies and procedures, and professional standards of practice and developed avoidable hospital acquired pressure injury (HAPI- a skin injury that occurs when prolonged pressure on a specific area of the body restricts blood flow, leading to tissue damage and cell death. (refer to A385) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner for all patients.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47205 Based on observation, interview, review of video surveillance, and record review, the hospital failed to provide a safe environment for quality patient care in the Emergency Department (ED-a hospital outpatient unit that provides immediate care to severe injuries and illness 24/7 without an appointment) for patients (Pts) in the ED when: 1. The hospital did not consider the benefits and the rights of patients to receive an emotionally safe environment similar to that of an inpatient unit (a dedicated area in the hospital where patients who require extended hospital stay for medical treatment are admitted and cared for) when deciding to keep inpatients in the ED. The hospital designated areas of the ED, an outpatient unit, for inpatient care and did not provide the level of inpatient care ordered for inpatients who remained in the ED. Six (6) of twelve (12) sampled patients (Pt 2, Pt 4, Pt 7, Pt 8, Pt 41 and Pt 42), waited from 3 hours to 86 hours (or 3.6 days) on a hospital hallway gurney (a bed on a frame with wheels that is used for moving people who are sick or injured) in the ED prior to being moved to an inpatient bed. (Refer to A144) 2. The hospital failed to implement effective measures to provide inpatient care in an approved [by the California Department of Public Health (CDPH)] 30-bed unit in the hospital [for unspecified general acute beds and intensive care beds total of 144 beds] that remained ready to be used but was not utilized as an inpatient unit. Eleven (11) of twelve (12) sampled Pts (Pt 2, Pt 3, Pt 4, Pt 7, Pt 8, Pt 9, Pt 38, Pt 39, Pt 40, Pt 41, and Pt 42) who had physician orders to provide a specific level of inpatient unit care and nursing staff did not implement effective and safe measures in accordance with hospital policies and procedures, and professional standards of practice and developed avoidable hospital acquired pressure injury (HAPI- a skin injury that occurs when prolonged pressure on a specific area of the body restricts blood flow, leading to tissue damage and cell death). (Refer to A144) 3. The hospital failed to ensure patients with a physician order for inpatient care were transferred to the ordered inpatient unit to receive care. In a comparison of the number of inpatients discharged from the ED (never having been physically on an inpatient unit their entire stay), from October 2023 through January 2024 was 829 (21%), and 823 (19.7%) from October 2024 through January 2025 (or a 1.3% difference). (Refer to A144) 4. The hospital failed to ensure patients’ right to be free from physical abuse and free from restraints for one of one patient, Patient (Pt) 43, when on 2/2/25 the Security Watch Commander (SWC) deployed the use of a taser (a handheld, battery-powered device that delivers an electric shock to temporarily disable a person) to restrain Pt 43 against the hospital’s policy and procedure on use of tasers and against CMS guidance on use of tasers. Registered Nurses (RN)s failed to document the use of a taser in Pt 43’s medical record, failed to assess Pt 43 after a change of condition, and failed to have a physician assess Pt 43 after a taser strike. (Refer to A154) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 49884 Based on observations, staff interviews, and medical record reviews, the hospital failed to ensure an active, effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI-is a systematic approach to improving the quality of care and services delivered to patients) program had been developed, implemented, and adjusted in order that the hospital could achieve sustainable regulatory compliance, quality care and safe standards of care when: Findings: 1.The hospital failed to have a QAPI program that implemented changes to lead to improvement when the Plan of Correction submitted to CDPH for a survey exited 12/10/24 was not implemented. The QAPI program did not implement effective improvement activities to address the use of the Emergency Department (ED- an outpatient area in the hospital that provides immediate medical care to patients with urgent or life-threatening conditions) as a holding area for patients admitted as inpatients (patients who stays in the hospital overnight). (Refer to A0283) 2. The hospital failed to have a QAPI program that tracked and monitored adverse events (AE- a harmful and negative outcome that happens to a patient provided medical care) and implement preventive measures when Patient (Pt) 6 experienced a wrong side surgical procedure for a left sided interscalene block (an injection of medication that numbs the bundle of nerves that extend to the upper arms, hands and shoulders), and a left sided peripheral nerve block (a needle injects numbing medication near specific nerves in shoulder region, blocking pain signals) and a right shoulder nerve block was performed. The QAPI did not conduct a root cause analysis to determine the cause and implement measures to ensure future incidences would not occur. (Refer to A0286) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and professional manner.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47205 Based on observation, interview and record review, the facility failed to have a well-organized and effective nursing service when: 1. Based on interview and record review, the hospital failed to ensure the physician ordered Order Set titled, “Insulin Orders for Non-Pregnant Adult” (pre-written physician orders instructing the nurse as to what medication to give and what to do if the patient’s blood glucose is too low) provided safe directives for nursing staff when two registered nurses (RN 5 and RN 6) followed physician orders which resulted in one of 44 patients (Pt 1) having fluctuating blood glucose levels, resulting in a Code Blue (cardiac arrest). (Refer to A-395). 2. Nurses in the emergency department (ED- a hospital outpatient area that provides immediate care for severe injuries and illnesses 24/7 without appointments) did not document skin integrity assessments and wound care interventions for 11 of 12 patients (Pt 2, 3, 4, 7, 8, 9, 38, 39, 40, 41, and 42) who were determined to need inpatient services (a dedicated area in the hospital where patients who require extended hospital stay for medical treatment are admitted and cared for) and were holding in the ED in accordance with hospital P&P “Pressure Injury Risk Assessment, Prevention, Staging and Treatment” dated 9/13/24. (Refer to A-398 Finding 1). 3. Nurses in Labor and Delivery unit (L&D, area of the hospital where babies are born and pregnant patients are treated) failed to conduct daily check of the Crash Cart (a mobile medical unit stocked with essential supplies and medication for use in emergency situations) for supplies and equipment on 1/5/25 and 1/10/25 in accordance with hospital P&P titled, “Code Blue -Medications & Crash Carts (CB),” dated 6/14/2024. (Refer to A-398 Finding 2). 4. Nurses failed to document an incident involving taser (a handheld, battery-powered device that delivers an electric shock to temporarily disable or restrain a person) use on Pt 43. Security Officer personnel used the taser on Pt 43 on 2/2/25 and nursing staff observed and were aware of the incident. There were no entries in the medical record documenting the use of the taser, or the personnel using the taser. The medical record did not include an entry from a physician or from Registered Nurse (RN) 13 regarding an assessment of the patient’s condition following the taser use, according to the hospital Policy and Procedure P&P, titled, “Standard of Practice Emergency Department”. (Refer to A-398 Finding 3). The cumulative effect of these system problems resulted in the hospital’s inability to provide nursing services in a safe setting.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 49884 Based on observation, interview, and record review the hospital failed to provide surgical services in accordance with acceptable standards of practice when: The hospital failed to ensure prevention of surgical errors for Patient (Pt) 6, when Pt 6 was consented for a left reverse total shoulder arthroplasty (shoulder joints replaced with artificial parts, reversing the normal ball and socket structure) surgery and Anesthesia Medical Doctor (AMD) 1 ordered a left shoulder nerve block (a procedure that numbs the nerves in the shoulder area, providing pain relief) and did not verify correct surgical site in accordance with the hospital’s policy and procedure (P&P) titled “Universal Protocol - Procedural Areas” before performing a right shoulder nerve block. Medical Doctor (MD) 2 informed the family of the error of the nerve block to the wrong side and obtained consent to perform the left shoulder arthroplasty with local anesthesia to the left shoulder and Pt 6 under general anesthesia. These failures led to Pt 6 receiving the wrong-side nerve block to the right shoulder and avoidable pain and suffering and non-use of the right shoulder. This failure resulted in Pt 6 being under general anesthesia longer than expected, potentially causing inadequate post-operative pain relief, the need to administer opiates (strong pain medication) for pain, possibly unnecessarily; and the error required an unplanned overnight hospital stay. The cumulative effect of these systemic issues resulted in the hospital not ensuring quality patient care in a safe setting.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 45929 Based on interview and record review, the hospital failed to be in compliance with state laws regarding self-reporting of adverse events and nurse staffing levels when: 1. The hospital did not self-report a wrong side nerve block performed on Patient 6 in accordance with Health and Safety Code 1279.1 2. The hospital did not meet the required staffing levels for various units within the hospital in accordance with California Code of Regulations Title 22, Chapter 1 General Acute Care Hospitals, sections 70217 (a)(1)(8)(9)(10). These failures resulted in the potential harm of not ensuring the safety of patients and possibly negatively affecting quality of care. Findings: 1. During a concurrent interview and record review on 1/29/25 at 2:23 p.m. with Nurse Manager (NM) 7, Patient (Pt) 6’s “History & Physical [H&P- an assessment from physician including medical history and exam],” dated 12/2/25 was reviewed. The “H&P” indicated; Pt 6 was 71 years old and presented to the hospital on 12/2/24 for surgery. The “H&P,” indicated Pt 6, “ ... is indicated for reverse total shoulder arthroplasty [a surgical procedure that replaces the shoulder joint with artificial parts, reversing the normal ball-and-socket structure]. She was explained the risks, benefits, and alternatives ... The patient is consented [gave permission] for left reverse total shoulder arthroplasty ...”. NM 7 stated the operating physician speaks with the patient in the pre-operative unit (are in the hospital where patients are prepared for surgery) to answer any questions, ensure all consents have been signed, and mark the surgical site with a skin marker. During a review of Pt 6’s “Anesthesia Preprocedure Evaluation [APE],” dated 12/2/24 at 8:16 a.m., the “APE” indicated, Anesthesia Medical Doctor (AMD) 1 completed a physical exam of Pt 6 on 12/2/24 at 8:16 a.m. The “APE” indicated Pt 1’s anesthesia plan was general anesthesia (medication causing loss of feeling and awareness like a deep sleep), a left sided interscalene block (an injection of medication that numbs the bundle of nerves that extend to the upper arms, hands and shoulders), and a left sided peripheral nerve block (a needle injects numbing medication near specific nerves in shoulder region, blocking pain signals). The “APE” indicated, “ ... Informed Consent [Physician educates a Pt about risks, benefits, and alternatives of procedure] [AMD 1] have discussed the planned anesthesia care with the patient and/or legal representative, including the following: the nature and purpose of the planned anesthesia; the risks, benefits and side effects of the planned anesthesia; alternatives for the planned anesthesia and their associated risks, benefits, and side effects ... The patient and/or legal representative demonstrated understanding of the information provided. After careful consideration, the patient and/or legal representative agreed to proceed with the planned anesthesia care ...”. During an interview on 1/31/25 at 10:07 a.m. with the Director of Risk Management (DRM), the DRM stated the Risk Management department received an IRIS (Incident Response Improvement System) report and investigated the incident. The DRM stated the hospital legal department reviewed the incident to decide if it needed to be reported to CDPH. The DRM stated, based on the review, the hospital determined the incident did not meet the CDPH reporting criteria for an adverse event. The DRM stated nerve block was not considered a surgery, however agreed the nerve block was given in the Operating Room (OR-dedicated space in the hospital where surgical procedures are performed) as part of the surgery process. The DRM stated a time-out (a brief pause in the surgical procedure to verify critical information and ensure patient safety) was completed to verify information and ensure patient safety. The DRM stated the nerve block was not a stand-alone procedure and did not carry some risk to Pt 6. The DRM stated the hospital did not conduct a root cause analysis (RCA- the process of discovering underlying causes of a problem to prevent recurrence) but completed actions items and held safety meetings about the incident. The DRM stated in retrospect, the anesthesia procedure was part of the surgical process. During an interview on 1/31/25 at 3:46 p.m. with the Director of Surgery (DS), the DS stated, he was informed of the wrong side block on 12/2/25 by NM7. The DS stated the investigation started on 12/2/25. The DS stated an incident report was filed by Registered Nurse (RN) 10, who was Pt 6’s nurse during surgery, after Pt 6 was moved from the OR. The DS stated the incident report was sent to the Risk Management department. During an interview on 2/3/25 at 12:04 p.m. with NM 7, NM 7 stated, she was the Manager on shift on 12/2/25, the day of Pt 6’s surgery. NM 7 stated she contacted the DS to inform him of the incident. NM 7 stated, RN 10 reported the wrong side nerve block from the OR over the phone. NM 7 stated she waited for Pt 6’s surgery to finish, then met with RN 10 to help with the incident report and talk to the staff about the incident. During a review of the facility’s policy and procedure (P&P) titled, “Adverse Event Reporting to the California Department of Health Services,” dated 1/3/22, the P&P indicated, “To comply with the mandated reporting requirements of Health and Safety Code 1279.1 (b). To support the improvement of patient safety and quality improvement initiatives ... Adverse event includes any of the following: Surgery performed on a wrong body part that is inconsistent with the documented informed consent for that patient ... It shall be the policy of [hospital name] to report an adverse event, as define within Health Safety Code 1279.1, to the California Department of Public Health (CDPH) no later than five days after the event has been detected; or, if the event is an ongoing urgent or emergent threat to the welfare, health, or safety of patients ... not later than twenty-four (24) hours after the adverse event has been detected ... In addition, the regulations specify the hospital is subject to an onsite investigation when CDPH determines that an adverse event or complaint is an ongoing threat of imminent danger of death or serious bodily harm. It is also our policy to investigate the source of the event, initiate any mitigation actions that may be indicated and cooperate fully with the CDPH throughout the process. All adverse events which may be considered reportable as defined by this policy shall be reported to the Supervisor/Manager immediately by involved staff and an Incident Reporting Intranet System (IRIS) completed within 24 hours ...It will be the responsibility of the Risk Manager to develop and submit the initial report to the CDPH, as well as serve as liaison with the agency during subsequent investigation process ...” 2a. During a concurrent interview and record review on 1/31/25 at 1:38 p.m. with Manager (NM) 3, the “ICU Staffing Assignment Sheets (ISA)”, dated 12/31/24 and 1/13/25, were reviewed. NM 3 stated the maximum nurse-to-patient ratio for ICU patients was 1:2 [one nurse assigned with 2 patients]. NM 3 stated on 12/31/24 three Registered Nurses (RN) each had a nurse-to-patient ratio of 1:3 on day shift and one RN had a 1:3 nurse-to-patient ratio on the night shift. The “ISA” dated 12/31/24 indicated, “ ... No Break RN [nurse to care for a patient assignment while their RN is on break] ...”. NM 3 stated when there is no Break RN was available, the Clinical Supervisor (CS), Clinical Educator (CE) or Clinical Nurse Specialist (CNS) will cover for a break, but only the CS is available on the night shift. NM 3 stated with a CS relieving 10 RNs with patient assignments, for their thirty- minute break, it would take over five hours to give all the nurses their meal breaks. The “ISA”, dated 1/13/25, and indicated, “ ... 4 teams tripled @ 0700 [7:00 a.m.] ... stopped triple @ 0930 [9:30 a.m.] ... [RN name] - tripled @ 1609 [4:19 p.m.] ...” and NM 3 stated this meant the four nurses were assigned to three patients each from 7:00 a.m. to 9:30 a.m. and another nurse had three patients from 4:09 p.m. to 7:00 p.m. During a review of the “ISA”, dated 12/30/24, the “ISA” indicated a Registered Nurse (RN) on day shift was assigned to care for three patients. The “ISA” indicated, “ ... Ø [no] break RN coverage - day shift ... [RN’s first name] with 3 pt [patient] assignment from 1300 -1700 [1:00 p.m. to 5:00 p.m.] ...”. During a review of the “ISA”, dated 1/1/25, the “ISA” indicated two RNs on day shift had a 1:3 nurse-to-patient ratio. 2b. During a review of “Stepdown Assignment Sheets (SDA)”, dated 11/1/24, the “SDA” indicated three nurses were caring for stepdown acuity patients with a nurse-to-patient ratio of 1:4 on the night shift. During a review of “SDA”, dated 12/11/24, the “SDA” indicated two nurses were caring for stepdown acuity patients with a nurse-to-patient ratio of 1:4 on the day shift. During a review of “SDA”, dated 1/4/25, the “SDA” indicated one nurse was caring for four stepdown acuity patients with a nurse-to-patient ratio of 1:4 on the day shift. During a review of “SDA”, dated 1/11/25, the “SDA” indicated one nurse was caring for a stepdown acuity patient with a nurse-to-patient ratio of 1:4 on the day shift and one nurse was caring for a stepdown acuity patient with a nurse-to-patient ratio of 1:4 on the night shift. During a review of “SDA”, dated 1/13/25, the “SDA” indicated one nurse was caring for a stepdown acuity patient with a nurse-to-patient ratio of 1:4 on the day shift and one nurse was caring for three stepdown acuity patients with a nurse-to-patient ratio of 1:4 on the night shift. During a concurrent interview and record review on 2/3/25 at 2:03 p.m. with Nurse Manager (NM) 2, the “SDA”, dated 1/24/25 was reviewed. NM 2 stated two nurses caring for stepdown acuity patients had a nurse-to-patient ratio of 1:4. NM 2 stated the maximum nurse-to-patient ratio for stepdown patients was 1:3. 2c. During an interview on 1/29/25 at 3:15 p.m. with RN 1 on CPCU Tower 2, RN 1 stated the maximum nurse-to-patient ratio for the CPCU was 1:4, but assignments were often 1:5. RN 1 stated he was caring for five patients today. RN 1 stated for the past six months, usually two nurses each shift had 1:5 nurse to patient ratio. RN 1 stated the CPCU has a break nurse approximately 70% of the time. RN 1 stated for the last two months the Clinical Supervisor (CS) covers for breaks if there is no break nurse. RN 1 stated before, nurses would cover for each other during breaks, caring for their own patients as well as the other nurse’s patients, which made the nurse-to-patient ratio 1:8 during breaks. During an interview on 1/29/25 at 3:20 p.m. with RN 2 on CPCU Tower 2, RN 2 stated, “ ... I have five patients every two - three weeks myself ...”. RN 2 stated after the new year (2025) it became more common to have a 1:5 nurse-to-patient ratio. RN 2 stated she had five patients today. RN 2 stated when nurses cover breaks for each other, the covering nurse carried two phones and cares for 8-10 patients during the other nurse’s break. During an interview on 1/29/25 at 3:25 p.m. with RN 3 on CPCU Tower 2, RN 3 stated he had five patients today and last week she had five patients on four of six days. RN 3 stated last week all nurses in the CPCU had a 1:5 nurse-to-patient ratio. During an interview on 1/30/25 at 10:59 a.m. with Complainant (CO) 2, CO 2 stated 3 North CPCU had a 1:5 nurse-to-patient ratio for at least two nurses on each day shift for over a month. During an interview on 1/31/25 at 9:50 a.m. with CO 1, CO 1 stated CPCU staffing was unsafe, there was frequently no break nurse and if he went on break, he was told to give report and his assignment to another nurse with a full patient assignment. During a review of “North Tower 3 Assignment Sheets (NTA)”, dated 11/1/24, The “NTA” indicated one nurse on 1 North was assigned 5 CPCU patients on the day shift and on 3 North Surgical CPCU two nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “NTA”, dated 12/11/24, the “NTA” indicated two nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift. During a review of “NTA”, dated 1/4/25, The “NTA” indicated two nurses on 1 North were each assigned 5 CPCU patients on the day shift. During a review of “Tower 2 CPCUs Assignment Sheets (T2A)”, dated 1/4/25, the “T2A” indicated 4 nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift. During a review of “NTA”, dated 1/11/25, the “NTA” indicated three nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “T2A”, dated 1/11/25, the “T2A” indicated four nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “NTA”, dated 1/13/25, the “NTA” indicated three nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift. During a review of “T2A”, dated 1/13/25, the “T2A” indicated eight nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift and two nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “NTA”, dated 1/18/25, the “NTA” indicated two nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift and two nurse were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “T2A”, dated 1/18/25, the “T2A” indicated four nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift and two nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “NTA”, dated 1/24/25, The “NTA” indicated one nurse on 1 North was assigned CPCU patients with a 1:5 nurse-to-patient ratio and two nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on day shift. During a review of “T2A”, dated 1/24/25, the “T2A” indicated four nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift. During a review of “NTA”, dated 1/29/25, The “NTA” indicated three nurses on 1 North were assigned 5 CPCU patients at a 1:5 nurse-to-patient ratio and two nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift. The “NTA” indicated two nurses on 3 North Surgical CPCU were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of “T2A”, dated 1/29/25, the “T2A” indicated four nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the day shift. The “T2A” indicated four nurses were assigned CPCU patients with a 1:5 nurse-to-patient ratio on the night shift. During a review of a professional reference titled, “How staffing shortages affect patient safety in healthcare and nursing (HSS)”, dated 3/5/24, the “HSS” indicated, “ ... Having appropriate and adequate nurse staffing is one of the basic elements of healthcare organization management and for good reason. Nurses not only provide care to multiple patients per shift, but nurse teams are the sentinels of healthcare safety, monitoring patients 24-hours a day and responding to their needs in real-time. Such responsibilities require constant vigilance from nurses who have the right skills to handle the kinds of patients they’re caring for and their particular needs. Appropriate nurse staffing is complicated and involves many variables, from nurse skill mix to patient acuity, but at its most basic, having enough nurses at the bedside to effectively monitor and respond to patients and their needs is imperative for quality management. Because of this, it makes sense that research has tied so many safety and quality indicators to nurse staffing. Nurse-to-patient ratios and overall nurse workload are linked to safety factors like medication errors, pneumonia, and even in-hospital mortality [death] ...”. 2d. During an interview on 2/3/25 at 10:08 a.m. with Emergency Department Manager (EDM) 2, EDM 2 stated an area in the ED called EDIN (ED inpatient) was a designated location where nurses care for patients who are admitted while they wait for an inpatient bed. During a review of the “ED Tracking Board for the EDIN (TB, an electronic screen, listing patient’s location, patient’s complaint, type of inpatient bed requested, and nurse assigned to care for the patient)”, dated 2/3/25 at 10:41 a.m., the “TB” indicated Registered Nurse (RN) 17, RN 18, RN 19, and RN 20 each were assigned care for six patients. During a review of the “TB”, dated 2/3/24 at 11:08 a.m., the “TB” indicated RN 14, RN 15, and RN 16 were each were assigned care for five patients. During a review of the “TB”, dated 2/3/25 at 10:41 a.m., the “TB” indicated RN 19 was assigned four patients requiring beds in the telemetry and two patients requiring beds in the medical/surgical (M/S) unit. The “TB” indicated RN 20 was assigned three patients requiring telemetry beds and three patients requiring M/S beds. The “TB” indicated RN 17 was assigned two patients requiring telemetry beds, three patients requiring M/S beds, and one patient requiring a stepdown bed. During an interview on 2/3/25 at 5 p.m. with EDM 2, EDM 2 stated The EDM 2 stated the EDIN was staffed according to bed type requested and not according to the acuity (the severity or complexity of a patient’s medical condition). During a review of a professional reference titled, “Injuries Caused by Emergency Room Understaffing (ICERU)”, dated 3/9/20, the “ICERU” indicated, “ ...When emergency rooms are understaffed ...patients with serious conditions may be overlooked and don’t receive the care they need ... common mistakes that can occur in an understaffed emergency room include ... Failing to diagnose a patient ... patients being given the incorrect medication ... patients being given incorrect blood transfusions ... errors caused by miscommunications and failure to thoroughly read a patient’s chart ... treatment of the wrong patient ... ignoring patient’s concerns ... Any of these incidences can lead to a serious illness or injury that could have been prevented with proper emergency room staffing ...”.”

“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: 47205 Based on observation, interview, and record review, the hospital failed to provide a safe environment for quality patient care in the Emergency Department (ED- a hospital outpatient unit that provides immediate care to severe injuries and illness 24/7 without an appointment) for patients (Pts) with orders to be admitted to an inpatient unit (a dedicated area in the hospital where patients who require extended hospital stay for medical treatment are admitted and cared for) who remained in the ED when: 1. The hospital did not consider the benefits and the rights of patients to receive an emotionally safe environment similar to that of an inpatient unit when deciding to keep inpatients in the ED. The hospital designated areas of the ED, an outpatient unit, for inpatient care and did not provide the level of inpatient care ordered for inpatients who remained in the ED. Six (6) of twelve (12) sampled patients (Pt 2, Pt 4, Pt 7, Pt 8, Pt 41 and Pt 42), waited from 3 hours to 86 hours (or 3.6 days) on a hospital hallway gurney (a bed on a frame with wheels that is used for moving people who are sick or injured) in the ED prior to being moved to an inpatient bed. 2. The hospital failed to implement effective measures to provide inpatient care in an approved [by the California Department of Public Health (CDPH)] 30-bed unit in the hospital [for unspecified general acute beds and intensive care beds total of 144 beds] that remained ready to be used but was not utilized as an inpatient unit. Eleven (11) of twelve (12) sampled Pts (Pt 2, Pt 3, Pt 4, Pt 7, Pt 8, Pt 9, Pt 38, Pt 39, Pt 40, Pt 41, and Pt 42) who had physician orders to provide a specific level of inpatient unit care and nursing staff did not implement effective and safe measures in accordance with hospital policies and procedures, and professional standards of practice and developed avoidable hospital acquired pressure injury (HAPI- a skin injury that occurs when prolonged pressure on a specific area of the body restricts blood flow, leading to tissue damage and cell death). 3. The hospital failed to ensure patients with a physician order for inpatient care were transferred to the ordered inpatient unit to receive care. In a comparison of the number of inpatients discharged from the ED (never having been physically on an inpatient unit their entire stay), from October 2023 through January 2024 was 829 (21%), and 823 (19.7%) from October 2024 through January 2025 (or a 1.3% difference). These failures resulted in denying all patients admitted as inpatients, who remained in the ED, the right to have care in a safe setting and denied patients the respect and dignity of care provided for while in an inpatient unit. These failures resulted in patients not being provided the level of physician ordered care as inpatients while in the ED and led to avoidable negative outcomes such as HAPI. For the months between 10/25/24 and 01/25/25, the hospital submitted data indicating 823 patients were admitted through the ED and remained in the ED without being admitted to an inpatient bed. Findings: 1. During a concurrent observation and interview on 1/28/25 at 10:12 a.m., in the ED with ED Director (EDD) of the unit, the ED was observed to be very busy, with many patients of all ages on gurneys or hallway beds as well as in rooms. EDD stated the unit was currently experiencing high volumes of ED patients coming to the ED, and inpatients waiting in the ED for an inpatient bed assignment. During the tour, patients were observed to be waiting, eating, sitting on gurneys interacting with the one visitor allowed at bedside and/or receiving infusions of IV medications. Hallways were congested with ED and ancillary staff (Ultrasound, X-ray, Physical Therapy, etc.) providing care in the hallways and in the rare corridors where make shift private areas (using partitions) were placed to complete patient exams. During the tour, Pt 41 and Pt 42 were observed to be holding in hallway gurneys. During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with EDD, the Electronic Health Records (EHR) for Pt 41 was reviewed. Pt 41’s “ED Pt Care Timeline” dated 1/28/25, indicated, “ ...TT 65:45 (hours:minutes) ...” EDD explained “TT” represented the time Pt 41 waited in the ED before being moved to an inpatient admission bed (refers to a hospital bed used for a patient who needs to stay overnight in the hospital for extended medical care). EDD stated ED nurses are trained to provide appropriate level of care to inpatients holding in the ED for an inpatient bed assignment. 1a. During an interview on 2/3/25 at 10:08 a.m. with the ED Manager (EDM) 2, EDM 2 stated the initiation of the “ED Inpatient (EDIN) team” began April 2024. EDM 2 stated EDIN was initiated to relieve the need for an ED RN to be floated into an inpatient care assignment. EDM 2 stated the EDIN staff includes Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Patient Care Technicians (PCTs) recruited into EDIN. EDM 2 stated nurses hired into the EDIN may have prior experience in caring for the inpatient population. EDIN staff receive orientation with inpatient nurses to ensure they are competent to deliver the inpatient care level ordered by the provider. EDM 2 stated he was hired into a night shift manager position on June 2024, and was later assigned to manage EDIN and EDIN staff in September 2024, because of his prior experience in leading a similar unit in another state. EDM 2 stated he reports to the EDD. EDM 2 stated the ED is EDIN staff’s “home base” and staff are considered part of the ED team. EDM 2 stated EDIN staff or Float Pool staff are assigned to care for inpatients in the ED, if there are not enough EDIN or Float Pool staff members to care for the number of inpatients holding in the ED, ED staff are assigned to fill the need. EDM 2 stated EDIN staff does not float to the ED to care for ED patients or go up to the units with the admitted patient. EDM 2 stated EDIN staffs an EDIN Clinical Supervisor (CS) to oversee EDIN staff working in designated zones in the ED. During concurrent interview and record review on 2/3/25 at 10:15 a.m., of the facility “ED Map” dated 3/28/2022, with EDM 2, EDM 2 referenced the ED Map and indicated there was a more current version, but he could still provide basic details as he explained the ED layout. Review of the ED layout indicated the ED was configured in a rectangle with designated color-coded zones, such as green, yellow and red zones. The color code of the zone corresponded to the level of services the patient needed in the ED with green the least complex care and red, the most complex care. EDM 2 stated inpatients are routinely moved into the Green and Yellow-West Zones. EDM 2 stated sometimes inpatients are moved into the Yellow East Zone where they may be mixed in with ED patients temporarily, while waiting for either an inpatient admission bed or to be moved into the Green or Yellow -West Zone. EDM 2 stated inpatients are not routinely held in the Red Zone. EDM 2 stated the goal is to group inpatients into a designated area to facilitate their care. During concurrent observation, interview and record review on 2/3/25 at 10:40 a.m., with ED Manager (EDM) 2 and ED Registered Nurse (RN) 17 in the ED, RN 17 stated she was assigned to care for ED inpatients today, and normally works in the ED. ED RN 17 stated she was the primary RN for Pt 39 and reviewed Pt 39’s EHR. ED RN 17 stated Pt 39’s EHR “IP Charting [where nurses document care of the inpatient waiting in the ED and IP stands for In Patient] indicated Pt 39 was placed on an overlay (air overlay cradles the body, providing protection and treatment for pressure ulcers) was performed on 2/2/25 at 11:00 a.m., with a nursing assessment of Pt 39’s skin documented on 2/2/25 at 4:59 p.m. Pt 39’s Braden Scale Score (BSS- a numerical value used to assess a patient’s risk of developing pressure ulcers. A lower score indicates a higher risk. The BSS is calculated by evaluating six factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A total score ranging from 6 (high risk) to 23 (low risk): 19-23: No risk, 15-18: Mild risk, 13-14: Moderate risk 10-12: High risk, 9 or less: Very high risk) was 19. RN 17 stated as an ED RN, she floats into EDIN as needed. RN 17 stated the EDIN and Float Pool staff were not sufficiently staffed today to take care of all the EDIN patients waiting for an inpatient bed. RN 17 stated in reviewing the prior shifts documentation she would have expected the nurse to first assess and learn the patients BSS, then implement interventions (turning, waffle overlay, etc.) according to the skin saving “bundle” [grouped interventions based on BSS] corresponding to the patients BSS and skin care needs. RN 17 stated the potential harm to the patient is a missed care need or risk and implementing the wrong intervention, which could lead to patient harm. During a concurrent observation and interview on 2/3/25 at 11:23 a.m., with Pt 38 and ED RN 15 in ED patient room Y-12 (Yellow zone, room 12), Pt 38 was lying on his back, with head propped up on a gurney, high-flow oxygen (high-flow oxygen therapy system includes those that supply a flow that meets or exceeds the patient’s inspiratory flow demand) was in place along with IV (intravenous- administered into a vein or veins) catheter (a thin, flexible tube that’s inserted into a vein to provide fluids, medications, or blood transfusions) and IV antibiotics (drug used to treat infections caused by bacteria and other microorganisms) being administered. Pt 38 stated he was admitted for “pneumonia and came to the ED for trouble breathing.” Pt 38 stated he had not been offered a hospital bed, a toothbrush or clean towel to at minimum wipe his hands and face clean. Pt 38 stated because he needed staff assistant to get out of the gurney (oxygen and IV tubing and cardiac monitor connections) he was not getting out of the gurney much. It was observed there was no television or restroom in the private ED room. Pt 38 stated staff offered a bedside commode (portable toilet). Pt 38 stated he used it despite feeling “embarrassed” at staff having to clean up his stool after he used the bedside commode. Pt 38 stated his father brought him a wet paper towel [from towel dispenser at a small sink in the room] and that is what he used to clean his face and hands. Pt 38 stated he had not been updated on when an inpatient bed might be assigned. Pt 38 stated a visit from the doctor this morning indicated he might be discharged 2/4/25. Pt 38 stated he might not be moved [to an inpatient unit] at all. RN 15 stated Pt 38 had orders to remove the high flow oxygen and continue with IV antibiotics. RN 15 stated she took care of Pt 38 on 2/3/25. RN 15 stated she had not offered to order a hospital bed or provided opportunities for Pt 38 to take care of his hygiene needs (brush teeth, bathe, etc.). 1b. During a concurrent observation and interview on 1/28/25 at 10:12 a.m., in the ED with ED Director (EDD) the EDD explained the unit was busy with several overflow areas having been opened in response to an increased volume of patients coming to the ED for medical care. During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with Clinical Supervisor (CS) 7 and EDD the Electronic Health Records (EHR) for Pt 41 and Pt 42 were reviewed. The EHR “ED Timeline” indicated Pt 41 and Pt 42 had been held in a hallway gurney for a significant length of time in the ED while waiting for a physical inpatient bed assignment. CS 7 stated a pressure injury may begin as early as 24 hours; inpatient documentation is required to be documented within 24 hours of admission. Pt 41 waited 25 hours in a hallway gurney before being moved to the ordered inpatient unit. Pt 42 waited 65 hours in a hallway gurney before being moved to the ordered inpatient unit. During a review of the ED census titled “ED CCMC All Patients” dated 1/28/25 at 8:43 a.m., the ED census indicated the total number of patients in the ED was 136. Of these 136 patients, 86 patients were in an inpatient “class [status].” This review indicated that 63% of the patients in the ED were waiting for an admission bed, and receiving care in an outpatient setting. During a review of “ED Holds Moved to Bed 1/27-1/28” undated, the report indicated 64 in-patients were moved from the ED to the flex/overflow units (2N, L&D and PACU). During a review of a more current ED Map (Map 2), undated, ED Map 2 indicated the number of shared restrooms/showers available in a zone/area were as follows: Green Zone: unable to determine if a restroom for capacity of 16 possible patient rooms (includes rooms and hallway gurneys); Yellow Zone: 2 restrooms for capacity of 19 possible patient rooms; and 1 shower room for the entire ED. During record review on 2/6/25 of the documents provided by the hospital, the EHR for Pt 2, Pt 4, Pt 7, and Pt 8 were reviewed. According to the EHR “ED Timeline,” these patients had been held in a hallway gurney for a significant length of time in the ED while waiting for a physical inpatient bed assignment: Pt 2 waited 86 hours in a hallway gurney before being moved to the ordered inpatient unit. Pt 4 waited 22 hours before being moved into a room in the ED with eventual move to ordered inpatient unit (spent a total of 103 hours in the ED). Pt 7 waited 42 hours in a hallway gurney before being moved to the ordered inpatient unit. Pt 8 waited 24 hours in a hallway gurney before being moved into an ED room with eventual move to ordered inpatient unit (spent a total of 40 hours in the ED). 2. During an interview on 1/30/25 at 9:10 a.m. with Chief Nursing Officer (CNO) and Chief Operations Officer (COO), the CNO stated they have an empty 30-bed unit on the 5th floor. The CNO stated they have not opened the 30-bed unit that was approved for use on 4/27/22, but they plan to open it on 2/26/25. The CNO stated the reason they have not opened the new unit was because they do not have enough staff; not just nurses but also nursing assistants, unit clerks, and other people who are needed to support a unit. The CNO stated they are using other areas of the hospital for overflow patients, including 20 beds in the Women’s Pavilion, which is staffed by EDIN nurses. During an interview on 1/30/25 at 11:38 a.m. with Director, Nursing Administration (DNA) he explained in his role he provided oversight of the House Supervisors (HS, nurse who manages staffing and patient placement in the hospital) and stated HS make final decisions on staffing throughout the day. DNA stated shift report is passed on but [they] do not keep track ratio compliance. DNA stated HSs do a lot of shuffling of staff. Staffing ratio compliance goes in cycles of being non-compliant. DNA stated [we] try to staff by patient acuity but do not want to short ICU for acuity reasons. CPCU nurses get floated a lot because they can go both ways [M/S & Stepdown- the most intensive care provided in Intensive Care Units (ICUs), followed by step-down units (like a “telemetry” unit) for patients requiring less intensive monitoring, then general medical-surgical units for patients with stable conditions, and finally specialized units like oncology or pediatric wards depending on the patient’s needs].” DNA stated reports when ratios are not in compliance are sent daily to a group of leaders. DNA stated the ED is out of compliance more than anyone else “because you can’t close the doors.” DNA stated “ ... the ED is the biggest inpatient unit in the hospital due to admit holds ...” The DNA confirmed there were 104 pts in ED today (1/30/25). During an interview on 2/3/25 at 5:00 p.m., with ED Manager (EDM) 2, EDM 2 stated “sometimes ED nurses are taking care of admit pts. ED do not float up to inpatient areas at all.” EDM 2 stated the ED “Tracking Bar (electronic board indicating patient diagnosis, nurse assignment, patient location and type of inpatient bed requested) Clinical Supervisor (CS) is who nurse can go to EDIN-(ED Inpatient- where admitted patients are routinely held in the ED while awaiting an inpatient bed) and view assignments. EDM 2 stated the CS can step in and change assignments or cares for patients as needed. EDM 2 stated, “ ... We staff according to floor status not acuity ...” During a concurrent observation and interview on 1/28/25 at 10:12 a.m., in the ED with ED Director (EDD) observation of the ED included a tour of the unit. The ED was observed to be very busy, with many patients of all ages on gurneys or hallway beds as well as in rooms. EDD stated the unit was experiencing high volumes of ED patients coming to the ED, and inpatients waiting in the ED for an inpatient bed assignment. During the tour, patients were observed to be waiting, eating, sitting on gurneys interacting with the one visitor allowed at bedside and/or receiving infusions of IV medications. Pt 41 and Pt 42 were observed to be holding in a hallway gurney. Privacy screens were placed providing patient privacy, seemed to contribute to the already cluttered state of the hallways, and made visualization of patients difficult. EDD provided a department map to facilitate understanding of the ED layout. During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with Clinical Supervisor (CS) 7 and EDD, the Electronic Health Records (EHR) for Pt 41 and Pt 42 were reviewed. Pt 41’s “ED Pt Care Timeline” dated 1/28/25, indicated, “ ...TT 65:45 (hours:minutes) ...” EDD explained “TT” represented the time [the patient Pt) spent in the ED before being moved to an inpatient admission bed. EDD stated ED nurses are trained to provide appropriate level of care to in patients holding in the ED for an inpatient bed assignment. During concurrent interview and record review on 2/3/25 at 10:40 a.m., with ED Manager (EDM) 2 and ED Registered Nurse (RN) 17 ED in the ED, RN 17 stated she was assigned to care for ED inpatients today, and normally works in the ED. ED RN 17 stated she was the primary RN for Pt 39 and Pt 39’s EHR was reviewed. ED RN 17 stated Pt 39’s EHR “IP Charting [where nurses document care of the inpatient waiting in the ED] indicated Pt 39 was placed on an overlay [waffle overlay- according to the overlay vendor the waffle overlay is “clinically proven, cost-efficient pressure redistribution. The waffle overlay assists in lateral transfers (the movement of a patient from one flat surface to another, repositioning and turning to protect patients throughout the hospital journey.)” was performed on 2/2/25 at 11:00 a.m.. RN 17 stated a nursing assessment of Pt 39’s skin was documented on 2/2/25 at 4:59 p.m. RN 17 stated the Braden Scale Score (BSS- a numerical value used to assess a patient’s risk of developing pressure ulcers, with a lower score indicating a higher risk; it is calculated by evaluating six factors including sensory perception, moisture, activity, mobility, nutrition, and friction/shear, with a total score ranging from 6 (high risk) to 23 (low risk) with core interpretation: 19-23: No risk, 15-18: Mild risk, 13-14: Moderate risk 10-12: High risk, 9 or less: Very high risk) was 19. RN 17 stated as an ED RN, she floats into EDIN as needed. RN 17 stated the EDIN and Float Pool staff were not staffed to take care of all the EDIN patients waiting for an inpatient bed. RN 17 stated in reviewing the prior shifts documentation she would have expected the nurse to first assess and learn the patients BSS, then implement interventions (turning, waffle overlay, protective dressings, etc.) according to the skin saving “bundle” [grouped interventions based on BSS] corresponding to the patients BSS and skin care needs. RN 17 stated the potential harm to the patient is a missed care need or risk and implementing the wrong intervention, which could lead to patient harm. 2a. During a concurrent interview and record review on 1/30/25 at 2:30 p.m., with The CPCU (NM) 1 and CPCU (CS 1), NM 1 stated manages several units in the Tower 2 3 & 4 areas. EHR records for Pts 4, 5, 3, 2 were reviewed. CS 1 explained the process for PIP in the 4 CPCU is for upon admission 1 nurse and the supervision CS perform a full skin check, together taking photos and documenting skin condition and implementing interventions to preserve skin integrity, immediately. CS 1 stated CSs are required to perform 1 chart audit per shift, in the 4CPCU with real time feedback with the nurse and opportunity to ask questions of the CS, who has more clinical experience in wound management. CSs are expected to monitor every patient at risk for developing a skin injury. CS 1 stated CSs on her unit round daily and ensure staff are managing patient skin according to hospital P&P to prevent harm to patient skin. NM 1 and CS 1 stated after record review, the EHR review indicated staff in the ED were not consistently following the hospital P&P for skin care. During a record review of the hospital’s Facility Reported Incident (FRI) submitted to the California Department of Public Health (CDPH) on 1/14/25, the FRI indicated Pt 2 had a “...wound nurse consultation...revealed that patient’s evolving deep tissue injury (DTI-suspected deep tissue injury is when the surface of the skin looks like a stage I or II sore, but underneath the surface, it’s a stage III or IV sore) to [buttocks] have been determined as stage III pressure injury (these sores have gone through the second layer of skin into the fat tissue. The sore looks like a crater and may have a bad odor. It may show signs of infection: red edges, pus, odor, heat, and/or drainage. The tissue in or around the sore is black if it has died)...” During record review of Pt 2’s EHR [documents provided by the hospital], on 2/6/25 Pt 2’s “Face Sheet (FS)” dated 2/2/25 was reviewed. The FS indicated, Pt 2 was a “...29-year-old ... admitted on 1/1/25 for Altered Mental State (AMS- a change in mental function, such as a change in awareness, attention, or consciousness) and Seizures (SZ- when there’s a burst of abnormal electrical activity in the brain, which can cause temporary changes in movement, behavior, or awareness. SZs can range from minor to severe, and can involve convulsions or loss of consciousness) and discharged on 1/10/25 with Home Health (Home health care includes a wide range of health and social services delivered in your home to treat illness or injury) care.” During record review of Pt 2’s EHR, on 2/6/25 Pt 2’s “History & Physical [H&P- an assessment from physician including medical history and exam],” dated 1/1/25, was reviewed. The H&P indicated Pt 2 “...presented to the ED for taking multiple tablets of baclofen (a muscle relaxing medication) and DUI (Driving Under Influence [of a substance]) and under Police Custody... 29 years old... history of ...obesity (obese- abnormal or excessive fat accumulation that presents a risk to health), hypothyroidism (a condition where the thyroid gland doesn’t produce enough thyroid hormones), and MS (Multiple Sclerosis-a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control)...” During record review of Pt 2’s EHR, on 2/6/25 Pt 2’s ED Timeline, dated 2/2/25 was reviewed. Pt 2’s ED Timeline indicated, “...TT: 86:02 [Pt 4 remained in the ED on a hallway gurney until admission bed transfer]...on 1/1/25 at 18:50 (6:50 p.m.)...” During a record review of the complaint submitted to CDPH on 12/16/24, the complaint indicated Pt 3 “... a resident of a local skilled nursing facility (SNF- a long-term healthcare facility)admitted on April 2024 at 128 lbs. then discharged on May 2024 at 141 lbs., then admitted on 8/16/2024 back to SNF at 123 lbs. from this facility [hospital]. His weight when admitted to this facility [hospital] on 8/11/24 was 143 lbs. Weight loss appears to have occurred at the hospital. There are two stage 2 decubitus noted on the Patient also upon arrival to the SNF. Nothing was noted on the hospital records or treatment plan sent to the SNF by this facility [hospital]. Nothing indicated on the hospital records stated that he was admitted to hospital with any signs of decubitus (pressure injury or bedsore) either. Admission was due to seizure activity. At this time it appears that both the significant weight loss and decubitus occurred while he was at the hospital from 8/11/24 to today, 8/16/2024...” During record review of Pt 3’s EHR on 2/6/25 Pt 3’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 3’s “...Admit Reason (s) Seizure Disorder...ED Arrival Date/Time: 8/11/24, 12:44 (p.m.)...Date/Time First Inpatient: 8/11/24, 16:32 (4:32 p.m.)...Discharge Date/Time 8/15/24, 18:52 (6:52 p.m.)...Dispo [disposition- the destination of the patient after hospital discharge]: To Another SNF for Skilled Nursing Care...” During record review of Pt 3’s EHR, on 2/6/25 Pt 3’s “H&P,” dated 11/22/24, was reviewed. The H&P indicated Pt 3 was a “...75-year-old...patient with a history of Diabetes mellitus (high blood sugar disease), Hypertension, Mental retardation...Seizures, and Thyroid disease...” During record review of Pt 3’s EHR, on 2/6/25 Pt 3’s ED Timeline, dated 1/31/25 was reviewed. Pt 3’s ED Timeline indicated, “...TT: 29:27 [Pt 3 remained in the ED until admission bed transfer]...on 8/11/24 at 16:36 (4:36 p.m.)...” During a record review of the hospital’s FRI submitted to CDPH on 12/13/24 indicated Pt 4 was an “ ...83-year-old patient admitted...on 11/22/24 for acute kidney injury (AKI-where your kidneys suddenly stop working properly) and UTI- (Urinary Tract Infection- an infection in the urinary system). Hospitalization complicated by severe agitation requiring restraints, fluctuating mentation (mental activity)/dementia- (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Patient was noted with a deep tissue injury to sacrum area on 11/28/24, wound consult was placed. Sacral (a large, triangular bone at the base of the spine) wound has evolved into an unstageable full thickness pressure injury (when the stage is not clear), and the right gluteus (any of the large muscles of the buttocks) has evolved into a partial thickness injury that has new epithelialization (the process of becoming covered in epithelium (a layer of cells covering all the surfaces of the body), which helps the body to repair damage) and is resolving.) ...” During record review of Pt 4’s EHR [documents provided by the hospital on 2/6/25 Pt 4’s FS dated 1/31/25, the FS indicated, “...ED Arrival Date/Time: 11/22/23 11:16 (a.m.)...Date/Time First Inpatient: 11/22/224, 16:59 (4:59 p.m.)...Discharge Date/Time: 12/12/24, 14:48 (2:48 p.m.)...Dispo: To Another Facility or SNF...” During record review of Pt 4’s EHR, on 2/6/25 Pt 4’s “H&P” dated 11/22/24, was reviewed. The H&P indicated Pt 4 was an “...83-year-old...patient with a history of hypertension (high blood pressure) and dementia...brought in by ambulance due to concern for abnormal kidney function on recent labs...” During a record review of Pt 4’s EHR, on 2/6/25, Pt 4’s “ED Timeline” dated 1/31/25, was reviewed. The Timeline indicated, “...TT: 103:29...[Pt 4 remained in the ED on a hallway gurney for 22 hours before being moved into a room in the ED. Pt 4 remained on a gurney until admission bed transfer]...on 11/26/24 at 18:45 (6:45 p.m.)...” During a record review of the hospital’s FRI submitted to CDPH on 1/21/25 indicated Pt 7 was a “...31 y.o. (year-old) pt BIBA (brought in by ambulance) post (after) ground-level fall. Imaging studies revealed a right femoral neck fracture (a break in the bone that connects the femoral head (ball of the hip) to the femoral shaft (thigh bone) and pt was admitted 1/4/2025 for surgical intervention. Wound consultation on 1/15/2025 has revealed that the patient’s evolving DTI to the left aspect (area) of the coccyx (tail bone) has opened and is now an unstageable pressure injury...” During a concurrent interview and record review on 1/30/25 at 1:15 p.m., with the CPCU Nurse Manager (NM 2), EHR records for Pt 7 was reviewed. NM 2 Manager stated CPCU staff are expected to conduct a new admit dual skin verification (2 nurses required to assess and attest to their findings), to take pictures of any skin concerns, it is NM 2’s expectation that the new admit will have pictures of coccyx and heels, even if no concern is assessed, unless patient refuses. NM 2 stated the preventive care turning/repositioning, pressure relieving overlay, do not require an order, nurse follows hospital P&Ps. Any concerns are to be reported to the provider for possible orders. NM 2 stated some interventions are nurse driven [meaning the nurse can begin preventative skin care) and can be started as soon as it is assessed. NM 2 stated while inpatients are holding in the ED, the EDD Leaders are responsible for the oversight of these inpatients. NM 2 stated after review of patient 7’s record, it did not indicate skin interventions were done, or done consistently while patient was waiting in the ED. During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 7’s “...Admit Reason (s): Closed Right Hip Fracture...ED Arrival Date/Time: 1/4/25, 3:15 (a.m.)...Dater/Time First Inpatient: 1/4/25, 07:47 (a.m.)...Discharge Date/Time: 1/23/25, 14:33 (2:33 p.m.)...Dispo: Home with Home Hlth (Health) Service...” During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s “H&P” dated 1/4/25 was reviewed. The H&P indicated, Pt 7’s “...on [brand name blood thinner]...for thrombus (blood clot)...Past Medical History:...Dialysis daily via PD Cath (Peritoneal Dialysis Catheter- a treatment for kidney failure that uses the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood)...End Stage Renal Disease (ESRD-a medical condition in which a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life)...Hypertension...Lupus (disease where the body’s defense system attacks healthy cells and tissues, causing damage to many parts of the body)...” During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s ED Timeline, dated 1/31/25 was reviewed. Pt 7’s ED Timeline indicated, “...TT: 42:25 [Pt 4 remained in the ED on a hallway gurney until admission bed transfer]...on 1/4/25 at 19:42 (7:42 p.m.)...” During a record review of the hospital’s FRI submitted to CDPH on 1/29/25 indicated Pt 8 was “...an 88 y.o. male who presented to the ED 1/9/25 with AMS, cough, abdominal (stomach) pain, nausea, vomiting, and chest pain. On 1/24/25 nurses and provider assessed patient had Stage 3 pressure injury to coccyx (tail bone) ...” During record review of Pt 8’s EHR, on 2/6/25 Pt 8’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 8’s “...Admit Reason (s): Altered Mental Status...ED Arrival Date/Time: 1/9/25, 18:46 (6:46 p.m.)...Dater/Time First Inpatient: 1/10/25, 08:19 (a.m.)...Discharge Date/Time: 1/25/25, 14:30 (2:30 p.m.)...Dispo: To Another SNF for Skilled Nursing Care...” During record review of Pt 8’s EHR on 2/6/25 Pt 8’s “H&P” dated 1/10/25 was reviewed. The “H&P” indicated, Pt 8 “[past medical] history of hypertension, CVA (Cerebrovascular Accident- (or stroke- a medical condition characterized by the sudden interruption of blood flow to the brain, leading to the death of brain cells) , Parkinson’s disease (a brain disorder that causes unintended or uncontrollable movements), and dementia...” During record review of Pt 8’s EHR, on 2/6/25 Pt 8’s ED Timeline, dated 1/31/25, was reviewed. Pt 8’s ED Timeline indicated, “...TT: 40:32 ...[Pt 8 remained in the ED on a hallway gurney for 24 hours before being moved into a room in the ED. Pt 8 remained on a gurney until admission bed transfer]...on 1/11/25 at 11:18 (a.m.)...” During a record review of Pt 9’s “H&P,” dated 1/25/25, the “H&P” indicated, Pt 9 was a 75-year-old brought in by ambulance from home due to family concern of AMS. Patient 9 arrived at the ED on 1/25/25 at 11:56 a.m., and was admitted to the hospital on 1/25/25 at 5:26 p.m. for acute metabolic encephalopathy (brain is affected by lack of oxygen causing confusion), severe sepsis, and thrombocytopenia (low platelets-cell fragments in blood crucial to blood clotting). Pt 9 was moved to the Cardiac Progressive Care Unit (CPCU - a hospital unit providing care for patients with heart related conditions recovering from a critical stage) on 1/27/25 at 3:07 p.m.. Pt 9 had a Glasgow Coma Scale (GCS - a brain, spinal cord, and nerve assessment tool used to measure a person’s level of consciousness after a brain injury, a higher score indicating a higher level of consciousness) of 11 (moderate brain injury), she was bed bound since September 2024. During a record review of Pt 9’s “Physician Order [PO]1,” dated 1/25/25 at 5:26 p.m., the “PO 1” indicated, Pt 9 was admitted to the hospital as an inpatient on 1/25/25 at 5:26 p.m. During a concurrent interview and record review on 1/30/25 at 11:22 a.m. Pt 9’s “Wound Flowsheet Summary [WFS],” dated 1/25/25 to 1/28/25 was reviewed. The “WFS” indicated a skin assessment was completed on 1/25/25 at 7:30 p.m. The “WFS” indicated Pt 9 had “broken skin to coccyx area” documented in the skin integrity cell. The “WFS” indicated Pt 9’s BSS was 12, CS 6 stated a BSS of 12 was considered a high risk for skin breakdown. The “WFS” indicated no special mattress, or preventative dressing was documented for Pt 9. CS 6 stated Pt 9 should have been placed on a low air loss mattress and should have had a bordered dressing on her wound, when the nurse’s assessment indicated Pt 9 had a high risk for skin breakdown. The “WFS” indicated on 1/26/25 at 7:59 a.m. Pt 9’s “BSS” was 9. CS 6 stated a score of 9 was a severe risk for developing a pressure injury. The “WFS” indicated Pt 9 did not have another skin assessment completed until 1/27/25 at 11:27 a.m. Pt 9 went 27.5 hours without having a skin assessment documented by ED nurses. CS 6 stated on 1/26/25 Pt 9’s night shift nurses should have documented a skin assessment. The “WFS” indicated on 1/27/25 at 3:30 p.m. upon arrival from the ED to the inpatient CPCU Pt 9 had a skin assessment completed. The “WFS” indicated, Pt 9 had skin integrity documentation of a skin abrasion (scrape), bruising, infiltration (fluid leaking into tissues), redness, weeping (fluid leaking out), and a wound. The “WFS” indicated, skin integrity locations were the abdomen, breast, face, hand, cervical (neck) spine, arm, and coccyx. CS 6 stated nurses in the CPCU staged Pt 9’s coccyx wound a stage 2. CS 6 stated while Pt 9 was holding in the ED the only documented skin integrity (state of skin and its ability to function as a protective barrier) issue was a wound to the coccyx. CS 6 stated beginning skin interventions early and following the policy to protect skin were important to care for the patients skin and to prevent patients from getting sicker. During a concurrent observation and interview on 2/3/25 at 10:32 a.m. in Pt 9’s hospital room, Pt 9 was observed lying on her back in the hospital bed with her eyes open. Pt 9 was an Armenian speaking patient, and an interpreter was at bedside for interpretation. Pt 9 did not make eye contact or respond when greeted. Pt 9’s Family Member (FM 1) was at bedside. Pt 9 was not interview-able, due to her cognitive impairment (a decline in one or more mental functions, such as memory, attention, and reasoning). Pt 9’s FM 1 did not speak English, and responses were received through the interpreter. FM 1 stated Pt 9 was in the ED for three (3) days. FM 1 stated Pt 9 was very sick when she arrived at the hospital. FM 1 stated the physician started Pt 9 on antibiotics. FM 1 stated, Pt 9 only had a small healing wound to the lower back, near her bottom when she arrived at the ED. FM 1 stated, Pt 9 had a new wound to her back, and stomach, when she was moved to the CPCU from the ED. During a record review of Pt 9’s “Wound Care Consult Note [WCCN],” dated 2/2/25, the “WCCN” indicated Pt 9’s nurse entered a wound nurse consultation for a PI (Pressure Injury) to the sacrum (tail bone) on 1/28/25 at 2:24 p.m. On 1/29/25 at 8:12 a.m. Pt 9 had a Wound Care Specialist (WCS) consultation assessment completed. The WCS documented, “ ... Patient consulted for an open partial thickness wound [Stage 2] to the right aspect of the sacrum ... Wound is friction [skin rubbed against a surface] related. Wound Care Recommendations: ... Reduce/relieve pressure ... between bony prominences [bones are close to the skin] and the support surface ... Please re-consult Wound Care Specialist for new skin/wound symptoms, complications and/or deterioration [become worse]. During a concurrent observation and interview on 2/3/25 at 11:23 a.m., with Pt 38 and ED RN 15 in ED patient room Y-12 (Yellow zone, room 12), Pt 38 was lying on his back, with head propped up on a gurney (a bed on a frame with wheels that is used for moving people who are sick or injured), high-flow oxygen (high-flow oxygen therapy system includes those that supply a flow that meets or exceeds the patient’s inspiratory flow demand) was in place along with IV (intravenous- administered into a vein or veins) catheter (a thin, flexible tube that’s inserted into a vein to provide fluids, medications, or blood transfusions) and IV antibiotics (drug used to treat infections caused by bacteria and other microorganisms) being administered. Pt 38 stated he was admitted for “pneumonia and came to the ED for trouble breathing.” Pt 38 stated he was not offered a hospital bed, a toothbrush or clean towel to at minimum wipe his hands and face clean. Pt 38 stated because he needed staff assistant to get out of the gurney (oxygen and IV tubing and cardiac monitor connections) he was not getting out of the gurney much. It was observed there was no television or restroom in the private room. Pt 38 stated staff offered a bedside commode, and he used it despite feeling “embarrassed” at staff having to clean up his stool after he used the bedside commode (portable toilet). Pt 38 stated his father brought him a wet paper towel (from towel dispenser at a small sink in the room and that is what he used to clean his face and hands. Pt 38 stated he had not been updated on when an inpatient bed might be assigned. Pt 38 stated a visit from the doctor indicated he might be discharged 2/4/25 and not be moved at all. RN 15 stated Pt 38 had orders to remove the high flow oxygen and continue with IV antibiotics. RN 15 stated she took care of Pt 38 on 2/3/25. RN 15 stated she had not offered to order a hospital bed or provided opportunities for Pt 38 to take care of his hygiene needs (brush teeth, bathe, etc.). During record review of Pt 38’s EHR on 2/6/25 Pt 38’s “FS” dated 2/1/25, was reviewed. The FS indicated, Pt 38’s “...Admit Reason (s) Sepsis: (your body’s extreme reaction to an infection)...ED arrival Date/Time: 2/1/25, 05:14 (a.m.)...Date/Time First Inpatient: 2/1/25, 11:55 (a.m.)...” During record review of Pt 38’s EHR [documents provided by the hospital], on 2/6/25 Pt 38’s “H&P” dated 2/1/25, was reviewed. The H&P indicated, Pt 38 “a 22-year-old...super morbidly (defined as being 100 lbs. (pounds) or more over ideal body weight) obese...brought in to the ED by ambulance for difficulty breathing and cough. Pt 38 was admitted to the hospital on 2/1/25 at 11:55 a.m. ...for severe Sepsis and Pneumonia (inflammation (swelling) and fluid in your lungs caused by a bacterial (relating to or caused by bacteria (small germs (tiny organisms, or living things, that can infect you and make you sick)...[Pt 38] has no known medical conditions...” uring record review of Pt 39’s EHR, on 2/6/25 Pt 39’s “FS” dated 2/3/25 was reviewed. The FS indicated, Pt 39’s “...Admit Reason (s): Dysphagia (difficulty swallowing)...ED Arrival Date/Time: 2/2/25, 00:36 (12:36 p.m.)...Date/Time First Inpatient: 2/2/25, 03:46 (a.m.)...” During record review of Pt 39’s EHR, on 2/6/25, Pt 39’s “H&P” dated 2/2/25 was reviewed. The H&P indicated, Pt 39 was a “...49-year-old, with past medical history of uncontrolled DM, multiple diabetic foot infections, L (Left) TMA (Trans metatarsal amputation-surgical procedure that removes part of the foot), R (Right) BKA (Below the knee amputation-surgical procedure that removes part of the leg), and drug abuse...presented to the ED due to choking episode...” During record review of Pt 40’s EHR, on 2/6/25 Pt 40’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 40’s “...Admit Reason (s): Altered Mental Status...ED Arrival Date/Time: 1/9/25, 18:46 (6:46 p.m.)...Dater/Time First Inpatient: 1/10/25, 08:19 (a.m.)...Discharge Date/Time: 1/25/25, 14:30 (2:30 p.m.)...Dispo: To Another SNF for Skilled Nursing Care...” During record review of Pt 40’s EHR on 2/6/25, Pt 40’s “H&P” dated 1/28/25 was reviewed. The H&P indicated, Pt 40 was “...a 79-year-old, with history of recurrent stage IV lung adenocarcinoma (lung cancer) ...with bone mets (bone metastases- bone metastasis occurs when cancer cells spread from their original site to a bone) in the ribs, s/p resection radiation in the past, COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe)...presented to the hospital due to short of breath cough generalized weakness, poor oral intake...” During record review of Pt 40’s EHR, on 2/6/25 Pt 40’s ED Timeline, dated 1/29/25, was reviewed. Pt 40’s ED Timeline indicated, “...TT: 30:35 ...[Pt 40 remained in the ED on a gurney until admission bed transfer]...on 1/11/25 at 11:18 (a.m.)...” During a record review of Pt 40’s EHR, the EHR indicated the first documented Head to Toe (a physical exam that evaluates a patient’s entire body to assess their health) assessment was on 1/28/25 at 8:00 p.m., the EHR indicates the BSS was 19 with skin “intact...bruising to [pt] back. On 1/29/25 at 7:00 a.m., a pillow was documented for “proper alignment.” On 1/29/25 at 8:00 a.m., turns every 2 hours and overlay were documented/implemented. Turns were inconsistently documented with first turn (after first head to toe assessment) documented at 2:48 a.m. on 1/29/25 (or 6 hours later). On 1/30/25 at 11:34 p.m., photos of Pt 40 taken per unit expectation on arrival with documentation of left buttock impairment. During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with Clinical Supervisor (CS) 7 and EDD, the Electronic Health Records (EHR) for Pt 41 and Pt 42 were reviewed. CS 7 stated she believed that pressure injury occurs in patients at 24-hours. EDD explained nurses have 24-hours to document admission assessments per hospital P&P. During record review of Pt 41’s EHR, on 2/6/25 Pt 41’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 41’s “...Admit Reason (s): AMS...ED Arrival Date/Time: 1/26/25, 22:16 (10:16 p.m.) ...Date/Time First Inpatient: 1/27/25, 08:19 (a.m.)...” During record review of Pt 41’s EHR on 2/6/25, Pt 41’s “H&P” dated 1/27/25 was reviewed. The H&P indicated, Pt 41 was “...83-year-old...with past medical history of dementia, CVA..., atrial fibrillation (a-fib- a heart condition that causes an irregular heartbeat), hypertension, congestive heart failure (CHF- chronic condition where the heart muscle is weakened and cannot pump blood effectively)...appears ill and frail...likely septic...UTI...” During record review of Pt 41’s EHR, on 2/6/25 Pt 41’s ED Timeline, dated 1/29/25, was reviewed. Pt 41’s ED Timeline indicated, “...TT: 65:45 ...[Pt 41 remained in the ED on a gurney]...” During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with CS 7 and EDD, of Pt 41’s EHR, Pt 41’s EHR indicated the first documented Head to Toe assessment was on 1/26/25 at 11:46 p.m., the EHR indicates the BSS was 13 with skin described as “Present on Admission; Redness ...coccyx, foot, heel...” Turns were inconsistently documented with first turn (after first head to toe assessment) documented at 4:11 p.m. on 1/27/25 (or greater than 5 hours later). On 1/27/25 at 4:11 p.m., a waffle overlay was documented. On 1/30/25 at 8:20 p.m., 3 CPCU nurse took photos of Pt 41 on arrival to the unit, per 3 CPCU unit expectation, the documentation indicated skin impairment: “...Intact, Redness, Excoriation (when the top layer of skin is removed or abraded (a minor injury that occurs when the top layers of skin are broken))...Toe, abdomen, coccyx, buttocks, thigh, perianal (of or pertaining to the areas immediately around the anus) [areas]...” EDD stated the findings during record review are not to department expectations. During record review of Pt 42’s EHR, on 2/6/25 Pt 42’s “FS” dated 1/29/25 was reviewed. The FS indicated, Pt 42’s “...Admit Reason (s): Syncope (another word for fainting or passing out....ED Arrival Date/Time: 1/27/25, 16:32 (4:32 p.m.)...Date/Time First Inpatient: 1/28/25, 08:20 (a.m.)...” Pt 42 During record review of Pt 42’s EHR, on 2/6/25 Pt 42’s “H&P” date 1/29/25 was reviewed. The H&P indicated, Pt 42 was an “...89-year-old, with history of Sjogren syndrome (a chronic autoimmune disorder that happens when the immune system attacks the glands that make moisture in the eyes, mouth, and other parts of the body)...chronic kidney disease...hypertension...” During a review of Pt 42’s EHR, the EHR indicated the first documented Head to Toe assessment was on 1/28/25 at 8:04 a.m., the EHR indicates the BSS was 20 with skin “intact.” Pillows and pressure relief overlay documented by Patient Care Technician (PCT) on 1/28/25 at 6:19 a.m. Pt 42 was transferred to the inpatient unit on 1/28/29 at 6:40 p.m. On 1/29/25 at 2:37 a.m., inpatient nurse documentation of “Plan of Care Signed” note indicated “...Skin check completed with secondary nurse. Redness noted to abdominal and groin fold. Blanchable redness to coccyx. Foam dressing applied. Educated patient to reposition throughout shift to prevent further skin breakdown...” During a concurrent interview and record review on 2/3/25 at 1:35 p.m., with Cardiovascular Services Director (CSD), CNO and the Director of Quality (DQ),who joined via telephone, the report CSD presented to the Quality Council and Steering Committee (which has oversight for wounds at the corporate level) on 1/9/25 (for August to November 2024) was reviewed. CSD stated he has just taken over the reporting and serving as chair for the hospital Wound Committee, the CNO had formerly filled this role. CNO stated that a change in leadership in the ED prompted a review to look at resources in the ED. CNO stated one gap identified was the need for a 2-person team to help with turning in-patients. The CNO explained this team was implement on 4/2024. In addition to this turn team, other factors were identified as opportunities in the ED, such as supplies (waffle mattresses, gurneys which pose a high risk for pressure injury, etc.) patients who are not able to ambulate independently requiring assistance, and frequent offloading (Offloading helps lower the risk of pressure ulcers and other wound-related issues) by staff. Photos (camera for unit); now have rovers available and readily distributed to the ED staff (ED, EDIN and Floats). Improved capture of photos and easier for nurses. Education was rolled out to all of the ED (ED/EDIN) with expectation that the care is consistent (clarified following the policy) with the standards of the inpt floors. Education to skin and wounds at huddles with ED staff re: how to assess, interventions, documents. ED staff educated to policy (9/2024). CNO stated all nurses able to see same data/assessments and ED may have floats from Float pool based on competency. CNO stated EDIN nurses do not float to ED unless they have a competency. Monitoring for compliance. Tracer tool through JC implemented 11/1/2024, per POC C.S. or designee to conduct 1 tracer per shift for INPTs not sure if for ED patients. CNO stated wound class 8 hr. or 4 hours are being offered to staff. CNO recommended that all ED nurses take both classes. Discussed findings [delayed assessments, incomplete BSSs, delayed or missing implementation of interventions, missing documentation of turns and other measures aimed at PIP, etc.] of tour and record review w/documentation not present in the EHR as expected with the leaders. CNO stated each department can do above and beyond and it is encouraged (example of the NM 2’s expectation that regardless of impairment, nurse will photograph the bottom and heels of each inpatient admitted). Each department may implement measures based on their focused chart reviews. CNO stated failing to get assessments done and other gaps in documentation are not the expectation. CNO stated training and education for staff in ED has been held. CNO stated other procedural areas (Dialysis, Surgery, etc.) have been invited to attend the wound committee for collaboration in the protection of and preventing patient skin injury. CNO stated the hospital does not currently participate in the NDNQI (National Database of Nursing Quality Indicators- allows staff nurses and nursing leadership to review and evaluate nursing performance in relation to patient outcomes) Skin Prevalence Study, but have plans to begin participating with anticipated roll-out to staff on 4/20/2025. During an interview on 2/5/25 at 9:39 a.m., with Chief Nursing Officer (CNO), a summary of the observations and interview with Pt 38 were provided. The CNO stated “we failed [in meeting Pt 38’s care]” and he developed breakdown of skin that he did not have when he came to the hospital. We are looking to improve and we are not there yet.” CNO stated she was aware of the gaps in care and documentation identified during record reviews. CNO stated leadership will now need to look at if the skin risk needs to be assessed while the patient is an ED pt to ensure that skin integrity measures are implemented timely no matter the admission status. The CNO stated her expectation for nurses is they follow hospital policy and procedures. CNO stated the purpose of following P&Ps is to ensure resources are available to nurses to keep patients safe and provide quality care. During an interview on 2/7/25 at 10:17 a.m. with the CNO, the CNO stated, nurses were expected to assess the patient’s skin within 24 hours after admission and then once per shift. The CNO stated skin integrity interventions were chosen based on nurse skin assessments. The CNO stated the longer nurses delayed skin care interventions, patients were more at risk for hospital acquired pressure injuries (HAPI). The CNO stated HAPIs result in patient harm. Therefore, skin interventions were important to prevent skin breakdown. 3. 3. The hospital failed to ensure patients with a physician order for inpatient care were transferred to the ordered inpatient unit to receive care. In a comparison of the number of inpatients discharged from the ED (never having been physically on an inpatient unit their entire stay), from October 2023 through January 2024 was 829 (21%), and 823 (19.7%) from October 2024 through January 2025 (or a 1.3% difference). During an interview on 1/30/25 at 9:00 a.m., with CNO and Chief Operations Officer (COO) the COO stated the number of ED holds has remained high but their total percentage of discharges (house-wide) has increased by 11%. The COO stated the 5 Tower has 30 inpatient beds, however staffing challenges and concern for financial viability were obstacles to opening the unit. In a report provided by the Director of Operations (DOO), undated, the report indicated “...from October 2023 through January 2024 there were 829 discharges compared to 823 October 2024 through January 2025...” During a review of a hospital report titled “Inpatients Discharged from the Emergency Department” undated, prepared by Director of Operations, the report indicated “...In comparing these two time periods (October 2023 through January 2024 and October 2024 through January 2025), we find the rate of inpatient discharges occurring in the ED has decreased by 10% from the period one baseline, despite total discharges house wide increasing from 3,776 to 4,179, an 11% increase...” During a review of the hospital “Standard of Practice for Emergency Department” policy and procedure (P&P) dated 9/23/24, the P&P indicated “...PURPOSE: These Standards of Practice are necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive by the Emergency Departments...of the [hospital system]... POLICY: A. The patient in the ED will receive care in accordance with the Standard of Practice for the ED area. The Standard of Practice categories are adopted by [hospital system’, which the Licensed Nurse must address when caring for each patient. B. Standards of Practice are to form the basis for monitoring and evaluating patient care in the ED... PROCEDURE: A. STANDARD OF PRACTICE: ... The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: ... 2. Adhere to all established [hospital] policies/procedures. 3. Intervene appropriately to correct unsafe situations... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order. a. Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs. i. Data will incorporate age-specific needs of the patient through the life span. ii. Assessment will reflect the cultural tradition/values of the patient/family. b. The data collection process for assessment is systematic, ongoing, and updated prior to transfer to another level of care and/or home... Evaluate all patients in a timely manner... d. A system specific assessment at the onset of patient treatment with ongoing assessment dependent upon patient condition and response to treatment. e. The data is to include a health history and physical assessment to determine patient’s capabilities, limitations, nutritional, physiological, psychosocial, cultural, and environmental needs/problems... Total intake/output monitored based on order or warranted by condition... 2. Advise the physician of any alterations in the patient’s psychological and/or physiological condition and any abnormal lab results. 3. Nursing intervention is to be administered in accordance with individual needs of the patient and include other disciplines, private physician, specialty physicians, social services, special programs, clinics or referral services as warranted... F. STANDARD OF PRACTICE: Skin integrity...Patient Rights... 1. The patient will be involved as actively as possible in planning interventions to maximize health capabilities. The RN will: a. Follow established policies/procedures of [the hospital] when implementing nursing care. b. Implement physician orders. c. Follow the recommendations for wound management as described in the Corporate Patient Care Policy Manual. d. Maintain and/or improve skin integrity during hospitalization through appropriate nursing interventions. Promote patient comfort, cleanliness, and sense of wellbeing by assisting with activities of daily living (ADL’s- [toileting, dressing, etc.]). e. Reposition patient every 2 hour or more frequently, as needed. f. Obtain a physician’s order for the use of pressure relieving devices when warranted. g. Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device... Document the nursing interventions/patient responses in the medical record...” During a review of the hospital “Standards of Practice - Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” P&P dated 9/25/24, the P&P indicated “...PURPOSE These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in the Critical Care, Step-Down/Progressive Care, Telemetry, and Medical/Surgical units...POLICY A. Licensed professionals are accountable for assigned patient care until end of shift, physical transfer, hand-off to another licensed staff member, or patient discharge.... B. If there is a difference between the physician order and the standards below, the one that is stricter will be followed (e.g. physician orders intake and outputs measured every 12 hours, but unit standard is every 8 hours; the unit standard will be followed)... E. Reposition patients who are unable to do so themselves every 2 hours or more frequently, while assessing the condition of the patient’s skin. F. Progressive mobility will be instituted utilizing the approved mobility assessment tool. G. Appropriate arrangements may be made to accommodate time outdoors for patients as clinically appropriate according to the patient’s stability level and plan of care... STANDARDS See Standards of Practice Documentation Grid...” During a review of the hospital “Standards of Practice Documentation Grid,” undated, the grid indicated “...Full Assessment: Document within 12 hours. General Medical Surgical...Telemetry...Progressive Care/Step-Down...within 2 hours of admission and at the beginning of every shift... On-going / Reassessment. Based on unit specific intervals... General Medical Surgical...Telemetry...Progressive Care/Step-Down... With changes in the patient condition and as needed (e.g. 2 to 4 hours, for no more than 8 hours;...” During a review of the hospital “Admission & Ongoing Assessment - Nursing (Acute Care)” P&P dated 8/11/22, the P&P indicated “...PURPOSE A. To provide a standard for the admission and ongoing assessment of the patient... E. To outline role-based and role-specific procedures for admitting and assessing the patient at the time of admission...POLICY... A. Admission... 4. Patients being admitted to the acute care facility through the Emergency Department (ED) will have the admission and assessment process initiated in the ED. The information gathered will be verified and completed as necessary by the RN in the inpatient receiving area. B. A comprehensive nursing admission assessment using the nursing process will be initiated by the RN within two hours of the patient’s admission... 2. A comprehensive initial assessment includes reviewing and/or establishing a baseline assessment including:... h. Nutritional status...m. Integumentary status n. Musculoskeletal status. o. Functional status... D. Ongoing nursing assessment will be initiated by the RN or LVN at the beginning of every shift in accordance with their scop of practice...” During a review of the hospital P&P titled “Pressure Injury Risk Assessment, Prevention, Staging and Treatment” dated 9/13/24 on 2/6/25, the P&P indicated “ ... PURPOSE A. To provide staff with a valid and reliable pressure injury risk assessment tool for admitted patients. B. To provide guidelines for the prevention of pressure injury development in the adult and adolescent (14-17 years of age) population. C. To provide guidelines for systematic staging, assessment, and treatment of pressure injuries. D. To implement wound management strategies to optimize the healing potential and prevent deterioration of existing pressure injuries. ...POLICY: A. All patients shall be assessed upon admission, then every shift, and with condition changes using the Braden Scale for Predicting Pressure Sore Risk. B. Prevention measures are to be applied based on the assessed level of risk according to the Braden Scale for Predicting Pressure Sore Risk. C. Patients with a subscale identified as a score of 1 or 2 are considered at risk for developing pressure injuries. The nurse will identify and implement an individualized plan of care that addresses the interventions appropriate to reduce the risk factors. D. Upon identification of a suspected pressure injury, whether present on admission or hospital-acquired, the RN shall photograph, describe and document the injury location on the appropriate section of the electronic health record (EHR). The pressure injury will be staged by a RN and they will complete an Incident Reporting Intranet System (IRIS) report. E. Notify the Clinical Supervisor and/or WS of all unstageable, stage 3, or stage 4 pressure injuries as soon as possible after discovery. F. Notify the provider of any skin breakdown and of any significant changes to the pressure injury. G. All pressure injury treatment requires a provider order. H. Obtain a nutritional consult for any patient with a stage 2 or greater pressure injury. I. The RN may implement all aspects of the policy. The licensed vocational nurse (LVN) may implement any portion of the policy as directed by the RN/provider and within their scope of practice. A patient care technician (PCT) may implement all preventive measures in care as directed by the nurse. PROCEDURE: A. Risk Assessment... 1. Use the “Braden Scale Risk Assessment tool” to identify patients at risk for pressure injury as part of the initial admission patient assessment. Subsequent Braden Risk assessments are completed each shift. 2. The initial skin assessment upon admission and/or transfer from another unit will be conducted by an RN and a secondary licensed staff [RN or LVN] member. 3. Refine the assessment by including these additional risk factors: a. Fragile skin b. Existing pressure injury of any stage, including those injuries that have healed or are closed. c. Impairments in blood flow to extremities from vascular disease, diabetes or tobacco use. 4. Develop a plan of care based on the areas of risks, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, positioning, and the support surface. If the risk is from malnutrition, address this problem, etc... B. Prevention (All patients regardless of score) 1. Skin Care a. Inspect all of the skin following admission and document the assessment in the medical record within 24 hours of admission. b. Re-assess the skin routinely per the “Standards of Practice Documentation Grid.” c. Assess pressure points, including under equipment contact sites, and also over boney prominences, such as the sacrum, coccyx, buttocks, heels, ischium (the lower, back part of the hip bone, known as the pelvic bone), trochanters (a bony prominence on the upper part of the femur (thigh) bone, near the hip joint), elbows, and under medical devices. d. When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent (near to) skin. Moistening the skin assists in identifying changes in color. e. Cleanse the skin promptly after episode of incontinence. f. Use skin cleansers that are pH balanced for the skin. g. Avoid positioning patient on an area of erythema (abnormal redness of the skin or mucous membranes) or pressure injury. h. Initiate standard pressure injury prevention(s) per Braden scoring. Interventions may include the following in the “Prevention by Risk Levels” section below (Procedure, section C), and also within the “Wound Bundle reference grid.”...2. Nutrition...3. Moisture Control...4. Pressure Reduction-Positioning...Friction and Shearing Reduction...C. Prevention by Risk Levels...Not at Risk - greater than 18 if no subscale scores of 1 or 2... If the patient scores a 1 or 2 .... implement any of the following interventions... E. Document finding in the EHR... 2. Photograph on discovery, weekly and with significant changes...3 if new pressure injury noted; initiate same pressure injury prevention measures as treatment, obtain a wound consult...4 IRIS (hospital event reporting application)...” During a review of the hospital’s “P&P” titled, “Pressure Injury Risk Assessment, Prevention, Staging and Treatment,” dated 9/13/24, the P&P indicated, “ ...All patients shall be assessed upon admission, then every shift, and with condition changes using the Braden Scale for Predicting Pressure Sore Risk ... Upon identification of a suspected pressure injury ... The pressure injury will be staged by an RN, and they will complete an Incident Reporting Intranet System (IRIS) report ... Develop a plan of care based on the areas of risks, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, positioning, and the support surface. If the risk is from malnutrition, address this problem, etc. ... Inspect all of the skin following admission and document the assessment in the medical record within 24 hours of admission ... Re-assess the skin routinely per the Standards of Practice Documentation Grid ... Initiate standard pressure injury prevention(s) per Braden scoring ... Pressure Reduction-Positioning ... Turn and position all patients ... Staging/Treatment ... Stage all pressure injuries according to amount of tissue loss ... Document finding in the EHR [Electronic Health Record] ... If new pressure injury noted; initiate same pressure injury prevention measures as treatment, obtain a wound consult ...”. During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility’s policy and procedure (P&P) titled, “Pressure Injury Assessment, Prevention, Staging and Treatment”, dated 09/13/24, Section III part A. indicated, Patient’s with a total score of nine or less are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk, for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear. During a review of facility’s policy and procedure (P&P) titled, “Standard of Practice for Emergency Department”, dated 9/23/24, the “P&P” indicated “ ...Maintain and/or improve skin integrity during hospitalization ...through appropriate nursing interventions ... Reposition patient every 2 hours or more frequently ... Obtain a physician’s order for the use of pressure relieving devices when warranted ... Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device ...” During a review of the hospital “Hospital Facility Surge Plan (Surge Plan)” dated 2024, on 2/6/2025, the Surge Plan indicated “...Triggers/Warning Signs Operational Warning Signs...The following are examples that may indicate a capacity challenges in the coming days or hours: ...Post-Anesthesia Care Unit (PACU) patient holding overnight...Emergency Medical Services (EMS) wait/wall times begin to increase...Hold ED times exceeding the average...Inpatient Registered Nurses (RNs) working outside of the Title 22 ratios (state regulatory requirement(s)...Sustained...or 80 admit holds withing the hospital Emergency Department... Capacity Surge Triggers: The hospital has designated several locations across the facility to address all patient acuity (the severity or complexity of a patient’s medical condition) levels, varying from licensed inpatient to non-licensed inpatient bed locations. It is important to note that the hospital will make every attempt to use licensed inpatient bed space before non-licensed bed locations; however, this may not be possible depending on the size, length, and scope of an incident. Surge space should only be activated if the event will present patients who will overwhelm the facility’s capability to manage and care for patients in a safe environment properly. When considering the activation of this surge plan, the following are independent triggers established to begin the consideration of activation of surge spaces...sustained for a period of time greater than 12 hours: Inpatient nursing staffing above the Title 22 ratios for 33% of staff, Capacity index of 1.33 or 90 admit holds within the hospital Emergency Department, A specific level of medical care is impacted, causing a significant increase in the hold time out of the proper level of care department, Number of high acuity holds (i.e., Intensive Care Unit (ICU)/Stepdown Unit (SDU)) outside non-ICU/SDU beds is 10% of normal ICU beds, Emergency Department Census above max value... After any of the triggers have been met and a surge space has been opened, each additional surge space shall be evaluated when 75% of the adult capacity is achieved within that unit, dependent on the level of acuity...” During a review of a professional reference titled, “Implementation of Pressure Injury Prevention (PIP) Strategies in Acute Care,” dated May/June 2022, (retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9093720/pdf/wocn-49-211.pdf) the professional reference indicated, “ ... In 2019, the Agency for Healthcare Research and Quality reported that HAPI rates are rising, while all other hospital-acquired conditions are decreasing ... there is room for improvement in the implementation of some of the most basic PI prevention strategies including repositioning, heel elevation, layers of bed linens, nutritional support, and moisture management. Future research should seek to build on the current study by focusing on prospective and longitudinal studies evaluating risk factors and prevention practices in acute care settings to better understand the occurrence of HAPIs in this population as well as provide insight into the potential occurrence of unavoidable PIs (Pressure Injuries)...” The Joint Commission Journal on Quality and Patient Safety article titled, titled “No More Useless Band-aids that Fail to Solve America’s Emergency Department Boarding Crisis,” dated 12/2023 retrieved 2/19/25 from https://www.jointcommissionjournal.com/article/S1553-7250(23)00234-9/fulltext indicated, “The causes of boarding as well as many proposed solutions have been well described. However, the suggestions are band-aid solutions such as changing ED workflow, surgical schedule smoothing, and alternate care sites, and none of them will alleviate boarding and its harms. Boarding is the manifestation of a dysfunctional health care system with misaligned financial incentives. It is a direct consequence of the United States’ patchwork, profit-driven health care system, not attributable to any single hospital or health care organization. While daily admissions from the ED will vary somewhat, the typical number can be easily determined from the ED’s historical records. Beds could easily be reserved for these anticipated admissions, and remaining beds could be allocated to elective admissions. Predicting the daily admission needs for the ED to function and serve the community is not a difficult task. We lack the will to do this, not the ability to make it happen. The lack of will arises from hospital administrators having no incentive to reserve space for ED admissions when they can allocate beds to elective admissions that generate higher profit. In both for-profit and not-for-profit ...” hospitals-which account for the overwhelming majority of annual acute inpatient admissions in the United States-the C-suite is tasked with remaining fiscally solvent. To do so, they favor patients with the kinds of insurance and the kinds of medical conditions that provide lucrative reimbursement for short lengths of stay. In following this strategy, admitted ED patients are queued up in the ED, occupying rooms and halls that need to be available to the patients in the ED waiting room. Consequently, our healthcare system caters better to a regional patient in need of advanced oncology therapy, organ transplant, or complex surgery than a local community member who presents to the ED with pneumonia or congestive heart failure who may find that emergency medical services cannot take them to their preferred hospital because its ED is diverting due to saturation. Boarding is a driver of ambulance diversion and leads to further inequities and disparities.15-21 Our healthcare system does not value care of the most vulnerable.22 While many factors contribute to the lack of acute inpatient psychiatric stabilization beds, a reimbursement system that undervalues such care is a major factor.23 Individuals suffering a mental health crisis experience some of the most egregious prolonged boarding in EDs awaiting acute inpatient psychiatric beds.24-27 The American College of Emergency Physicians policy statement titled, “Boarding of Admitted and Intensive Care Patients in the Emergency Department,” revised February 2023, retrieved 2/19/25 from https://www.acep.org/siteassets/new-pdfs/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department.pdf, indicated, “ ... Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Once admitted, patient care is most effectively and safely delivered on inpatient units. Boarding of admitted patients in the ED represents a hospital-wide failure and contributes to lower quality of care, decreased patient safety, reduced timeliness of care, reduced patient satisfaction, an increased number of patients leaving without being seen, and increased mortality. Additionally, it directly contributes to ED crowding due to the resultant loss of bed and resource capacity. ED crowding and its negative impacts on patients are due to misaligned health care economics and financial pressures on hospitals ...” The Journal of Academic Emergency Medicine article titled, “The Association Between Length of Emergency Department Boarding and Mortality” retrieved 2/19/25 from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2011.01236.x, indicated, “ ...ED boarding occurs when insufficient hospital capacity is available for admitted patients to be transferred to inpatient beds. The result is that admitted patients remain in the ED, sometimes for long periods. The concern is that due to competing demands by other patients and general system overload, boarders do not receive the same level of care that they would in inpatient beds. Several recent articles have identified safety issues with boarding, including adverse events, higher rates of ventilator-associated pneumonia, higher mortality rates for intensive care unit (ICU) patients per se, and for admissions overall. There are also higher rates of medication errors and preventable adverse events ...””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49884 Based on interview, review of video surveillance and document review, the hospital failed to ensure patients’ right to be free from physical abuse and free from restraints for one of one patient, Patient (Pt) 43, when on 2/2/25 the Security Watch Commander (SWC) deployed the use of a taser (a handheld, battery-powered device that delivers an electric shock to temporarily disable a person) to restrain Pt 43 against the hospital’s policy and procedure on use of tasers and against CMS guidance on use of tasers. Registered Nurses (RN)s failed to document the use of a taser in Pt 43’s medical record, failed to assess Pt 43 after a change of condition, and failed to have a physician assess Pt 43 after a taser strike. This failure resulted in the inappropriate use of tasers to restrain Pt 43, led to cuts and bleeding on Pt 43’s skin, had the potential for further injuring Pt 43’s fractured (broken bone) left hand, and for mental harm to Pt 43. The use of the taser directly led to harming another staff member, Security Officer (SO) 1. Findings: During a review of Pt 43’s “Emergency Department Provider Notes [EDPN- assessment from physician including medical history and exam]” dated 2/1/25, the “EDPN” indicated Pt 43 was admitted on 2/1/25 at 10:16 p.m. for Psychiatric 5150 Danger to Self [a state law that allows law enforcement and mental health professionals to detain someone for 72 hours for a mental health evaluation and treatment] (found by police walking barefoot through traffic with bleeding on face and hands and holding onto rose with thorns). Pt 43 had abrasions (scrapes) to the face, both hands and both feet. Pt 43 had a flat affect (absent display of emotions), and poor eye contact. Pt 43’s visit diagnosis was bizarre (very strange or unusual) behavior and closed displaced fracture (bone break not through the skin) of fifth metacarpal (connects the pinkie finger to the palm) bone of left hand. During a review of Pt 43’s “ED Care Timeline [EDCT],” dated 2/1/25 to 2/2/25, the “EDCT” indicated, Pt 43 was moved to the SCU [Special Care Unit- is a locked unit within the Emergency Department (ED) where patients who are in a psychiatric or behavioral emergency and do not require complex medical treatments are placed] on 2/1/25 at 10:16 p.m. The “EDCT” indicated, on 2/1/25 at 10:41 p.m. a head-to-toe assessment was completed by LNs indicating Pt 43 had cuts and redness to both hands, his face, his left knee, and left foot. The “EDCT” indicated, at 11:30 p.m. “ ... ED Notes: Writer and secondary RN entered SCU and attempted to clean pt’s open wounds. Pt refused care, pt states “I like the wounds how they are, I like to walk around barefoot, I dont want them cleaned. I have a right to say no ...” The “EDCT” indicated, on 2/1/25 at 11:33 p.m. Pt 43 was a flight risk (attempt to leave unit) and during Pt 43’s psychiatric assessment he was withdrawn (avoiding interaction), preoccupied (distracted), and guarded (cautious). The “EDCT” indicated, Pt 43’s general attitude was suspicious, and he was a low risk for violence on the violence assessment tool (tool used to assess risk for violence). The “EDCT” indicated, on 2/1/25 from 11:45 p.m. to 2/2/25 at 1:30 a.m. documented under “Continuous Observation” Pt 43 was awake, lying down, and quiet or awake lying down talking to staff. The “EDCT” indicated, on 2/2/25 at 1:19 a.m. an ED Note by RN 13: “ ... Writer attempted to initiate splint [medical device used to support and immobilize an injured body part] application process. Pt refused splint application. Writer explained benefits and risk of ignoring medical treatment and application of medical equipment. Pt states that he is going to hell regardless so there is no point “it is what it is” ... MD notified. Awaiting orders and further plan of care ...” The “EDCT” indicated, on 2/2/25 1:45 a.m. Pt 43 was “... Awake; Abusive to staff; Agitated (uneasiness, nervous); Evidence of harmful behavior (verbal or actions) (Patient assaulted officer. Pt being placed in four-point [both wrists and ankle] restraints [preventing movement of body and limbs]) ...”. The “EDCT” indicated, on 2/2/25 at 1:48 a.m. orders were placed for violent restraints, and 5 milligram (mg- a unit of measurement) haloperidol (medication used to treat agitation, and irritability) injection (a shot with a needle to give medication), 50 mg diphenhydramine (medication causes sedation) injection and 2 mg lorazepam (medication to treat anxiety and nervousness) injection were ordered. The “EDCT” indicated, 2/2/25 at 2:46 a.m. an ED note addendum documented by Registered Nurse (RN) 13 “ ...Writer witnessed pt [Pt 43] approached SCU door, security officer opened the door and spoke to pt. Pt assaulted [make a physical attack on] security officer at this time and officer was able to close the door at this time. Pt hitting body against door and barricaded [blocked] himself against the door. Code assessment was called overhead at this time, MD was also notified. Pt began to escalate [increase rapidly] in behaviors, became increasingly agitated. Security stepped in to carry out 4 point restraint orders. Pt restrained to gurney, bed wheels unlocked. Restraints applied on wrist. Prior left-hand injury at admission, restraint applied to lower wrist, hand in neutral position resting on the gurney. Medication orders were also carried out. Pt still agitated at this time ...”. The “EDCT” indicated, 2/2/25 at 4:15 a.m. Pt 43’s vital signs were taken by a Certified Nursing Assistant (CNA). The “EDCT” indicated, the next complete patient assessment was documented on 2/2/25 at 8:00 a.m. by a RN . The “EDCT” did not contain any reference to the use of a taser on Pt 43 and did not contain a head-to-toe assessment of Pt 43 by RN 13 after the taser strike. During a review of Pt 43’s “EDPN Continued”, dated 2/2/25 no time on documentation, the “EDPN Continued” indicated, “ ... The following face to face evaluation was performed within 1 hour of the patient being placed in restraints. Unable to obtain review of systems due to patient condition. The behavioral assessment indicates danger to self, danger to others, violent. I reviewed and assessed patient’s history, drugs and labs if available and determined that there are no immediately reversible conditions. The patient’s medical and behavioral condition and reaction to the intervention continued attempts or displays of harmful behaviors. I have determined the need to continue the restraint or seclusion ...” Pt 43’s medical record did not contain any reference of taser use and did not contain any “EDPN” with an assessment by a physician after the taser strike. During a concurrent interview and security footage video review on 2/4/25 at 2:37 p.m. with the Security Operations Manager (SOM), the security video from the SCU from 2/2/25 beginning at 1:45 a.m. was reviewed. The video footage angle was shot from the south facing north. Large glass observation windows, and a glass door were on the left (West) wall of the room. A solid wall was on the North side of the room with a glass door at a 90-degree angle to the door on the West side of the room. The only entry points to the room were the two glass doors. The right (East) side of the room had three gurneys against the wall in a row in view of the camera. Pt 43 was observed in the middle gurney, with an empty gurney on either side. At 1:45 a.m. Pt 43 was observed sitting in an upright position on the middle gurney with both metal siderails up rocking from front to back. At 1:46 a.m. Pt 43 got out of the gurney and went to the door on the West side of the room. Pt 43 was observed standing by the door for approximately 30-45 seconds. The door opened a small crack (door opens inward). Pt 43 quickly struck out his arm, palm first through the opening in the door. Pt 43 withdrew his arm. The SOM stated, Security Officer (SO) 1 was hit in the face when Pt 43 thrust his palm through the door. At 1:47 a.m. the door was closed, and Pt 43 was observed bracing himself against the door with his left shoulder. At 1:48 a.m. staff could be seen in the observation windows, and through the glass door on West side and in the door on the North side. The SOM stated two officers were at each entry point. At 1:49 a.m. Pt 43 moved away from the door and into a sitting position on the floor between the two doors. Pt 43 was sitting with legs folded to his side and hands up on both sides of his face. The SOM stated the officers were actively communicating with the patient for him to move away from the door. At 1:50 a.m. four officers entered the room at the same time, two from each door, surrounded Pt 43 and began attempting to restrain limbs. At 1:51 a.m. a flash of light could be seen on the lower left of the screen near the patient and between two officers. The SOM stated the flash of light was the taser being deployed (fired). The SOM stated, Pt 43 was hit with one prong and SO1 was hit with the other prong. Immediately after the taser flash another officer came into the room for a total of five. At 1:57 a.m. a restrained Pt 43 was lifted by five officers onto the gurney, and limbs restrained to gurney. At 2:01 a.m. all hospital staff exited the SCU. The SOM stated, there was another patient in the SCU out of the video frame that never moved from his gurney. During a telephone interview with Registered Nurse (RN) 13 on 2/4/25 at 3 p.m. RN 13 stated, she was Pt 43’s primary nurse on the night of 2/1/25 and morning of 2/2/25. RN 13 stated, she remembered the incident when Pt 43 was tased. RN 13 stated, she saw Pt 43 was attempting to get up out of the gurney, but his side rails were up. RN 13 stated, she turned her back to set something down and Pt 43 was at the door by the time she turned back around. RN 13 stated, SO1 pushed open the door a crack to ask what the patient wanted, and Pt 43 pulled the door inward by the inner door frame. RN 13 stated, Pt 43 then struck out his right hand and made direct contact with SO1’s face. RN 13 stated, SO1 pushed the door closed and once it was shut Pt 43 used his left shoulder to brace the door shut. RN 13 stated, SO1 contacted additional security officers. RN 13 stated, she messaged the physician and got an order for 4-point restraints and chemical restraint medications. RN 13 stated, she called a “code assessment [ an overhead page for assistance when a patient had escalating behaviors]” when Pt 43 hit SO1. RN 13 stated, she would call a “code assessment” when a patient started to escalate, and the physician was supposed to come to bedside to assess the situation. RN 13 stated, no one responded to her page for “code assessment”. RN 13 stated, officers told Pt 43 to sit down, and he complied. RN 13 stated, four officers went into the room and surrounded the patient. RN 13 stated, one officer had their taser drawn before they entered the room, as soon as the officer lowered the taser, Pt 43 grabbed his legs and RN 13 saw the taser fire. RN 13 stated, she looked at Pt 43’s skin after the incident and he had dried blood, but there were no taser prongs stuck in his skin. RN 13 stated Pt 43 “may or may not have been tased”. RN 13 stated, she saw the taser deployed, but did not see where the prongs struck Pt 43, or see any prong removed from Pt 43. RN 13 stated, she did not document the taser use, and the officers did not tell her where Pt 43 was struck with the prongs. RN 13 stated, she administered the ordered medications after Pt 43 was restrained on the gurney. RN 13 stated, Pt 43’s physician did not come and assess the patient after the taser strike. RN 13 stated, she did not complete a head-to-toe assessment on Pt 43 after the incident, but his respirations remained equal and unlabored (breathing normally). During an interview on 2/4/25 at 3:40 p.m. with Emergency Department Manager (EDM) 1, EDM 1 stated, her expectation was for RNs to contact security staff when a patient was going to hurt themselves or someone else. EDM 1 stated, when patient’s behaviors began escalating, RNs were supposed to call for a code assessment. EDM 1 stated, the Physician, the Charge Nurse and Clinical Supervisor should respond to the page for a code assessment. EDM 1 stated, medical staff were supposed to collaborate with security prior to application of restraints. EDM 1 stated, there was no documentation in Pt 43’s medical record indicating Pt 43 was tased. EDM 1 did not say why RN 13 did not document the taser strike to Pt 43. During a concurrent observation and interview on 2/5/25 at 7:39 a.m. with SO1, SO1 had no bruising around her left eye. SO1 had a bandage to the back of her left hand. SO1 stated, her left eye was still tender to the touch. SO1 stated, her left hand still had two small puncture wounds. SO1 stated, she worked the overnight shift on 2/1/25 to 2/2/25 and recalled the incident with Pt 43. SO1 stated, she saw Pt 43 approach the door and he knocked SO1 stated, Pt 43 was mumbling, so she opened the door a crack. SO1 stated, the SCU did not have an intercom system, the only way to communicate with patients inside the unit was to open the door or speak loudly through the glass. SO1 stated, she was struck hard by Pt 43’s right palm near her left eye. SO1 stated, she pushed the door closed and called the SWC to report the incident and get additional officers to the area. SO1 stated, RN 13 called the physician for violent-restraint and medication orders. SO1 stated, the plan was for all four responding officers to enter the room together and surround Pt 43 then apply restraints. SO1 the SWC told the officers if Pt 43 attacked anyone, “I’m going to pop him (clarified this meant he would tase Pt 43)”. SO1 stated, the SWC removed his taser from the holster, turned the taser camera on, and pointed the taser at Pt 43. SO1 stated, Pt 43 was sitting on the floor, and two officers entered the room from each door. SO1 stated the officers surrounded Pt 43 and began trying to apply restraints but Pt 43 reached out and grabbed the SWC’s legs. SO1 stated, the SWC fired the taser at Pt 43. SO1 stated, one of the taser prongs hit her left hand and she informed the SWC she had been hit. SO1 stated, she did not know if the other prong hit Pt 43. SO1 stated, she removed the wire and prong from her hand and continued restraining Pt 43. SO1 stated the officers restrained Pt 43 and moved him to the gurney, then left the SCU. SO1 stated she was then seen as a patient in the ED where the physician bandaged her hand and sent her for a Computed Tomography (CT - medical imaging procedure using X-Rays and a computer to create detailed pictures inside the body). During an interview on 2/5/25 at 8:06 a.m. with SO2, SO2 stated, he recalled the events from the overnight shift on 2/1/25 p.m. to 2/2/25 a.m. with Pt 43. SO2 stated, the plan was to enter the room two officers per door. SO2 arrived to the SCU area and Pt 43 was sitting on the floor, with his arms up and hands balled into fists next to his head. SO2 stated, the SWC “said something about a taser” but SO2 could not hear him because of the background noise around the unit. SO2 stated, SO1 and the SWC entered the door on the North and the SWC had his taser drawn. SO2 stated, him and SO3 entered through the West door. SO2 stated, after all officers entered the room and began surrounding Pt 43, Pt 43 grabbed for the SWC’s leg and the SWC fired the taser at Pt 43. SO2 stated, he assumed the taser hit Pt 43. SO2 stated, he heard SO1 announce twice she was hit by a taser prong. SO2 stated, SO1 removed the prong from her hand. SO2 stated, the officers continued applying restraints to Pt 43’s arms and legs. SO2 stated he was aware Pt 43 had a fracture in his hand, and he was trying not to manipulate (move around) his hand too much. SO2 stated he was applying the restraints to Pt 43’s arms and Pt 43’s hand was bleeding. SO2 stated, he could not see clearly where Pt 43 was hit by the taser prong. During an interview on 2/5/25 at 8:24 a.m. with SO3, SO3 stated, he responded to the SCU when he heard the call for officer response over the radio. SO3 stated, Pt 43 was bouncing on the balls of his feet (padded areas under the toes) “clearly agitated”. SO3 stated the SWC told him to go get restraints. SO3 stated the officers were given directives to open both doors at the same time and approach the patient. SO3 stated, the SWC advised their dispatch a taser application was likely because of Pt 43’s behavior. SO3 stated, the four security officers entered the SCU and the SWC had his taser drawn. SO3 stated Pt 43 had gone silent. SO3 stated Pt 43 reached for the SWC’s leg with his right arm, and his left arm came around, throwing his body weight toward the SWC. SO3 stated the SWC fired his taser hitting Pt 43 with one prong in his midsection and the other prong hit SO1 in her left hand. SO3 stated, he did not recall who removed the taser prong from Pt 43’s midsection. During an Interview on 2/5/25 at 8:51 a.m. with SOM, the SOM stated, the taser should not have been removed from the holster before Pt 43 grabbed the SWC’s leg. The SOM stated, the SWC did not follow hospital Policy and Procedure in many ways during the incident. The SOM stated, the SWC did not announce “taser” before deploying the weapon. The SOM stated, after discharging the taser the SWC should have called law enforcement to take custody of Pt 43. The SOM stated, the SWC should have requested assault charges be filed against Pt 43. The SOM stated, when a taser was discharged a clinical assessment of Pt 43 should have been done. The SOM stated the SWC did not notify RN 13 the taser hit Pt 43, which led to RN 13 not completing a clinical assessment and not notifying the physician. The SOM stated the SWC did not take photographs the site where Pt 43 was hit by the taser as policy dictated. During an interview on 2/5/25 at 9:45 a.m. with the Chief Nursing officer (CNO) the CNO stated the ED Charge Nurse, leadership, and the physician should have responded to the overhead page by RN 13 for Pt 43’s code assessment. The CNO stated her expectation was for clinical supervisors to be a part of the code assessment. The CNO stated the code assessment team should have a discussion to help come up with a plan for the patient to de-escalate or medicate and restrain. During a review of the hospital’s Policy and Procedure (P&P) titled, “Taser Usage,” dated 1/8/25, the P&P indicated, “ ... The use of a TASER by security staff is considered a law enforcement action, not a health care intervention The purpose of this policy is to establish guidelines for the deployment and use of the a TASER by Security Services Staff ... [Name of hospital] does not support the use of a TASER by any hospital staff as a means of achieving a clinical objective, including but not limited to, subduing a patient in order to place that patient in restraints or seclusion. If a TASER is used by a security officer or law enforcement personnel on a person on [Name of hospital] property (patient, staff, or visitor) to protect people or hospital property from harm, local law enforcement will be notified and [Name of hospital] will request that the person is taken into law enforcement custody ... Deploy/Deployment - The removal of a device from its carrying holster for display or use. The actual application or discharge of a tool or device, such as the TASER, is not required to be considered deployment ... Application - The firing of projectile probes regardless if contact with an individual is made or the application of a drive stun to an individual ... TASER - The TASER is a less than deadly device used to incapacitate subject(s) by discharging an electronic current into the subject via two wired probes. Weapon- Pursuant to CMS’ State Operation Manual, Appendix A, A “weapon” includes, but is not limited to ... pepper spray, mace, nightsticks, TASERS, cattle prods, stun guns and pistols ... Criteria for Use ... The use of a TASER by [Name of hospital] Security staff may only be used in response to imminent danger of bodily harm, unlawful touching or threat of harm to [Name of Hospital] property. Security officers who use a TASER to stop harm must affect a citizen’s arrest. Local law enforcement must be contacted and [Name of Hospital] must request that the individual is placed in law enforcement custody ... The following procedure shall be adhered to while deploying a TASER in an authorized manner and circumstances ... The TASER shall not be deployed or displayed at any time unless the officer has specific information that reasonably indicates the imminent use of a TASER is warranted ... The officer must reasonably believe that a credible threat to the safety of the officer or others exists ... The TASER should not be used to simply overcome resistance when adequate assistance is available ... The TASER shall not be used as an intimidation tool to gain compliance where the reasonable deployment is not justified ... A TASER shall never be used as a means of achieving a clinical objective, including but not limited to, subduing a patient in order to place that patient in restraints or seclusion ... Tactical Deployment ... Prior to discharging the TASER, the officer shall loudly announce “TASER” when the circumstances allow, to notify everyone that the TASER is being fired ... AFTER DISCHARGE RESPONSIBILITIES ... [Name of hospital] will contact local law enforcement and request that the person is taken into law enforcement custody ... The identification of the utilized TASER shall be identified in the documentation. ... After the subject has been taken into custody/control, security staff shall: ... Ensure the person’s injuries are promptly examined by clinical staff and any embedded probes are Removed ... Appropriate photographs should be taken to document the incident and any injuries that may have been sustained from the use of a TASER ... After each TASER deployment, the shift supervisor and manager shall review all documentation to evaluate the appropriateness for the deployment. All TASER deployment reviews shall be completed by the Use of Force Review Board as defined by the Use of Force policy. During a review of the hospital’s P&P titled, “Reporting and Investigation Requirements Concerning Qualifying Level 3 and All Level 4 Use of Force Incidents,” dated 1/8/25, the P&P indicated, “ ... It is the policy of [Name of Hospital] to conduct confidential investigations concerning ... all Level 4 use of force incidents as set forth below ... All level 4 incidents, including hard techniques such as tasers, strike points, impact weapons [ a tool used to gain control] and OC spray [a chemical irritant that’s also known as pepper spray] ... A security officer shall notify their supervisor or shift coordinator as soon as practical following the application of physical force and a referral to Risk Management shall be made through IRIS [hospital incident reporting system] for ... all Level 4 use of force incidents ...The use of defensive equipment (aka. “Weapons,” including but not limited to, pepper spray, mace, nightsticks, tasers, cattle prods, stun guns, and pistols) by security staff or law enforcement personnel on a person on [Name of Hospital] property is considered a law enforcement action, not a health care intervention. The supervisor, shift coordinator or designee is responsible for notifying local law enforcement anytime there is a use or application of defensive equipment and a request to have that person taken into custody must be made ...”. During a review of the hospital’s P&P titled, “Use of Force,” dated 1/8/25, the P&P indicated, “ ...The purpose of this policy is to provide security officers with guidelines for the legal and proper use of physical force where required to protect the safety of patient’s staff, visitors, others, and property ... It is the policy of [name of hospital] Security Department that security officers are permitted to use reasonable force when ... The security officer reasonably believes that he/she is in imminent danger of suffering bodily injury or being touched unlawfully (“self-defense”), someone else is in imminent danger of suffering bodily injury (“defense of another”) ... The security officer reasonably believes that the use of reasonable force is necessary to defend against that danger. The security officer shall use the minimum amount of force necessary to accomplish lawful objectives and immediately cease once an individual is under control. The security officer shall use no more force than is reasonably necessary to defend against the danger ... The use of force continuum is a system used by this department to determine the reasonable force in a given situation. If the subject continues to rise in hostility, it may be necessary for the security officer to raise the level of force to counter the actions of the subject for self-defense and/or defense of another and/or defense of property. The possible security officer response levels are as follows ... Level 1: Officer presence (examples: physical appearance, professional bearing) ... Level 2: Verbal Commands (examples: clear and deliberate) ... Level 3: Soft techniques (examples: physical control tactics/wrist locks) ... Level 4: Hard techniques (examples: Tasers/strike points/impact weapons/OC Spray) All levels identified above in the use of force continuum shall be documented and investigated pursuant to this department’s policy ... The following factors and circumstances should be taken into consideration when using physical force on a patient: ... if clinical restraints are ordered by a properly licensed clinician, and a patient resists the application of restraints, the minimum amount of force reasonably necessary to control the situation may be used in order to apply restraints ...”. During a review of the hospital’s P&P titled, “”Patient’s Rights and Responsibilities,” dated 2/10/2022, the P&P indicated, “ ... I. PURPOSE. To define the rights and responsibilities of patients who receive services at (Hospital A Name) ... IV. PATIENT RIGHTS ... 2. To receive considerate and respectful care, be made comfortable and maintain dignity in a safe setting, free from verbal or physical abuse or harassment ... 25. To be free from neglect; exploitation; and verbal, mental, physical, sexual abuse, and corporal punishment ...”. During a review of the hospital’s P&P titled, “Documentation in the Health Record,” dated 6/14/2018, the P&P indicated, “ ... PURPOSE ... To provide a complete record of patient care and patient progress ... To facilitate communication among care providers and enhance continuity of care ... To provide a legal record of patient care ... All care providers caring for the patient are to document within their scope of practice/job description ... All patient care and activities are to be documented at the time care is provided ...”. During a review of the hospital’s P&P titled, “Standard of Practice Emergency Department,” dated 9/23/24, the P&P indicated “ ... STANDARD OF PRACTICE: Safety, Medication, IV Therapy, Infection Control. The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: ... Adhere to all established [Name of Hospital] policies/procedures ... Intervene appropriately to correct unsafe situations ... Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order ... Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs ... system specific assessment at the onset of patient treatment with ongoing assessment dependent upon patient condition and response to treatment ... Advise the physician of any alterations in the patient’s psychological and/or physiological condition ...” During a review of a professional reference titled, “Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study,” dated 2/16/23, the professional article indicated, “ ... Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information and patient care plans, such as professionals’ evaluation and judgement about the patients, evaluation charts, tests, reports, subjective notes or professionals’ reflections ... Documenting routine practices is essential for the continuity of patient care, ... communication among healthcare professionals and better patient diagnoses and treatments ... it should be patient-focused, accurate, relevant, clear, permanent, confidential and timely ... Poor documentation practice affects patient management, continuity of patient care and medicolegal [medical and legal] issues, which arise from incomplete and inadequate documentation, lack of accuracy and poor quality. It leads to adverse patient outcomes, medication errors and patient deaths. Distorted health information may influence health professionals’ decision-making capabilities due to inappropriate and misleading documentation practices ...”. During a review of the State Operations Manual (SOM) Appendix A Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, dated 4/19/2024, the SOM indicated, “ ... CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term “weapon” includes, but is not limited to, pepper spray, mace, nightsticks, tasers, cattle prods, stun guns, and pistols. Security staff may carry weapons as allowed by hospital policy, and State and Federal law. However, the use of weapons by security staff is considered a law enforcement action, not a health care intervention. CMS does not support the use of weapons by any hospital staff as a means of subduing a patient in order to place that patient in restraint or seclusion. If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 49884 Based on observation, interview and record review, the hospital failed to have a Quality Assurance and Performance Improvement (QAPI-is a systematic approach to improving the quality of care and services delivered to patients) program that implemented changes to lead to improvement when the approved Plan of Correction submitted to CDPH for a survey exited 12/10/24 was not implemented. The QAPI program did not implement effective improvement activities to address the use of the Emergency Department (ED- an outpatient area in the hospital that provides immediate medical care to patients with urgent or life-threatening conditions) as a holding area for patients admitted as inpatients (patients who stays in the hospital overnight) and did not address nursing actions meant to address skin assessments and the preventing skin ulcers. These failures resulted in the potential and actual harm of patients experiencing avoidable negative outcomes in the ED and for improvements to care not being implemented. Findings: During a concurrent observation and interview on 1/28/25 at 10:12 a.m., in the ED with ED Director (EDD) of the unit, the ED was observed to be very busy, with many patients of all ages on gurneys (a wheeled bed used to move patients in a hospital) or hallway beds as well as in rooms. The EDD stated the unit was currently experiencing high volumes of ED patients coming to the ED, and inpatients waiting in the ED for an inpatient bed assignment. During the tour, patients were observed to be waiting, eating, sitting on gurneys interacting with the one visitor allowed at bedside and/or receiving infusions of IV medications. Hallways were congested with ED and ancillary staff (Ultrasound, X-ray, Physical Therapy, etc.) providing care in the hallways and in the rare corridors where makeshift private areas (using partitions) were placed to complete patient exams. During a review of a more current ED Map (Map 2), undated, ED Map 2 indicated the number of shared restrooms/showers available in a zone/area were as follows: Green Zone: unable to determine if a restroom for capacity of 16 possible patient rooms (includes rooms and hallway gurneys); Yellow Zone: 2 restrooms for capacity of 19 possible patient rooms; and 1 shower room for the entire ED. During a review of the ED census titled “ED CCMC All Patients” dated 1/28/25 at 8:43 a.m., the ED census indicated the total number of patients in the ED was 136. Of these 136 patients, 86 patients were in an inpatient “class [status].” This review indicated that 63% of the patients in the ED were waiting for an admission bed and receiving care in an outpatient setting. During a review of “ED Holds Moved to Bed 1/27-1/28” undated, the report indicated 64 in-patients were moved from the ED to the flex/overflow units (2N, L&D and PACU). During an interview on 1/30/25 at 9 a.m., with the Chief Operations Officer (COO), the COO stated the number of ED holds has remained high. The COO stated however the total percentage of discharges house-wide has increased by 11%. The COO stated the 5 Tower has 30 inpatient beds, but staffing challenges and concern about financial viability have made it difficult to open the unit. During an interview on 1/30/25 at 9:10 a.m. with Chief Nursing Officer (CNO), the CNO stated they have an empty 30-bed unit on the 5th floor. The CNO stated the unit was approved for use on 4/27/22, but it has not been opened. The CNO stated they plan to open the unit on 2/6/25. The CNO stated the delay was due to a lack of staff, including nurses, nursing assistant, unit clerks, and other necessary support staff. The CNO stated they are using other areas of the hospital for overflow patients, including 20 beds in the Women’s Pavilion, which is staffed by EDIN nurses (nurses designated to care for inpatients in the ED). During a review of a report provided by the hospital on 2/3/25, the report compared the total number of patients admitted to the hospital who were kept in the Emergency Department and discharged from the ED without ever going to a nursing unit. The report indicated that between the dates of 10/25/23 and 1/24/24 the total number of admitted patients discharged from the ED was 828, with a rate of ED Discharges of 21.9%. For 10/25/24 to 1/24/25 the total number was 823 with a rate of ED Discharges of 19.7%. The document showed an increase in the total number of discharges for the hospital of 11%. In a report provided by the Director of Operations (DOO), undated, the report indicated “...from October 2023 through January 2024 there were 829 discharges compared to 823 October 2024 through January 2025...” During a review of a hospital report titled “Inpatients Discharged from the Emergency Department” undated, prepared by Director of Operations, the report indicated “...In comparing these two time periods (October 2023 through January 2024 and October 2024 through January 2025), we find the rate of inpatient discharges occurring in the ED has decreased by 10% from the period one baseline, despite total discharges house wide increasing from 3,776 to 4,179, an 11% increase...” During a concurrent interview and record review on 1/30/25 at 1:15 p.m., with the CPCU Nurse Manager (NM 2), Electronic Medical Record (EHR) records for Pt 7 was reviewed. NM 2 stated nurses must do a dual skin verification for new admits. NM 2 stated this requires two nurses to assess and confirm their findings. NM 2 stated nurses must also take pictures of any skin concerns, including pictures of the coccyx and heels. NM 2 stated the preventative care, such as turning, repositioning and using pressure relieving overlay. NM 2 stated while inpatients remained in the ED, the ED management were responsible for overseeing the care provided. NM 2 stated the Pt 7’s EHR did not show skin interventions were done or done consistently while patient was in the ED waiting for an inpatient bed. During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 7’s “...Admit Reason (s): Closed Right Hip Fracture...ED Arrival Date/Time: 1/4/25, 3:15 (a.m.) ...Date/Time First Inpatient: 1/4/25, 07:47 (a.m.)...Discharge Date/Time: 1/23/25, 14:33 (2:33 p.m.)...Dispo: Home with Home Hlth (Health) Service...” During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s ED Timeline, dated 1/31/25 was reviewed. Pt 7’s ED Timeline indicated, “...TT: 42:25 [Pt 4 remained in the ED on a hallway gurney until admission bed transfer] ...on 1/4/25 at 19:42 (7:42 p.m.) ...” Pt 7 stayed in the ED gurney for11 hours and 55 minutes until transferred to an inpatient bed. During a concurrent interview and record review on 1/30/25 at 2:30 p.m., with The CPCU (NM) 1 and CPCU (CS 1), NM 1 stated manages several units in the Tower 2 3 & 4 areas. EHR records for Pts 2,3, and 4 were reviewed. CS 1 stated the process for Performance Improvement Plan (PIP- a process that helps employees improve their job performance) in the 4 CPCU-a specialized hospital unit that provides care to patients with heart conditions) was upon admission, one nurse and the supervision CS perform a full skin check. CS 1 stated they take photos, documents the skin condition, and start interventions to protect skin integrity. CS 1 stated the CSs are expected to monitor all patients at risk for skin injuries. CS 1 stated after reviewing Pt 2, 3, and 4’s EHR, Pt 2,3, and 4 was not provide the care to prevent skin breakdown in the ED. During record review of Pt 2’s EHR [documents provided by the hospital], on 2/6/25 Pt 2’s “Face Sheet (FS)” dated 2/2/25 was reviewed. The FS indicated, Pt 2 was a “...29-year-old ... admitted on 1/1/25 for Altered Mental State (AMS- a change in mental function, such as a change in awareness, attention, or consciousness) and Seizures (SZ- when there’s a burst of abnormal electrical activity in the brain, which can cause temporary changes in movement, behavior, or awareness. During record review of Pt 2’s EHR, on 2/6/25 Pt 2’s ED Timeline, dated 2/2/25 was reviewed. Pt 2’s ED Timeline indicated, “...TT: 86:02 [Pt 4 remained in the ED on a hallway gurney until admission bed transfer] ...on 1/1/25 at 18:50 (6:50 p.m.) ...” Pt 2 waited 86 hours in a hallway gurney until transferred to an inpatient bed. During record review of Pt 3’s EHR, on 2/6/25 Pt 3’s “H&P,” dated 11/22/24, was reviewed. The H&P indicated Pt 3 was a “...75-year-old...patient with a history of Diabetes mellitus (high blood sugar disease), Hypertension, Mental retardation...Seizures, and Thyroid disease...” During record review of Pt 3’s EHR on 2/6/25 Pt 3’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 3’s “...Admit Reason (s) Seizure Disorder...ED Arrival Date/Time: 8/11/24, 12:44 (p.m.)...Date/Time First Inpatient: 8/11/24, 16:32 (4:32 p.m.)...Discharge Date/Time 8/15/24, 18:52 (6:52 p.m.)...Dispo [disposition- the destination of the patient after hospital discharge]: To Another SNF for Skilled Nursing Care...” Pt 3 stayed in the ED for four days, 6 hours and 8 minutes and received care from admission to discharge. During record review of Pt 4’s EHR, on 2/6/25 Pt 4’s “H&P” dated 11/22/24, was reviewed. The H&P indicated Pt 4 was an “...83-year-old...patient with a history of hypertension (high blood pressure) and dementia...brought in by ambulance due to concern for abnormal kidney function on recent labs...” During a record review of Pt 4’s EHR, on 2/6/25, Pt 4’s “ED Timeline” dated 1/31/25, was reviewed. The Timeline indicated, “...TT: 103:29...[Pt 4 remained in the ED on a hallway gurney for 22 hours before being moved into a room in the ED. Pt 4 remained on a gurney until admission bed transfer]...on 11/26/24 at 18:45 (6:45 p.m.)...” Pt 4 stayed in a hallway gurney for 22 hours before being moved into a room in the ED with eventual move to ordered inpatient unit (spent a total of 103 hours in the ED). During record review of Pt 8’s EHR on 2/6/25 Pt 8’s “H&P” dated 1/10/25 was reviewed. The “H&P” indicated, Pt 8 was a 88 years old male, Pt 8 “[past medical] history of hypertension, CVA (Cerebrovascular Accident- (or stroke- a medical condition characterized by the sudden interruption of blood flow to the brain, leading to the death of brain cells), Parkinson’s disease (a brain disorder that causes unintended or uncontrollable movements), and dementia...” During record review of Pt 8’s EHR, on 2/6/25 Pt 8’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 8’s “...Admit Reason (s): Altered Mental Status...ED Arrival Date/Time: 1/9/25, 18:46 (6:46 p.m.) ...Date/Time First Inpatient: 1/10/25, 08:19 (a.m.)...Discharge Date/Time: 1/25/25, 14:30 (2:30 p.m.)...Dispo: To Another SNF for Skilled Nursing Care...” During record review of Pt 8’s EHR, on 2/6/25 Pt 8’s ED Timeline, dated 1/31/25, was reviewed. Pt 8’s ED Timeline indicated, “...TT: 40:32 ...[Pt 8 remained in the ED on a hallway gurney for 24 hours before being moved into a room in the ED. Pt 8 remained on a gurney until admission bed transfer]...on 1/11/25 at 11:18 (a.m.)...” Pt 8 stayed in the ED hallway gurney for 40 hours and 32 minutes until moved to an inpatient bed. During a record review of Pt 9’s “H&P,” dated 1/25/25, the “H&P” indicated, Pt 9 was a 75-year-old brought in by ambulance from home due to family concern of AMS. Patient 9 arrived at the ED on 1/25/25 at 11:56 a.m. and had an inpatient physician’s order on 1/25/25 at 5:26 p.m. Pt 9 was moved to the Cardiac Progressive Care Unit (CPCU - a hospital unit providing care for patients with heart related conditions recovering from a critical stage) on 1/27/25 at 3:07 p.m. Pt 9 remained in the ED for 46 hours and 54 minutes. During a record review of Pt 9’s “Wound Care Consult Note [WCCN],” dated 2/2/25, the “WCCN” indicated Pt 9’s nurse entered a wound nurse consultation for a PI (Pressure Injury) to the sacrum (tail bone) on 1/28/25 at 2:24 p.m. On 1/29/25 at 8:12 a.m. Pt 9 had a Wound Care Specialist (WCS) consultation assessment completed. The WCS documented, “ ... Patient consulted for an open partial thickness wound [Stage 2] to the right aspect of the sacrum ... Wound is friction [skin rubbed against a surface] related ...” During an interview on 2/3/25 at 10:08 a.m. with the ED Manager (EDM) 2, EDM 2 stated the initiation of the “ED Inpatient (EDIN) team” started April 2024. EDM 2 stated EDIN (ED Inpatient- where admitted patients are routinely held in the ED while awaiting an inpatient bed) was created to avoid floating ED RNs to inpatient care assignments. EDM 2 stated the EDIN staff includes Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Patient Care Technicians (PCTs). EDM 2 stated nurses hired into the EDIN may have prior experience with inpatient care. EDM 2 stated the EDIN staff receive orientation with inpatient nurses to ensure they are competent to provide the level of care ordered by the provider. EDM 2 stated the ED was considered the “home base” for EDIN staff and are considered part of the ED team. During concurrent interview and record review on 2/3/25 at 10:15 a.m., with EDM 2, the facility “ED Map” dated 3/28/2022 was reviewed. EDM 2 stated, the ED layout was configured in a rectangle with color-coded zones, such as green, yellow and red zones. The color code of the zone corresponded to the level of care needed, the green representing the least complex care and red representing the most complex care. EDM 2 stated inpatients are routinely moved into the Green and Yellow-West Zones. EDM 2 stated sometimes inpatients are placed in the Yellow East Zone, where they may be mixed with ED patients temporarily, while waiting for an inpatient admission bed or to be moved to the Green or Yellow -West Zone. EDM 2 stated the goal was to group inpatients together in a designated area to facilitate their care. During a concurrent observation and interview on 2/3/25 at 11:23 a.m., with Pt 38 and in the presence of RN 15 in ED patient room Y-12 (Yellow zone, room 12), Pt 38 was lying on his back, with head propped up on a gurney, high-flow oxygen (high-flow oxygen therapy system includes those that supply a flow that meets or exceeds the patient’s inspiratory flow demand) was in place along with IV (intravenous- administered into a vein or veins) catheter (a thin, flexible tube that’s inserted into a vein to provide fluids, medications, or blood transfusions) and IV antibiotics (drug used to treat infections caused by bacteria and other microorganisms) being administered. Pt 38 stated he was admitted for pneumonia and came to the ED for trouble breathing. Pt 38 stated he was not offered a hospital bed, a toothbrush or clean towel to wipe his hands and face. Pt 38 stated because he needed help to get out of the gurney due to oxygen, IV tubing and cardiac monitor connections so he did not get out much. There was no television or restroom in Pt 38’s ED room. Pt 38 stated staff offered a bedside commode, and he used it despite feeling embarrassed when staff had to clean up after him. Pt 38 stated he had not been told when he would get an inpatient bed. Pt 38 stated he might be discharge on 2/4/25 without being move to inpatient. During record review of Pt 38’s EHR on 2/6/25 at 11: 28 a.m. Pt 38’s “FS” dated 2/1/25, was reviewed. The FS indicated, Pt 38’s “...Admit Reason (s) Sepsis: (your body’s extreme reaction to an infection) ...ED arrival Date/Time: 2/1/25, 05:14 (a.m.) ...Date/Time First Inpatient: 2/1/25, 11:55 (a.m.) ...” During record review of Pt 38’s EHR [documents provided by the hospital], on 2/6/25 Pt 38’s “H&P” dated 2/1/25, was reviewed. The H&P indicated, Pt 38 “a 22-year-old...super morbidly (defined as being 100 lbs. (pounds) or more over ideal body weight) obese...brought into the ED by ambulance for difficulty breathing and cough. Pt 38 was admitted to the hospital on 2/1/25 at 11:55 a.m. ...for severe Sepsis and Pneumonia (inflammation (swelling) and fluid in your lungs caused by a bacterial (relating to or caused by bacteria (small germs (tiny organisms, or living things, that can infect you and make you sick) ...” Pt 38 stayed in the ED gurney for 47 hours and 28 minutes since an inpatient admission was ordered by the physician. During record review of Pt 39’s EHR, on 2/6/25, Pt 39’s “H&P” dated 2/2/25 was reviewed. The H&P indicated, Pt 39 was a “...49-year-old, with past medical history of uncontrolled DM, multiple diabetic foot infections, L (Left) TMA (Trans metatarsal amputation-surgical procedure that removes part of the foot), R (Right) BKA (Below the knee amputation-surgical procedure that removes part of the leg), and drug abuse...presented to the ED due to choking episode...” During record review of Pt 39’s EHR, on 2/6/25 at 11:32 a.m., Pt 39’s “FS” dated 2/3/25 was reviewed. The FS indicated, Pt 39’s “...Admit Reason (s): Dysphagia (difficulty swallowing) ...ED Arrival Date/Time: 2/2/25, 00:36 (12:36 p.m.)...Date/Time First Inpatient: 2/2/25, 03:46 (a.m.)...” Pt 39 had been in the ED for four days and 7 hours since an inpatient admission was ordered by the physician. During record review of Pt 40’s EHR on 2/6/25, Pt 40’s “H&P” dated 1/28/25 was reviewed. The H&P indicated, Pt 40 was “...a 79-year-old, with history of recurrent stage IV lung adenocarcinoma (lung cancer) ...with bone mets (bone metastases- bone metastasis occurs when cancer cells spread from their original site to a bone) in the ribs, s/p resection radiation in the past, COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe)...presented to the hospital due to short of breath cough generalized weakness, poor oral intake...” During record review of Pt 40’s EHR, on 2/6/25 Pt 40’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 40’s “...Admit Reason (s): Altered Mental Status...ED Arrival Date/Time: 1/9/25, 18:46 (6:46 p.m.)...Dater/Time First Inpatient: 1/10/25, 08:19 (a.m.)...Discharge Date/Time: 1/25/25, 14:30 (2:30 p.m.)...Dispo: To Another SNF for Skilled Nursing Care...” During record review of Pt 40’s EHR, on 2/6/25 Pt 40’s ED Timeline, dated 1/29/25, was reviewed. Pt 40’s ED Timeline indicated, “...TT: 30:35 ...[Pt 40 remained in the ED on a gurney until admission bed transfer]...on 1/11/25 at 11:18 (a.m.)...” Pt 40 had been in the ED gurney for one day, 2 hours and 59 minutes before moving to an inpatient bed. During a record review of Pt 40’s EHR, the EHR indicated the first documented Head to Toe (a physical exam that evaluates a patient’s entire body to assess their health) assessment was on 1/28/25 at 8:00 p.m., the EHR indicates the BSS was 19 with skin “intact...bruising to [pt] back. On 1/29/25 at 7:00 a.m., a pillow was documented for “proper alignment.” On 1/29/25 at 8:00 a.m., turns every 2 hours and overlay were documented/implemented. Turns were inconsistently documented with first turn (after first head to toe assessment) documented at 2:48 a.m. on 1/29/25 (or 6 hours later). On 1/30/25 at 11:34 p.m., photos of Pt 40 taken per unit expectation on arrival with documentation of left buttock impairment. During a concurrent tour observation on 1/28/25 at 10:12 a.m., in the ED Pt 41 and Pt 42 were observed in ED hallway gurney. During a review of Pt 42’s EHR, the EHR indicated the first documented Head to Toe assessment was on 1/28/25 at 8:04 a.m., the EHR indicates “Pt 42 was transferred to the inpatient unit on 1/28/29 at 6:40 p.m. On 1/29/25 at 2:37 a.m., inpatient nurse documentation of “Plan of Care Signed” note indicated “...Skin check completed with secondary nurse. Redness noted to abdominal and groin fold. Blanchable redness to coccyx. Foam dressing applied ...” During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with Clinical Supervisor (CS) 7 and EDD, the Electronic Health Records (EHR) for Pt 41 and Pt 42 were reviewed. CS 7 stated she believed t pressure injury occurs in first 24-hours. During record review of Pt 41’s EHR on 2/6/25, Pt 41’s “H&P” dated 1/27/25 was reviewed. The H&P indicated, Pt 41 was “...83-year-old...with past medical history of dementia, CVA..., atrial fibrillation (a-fib- a heart condition that causes an irregular heartbeat), hypertension, congestive heart failure (CHF- chronic condition where the heart muscle is weakened and cannot pump blood effectively) ...appears ill and frail...likely septic...UTI...” During record review of Pt 41’s EHR, on 2/6/25 Pt 41’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 41’s “...Admit Reason (s): AMS...ED Arrival Date/Time: 1/26/25, 22:16 (10:16 p.m.) ...Date/Time First Inpatient: 1/27/25, 08:19 (a.m.) ...” During record review of Pt 41’s EHR, on 2/6/25 Pt 41’s ED Timeline, dated 1/29/25, was reviewed. Pt 41’s ED Timeline indicated, “...TT: 65:45 ...[Pt 41 remained in the ED on a gurney]...” Pt 41 stayed in the hallway gurney for 25 hours before being moved to the ordered inpatient unit. Pt 42 During record review of Pt 42’s EHR, on 2/6/25 Pt 42’s “H&P” date 1/29/25 was reviewed. The H&P indicated, Pt 42 was an “...89-year-old, with history of Sjogren syndrome (a chronic autoimmune disorder that happens when the immune system attacks the glands that make moisture in the eyes, mouth, and other parts of the body) ...chronic kidney disease...hypertension...” During record review of Pt 42’s EHR, on 2/6/25 Pt 42’s “FS” dated 1/29/25 was reviewed. The FS indicated, Pt 42’s “...Admit Reason (s): Syncope (another word for fainting or passing out.... ED Arrival Date/Time: 1/27/25, 16:32 (4:32 p.m.) ...Date/Time First Inpatient: 1/28/25, 08:20 (a.m.) ...” Pt 42 stayed in the ED hallway gurney for 65 hours before being moved to the ordered inpatient unit. During a concurrent interview and record review on 2/3/25 at 1:35 p.m., with Cardiovascular Services Director (CSD), CNO and the Director of Quality (DQ), who joined via telephone, The report CSD presented to the Quality Council and Steering Committee (which has oversight for wounds at the corporate level) on 1/9/25 was reviewed. The CSD report covered data from 8/2024 to 11/2024. The CSD stated he recently took over the has just taken over the Wound Committee chairperson, previously held by the CNO. The CNO stated the leadership changed in the ED led to a review of resources. The CNO stated one gap identified was the need for a two-person to turn patients. The CNO stated the review also found the used of gurneys in the ED for extended periods posed a high risk for pressure injuries. During an interview on 2/4/25 at 9:35 a.m. with the CNO, the CNO stated the hospital’s goal was to eliminate the patients with inpatient physician’s order who remained and received care in ED while waiting for an inpatient bed. The CNO stated the ED was considered an outpatient area and not licensed for inpatient. The CNO stated the care should be focused on the patient and should be patient-based. A review of the hospital document titled, “Performance Excellence Plan” dated 2025, indicated, “ ...(name of hospital) aims to deliver exceptional healthcare to our patients through a commitment to continuous improvement and performance excellence... strategies for advancing clinical quality outcomes, patient safety strategies, ... Continuous improvement relies on: Leadership’s commitment to achieving zero preventable harm, fostering a culture of safety ... Establishing assessing, monitoring, and improving organizational quality and patient safety goals that are consistent with the needs of internal and external customers, Identification, development and adherence to best practices associated with clinical, managerial and leadership practices to minimize variation, Education and application of robust performance improvement tools, Validated data systems and metrics to monitor and direct quality and patient safety performance improvement endeavors ... Each year, (name of hospital) facilities conduct a formal review of its QAPI program and PEP, which includes: A. Ongoing performance improvement targets associated with important aspects of care, processes, functions, and outcomes. Performance improvement priorities identified by leaders will include service line activities. Service lines will focus on system integration and performance improvement activities including evidence-based care and measured outcomes through review of quality/safety reports, setting action for improvement, and monitoring of actions to goals. C. CMC service lines will be formed, as appropriate, to maintain the integrity of patient care across the system and among facilities. Each service line will use criteria (high volume, high cost and/or high risk) to determine performance improvement projects to focus on for each fiscal year. Projects will be centered on evidence-based care, resource utilization, and care process standardization ...” During a review of the hospital “Standard of Practice for Emergency Department” policy and procedure (P&P) dated 9/23/24, the P&P indicated “...PURPOSE: These Standards of Practice are necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive by the Emergency Departments...of the [hospital system]... POLICY: A. The patient in the ED will receive care in accordance with the Standard of Practice for the ED area. The Standard of Practice categories are adopted by [hospital system’, which the Licensed Nurse must address when caring for each patient. B. Standards of Practice are to form the basis for monitoring and evaluating patient care in the ED... PROCEDURE: A. STANDARD OF PRACTICE: ... The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: ... 2. Adhere to all established [hospital] policies/procedures. 3. Intervene appropriately to correct unsafe situations... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order. a. Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs. i. Data will incorporate age-specific needs of the patient through the life span. ii. Assessment will reflect the cultural tradition/values of the patient/family. b. The data collection process for assessment is systematic, ongoing, and updated prior to transfer to another level of care and/or home... Evaluate all patients in a timely manner... d. A system specific assessment at the onset of patient treatment with ongoing assessment dependent upon patient condition and response to treatment. e. The data is to include a health history and physical assessment to determine patient’s capabilities, limitations, nutritional, physiological, psychosocial, cultural, and environmental needs/problems... Total intake/output monitored based on order or warranted by condition... 2. Advise the physician of any alterations in the patient’s psychological and/or physiological condition and any abnormal lab results. 3. Nursing intervention is to be administered in accordance with individual needs of the patient and include other disciplines, private physician, specialty physicians, social services, special programs, clinics or referral services as warranted... F. STANDARD OF PRACTICE: Skin integrity...Patient Rights... 1. The patient will be involved as actively as possible in planning interventions to maximize health capabilities. The RN will: a. Follow established policies/procedures of [the hospital] when implementing nursing care. b. Implement physician orders. c. Follow the recommendations for wound management as described in the Corporate Patient Care Policy Manual. d. Maintain and/or improve skin integrity during hospitalization through appropriate nursing interventions. Promote patient comfort, cleanliness, and sense of wellbeing by assisting with activities of daily living (ADL’s- [toileting, dressing, etc.]). e. Reposition patient every 2 hour or more frequently, as needed. f. Obtain a physician’s order for the use of pressure relieving devices when warranted. g. Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device... Document the nursing interventions/patient responses in the medical record...” During a review of the hospital “Standards of Practice - Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” P&P dated 9/25/24, the P&P indicated “...PURPOSE These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in the Critical Care, Step-Down/Progressive Care, Telemetry, and Medical/Surgical units...POLICY A. Licensed professionals are accountable for assigned patient care until end of shift, physical transfer, hand-off to another licensed staff member, or patient discharge.... B. If there is a difference between the physician order and the standards below, the one that is stricter will be followed (e.g. physician orders intake and outputs measured every 12 hours, but unit standard is every 8 hours; the unit standard will be followed)... E. Reposition patients who are unable to do so themselves every 2 hours or more frequently, while assessing the condition of the patient’s skin. F. Progressive mobility will be instituted utilizing the approved mobility assessment tool. G. Appropriate arrangements may be made to accommodate time outdoors for patients as clinically appropriate according to the patient’s stability level and plan of care... STANDARDS See Standards of Practice Documentation Grid...” The Joint Commission Journal on Quality and Patient Safety article titled, titled “No More Useless Band-aids that Fail to Solve America’s Emergency Department Boarding Crisis,” dated 12/2023 retrieved 2/19/25 from https://www.jointcommissionjournal.com/article/S1553-7250(23)00234-9/fulltext indicated, “The causes of boarding as well as many proposed solutions have been well described. However, the suggestions are band-aid solutions such as changing ED workflow, surgical schedule smoothing, and alternate care sites, and none of them will alleviate boarding and its harms. Boarding is the manifestation of a dysfunctional health care system with misaligned financial incentives. It is a direct consequence of the United States’ patchwork, profit-driven health care system, not attributable to any single hospital or health care organization. While daily admissions from the ED will vary somewhat, the typical number can be easily determined from the ED’s historical records. Beds could easily be reserved for these anticipated admissions, and remaining beds could be allocated to elective admissions. Predicting the daily admission needs for the ED to function and serve the community is not a difficult task. We lack the will to do this, not the ability to make it happen. The lack of will arises from hospital administrators having no incentive to reserve space for ED admissions when they can allocate beds to elective admissions that generate higher profit. In both for-profit and not-for-profit ...” hospitals-which account for the overwhelming majority of annual acute inpatient admissions in the United States-the C-suite is tasked with remaining fiscally solvent. To do so, they favor patients with the kinds of insurance and the kinds of medical conditions that provide lucrative reimbursement for short lengths of stay. In following this strategy, admitted ED patients are queued up in the ED, occupying rooms and halls that need to be available to the patients in the ED waiting room. Consequently, our healthcare system caters better to a regional patient in need of advanced oncology therapy, organ transplant, or complex surgery than a local community member who presents to the ED with pneumonia or congestive heart failure who may find that emergency medical services cannot take them to their preferred hospital because its ED is diverting due to saturation. Boarding is a driver of ambulance diversion and leads to further inequities and disparities.15-21 Our healthcare system does not value care of the most vulnerable.22 While many factors contribute to the lack of acute inpatient psychiatric stabilization beds, a reimbursement system that undervalues such care is a major factor.23 Individuals suffering a mental health crisis experience some of the most egregious prolonged boarding in EDs awaiting acute inpatient psychiatric beds.24-27 The American College of Emergency Physicians policy statement titled, “Boarding of Admitted and Intensive Care Patients in the Emergency Department,” revised February 2023, retrieved 2/19/25 from https://www.acep.org/siteassets/new-pdfs/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department.pdf, indicated, “ ... Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Once admitted, patient care is most effectively and safely delivered on inpatient units. Boarding of admitted patients in the ED represents a hospital-wide failure and contributes to lower quality of care, decreased patient safety, reduced timeliness of care, reduced patient satisfaction, an increased number of patients leaving without being seen, and increased mortality. Additionally, it directly contributes to ED crowding due to the resultant loss of bed and resource capacity. ED crowding and its negative impacts on patients are due to misaligned health care economics and financial pressures on hospitals ...” The Journal of Academic Emergency Medicine article titled, “The Association Between Length of Emergency Department Boarding and Mortality” retrieved 2/19/25 from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2011.01236.x, indicated, “ ...ED boarding occurs when insufficient hospital capacity is available for admitted patients to be transferred to inpatient beds. The result is that admitted patients remain in the ED, sometimes for long periods. The concern is that due to competing demands by other patients and general system overload, boarders do not receive the same level of care that they would in inpatient beds. Several recent articles have identified safety issues with boarding, including adverse events, higher rates of ventilator-associated pneumonia, higher mortality rates for intensive care unit (ICU) patients per se, and for admissions overall. There are also higher rates of medication errors and preventable adverse events ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 49884 Based on interview and record review, the hospital failed to have a Quality Assurance and Performance Improvement (QAPI-is a systematic approach to improving the quality of care and services delivered to patients) program that tracked and monitored adverse events (AE- a harmful and negative outcome that happens to a patient provided medical care) and implement preventive measures when Patient (Pt) 6 experienced a wrong side surgical procedure for a left sided interscalene block (an injection of medication that numbs the bundle of nerves that extend to the upper arms, hands and shoulders), and a left sided peripheral nerve block (a needle injects numbing medication near specific nerves in shoulder region, blocking pain signals) and instead a right shoulder nerve block was performed. The QAPI program did not conduct a root cause analysis (is a method used to identify the main cause of an issue) to determine the cause and implement measures to ensure future incidences would not occur. This failure resulted in the potential harm of patients not benefiting from effective measure and reoccurrence of adverse events and negative patient outcomes. Findings: During a review of Pt 6’s “Anesthesia Preprocedure Evaluation [APE],” dated 12/2/24 at 8:16 a.m., the “APE” indicated, Anesthesia Medical Doctor (AMD) 1 completed a physical exam of Pt 6 on 12/2/24 at 8:16 a.m. The “APE” indicated Pt 1’s anesthesia plan was general anesthesia (medication causing loss of feeling and awareness like a deep sleep), a left sided interscalene block (an injection of medication that numbs the bundle of nerves that extend to the upper arms, hands and shoulders), and a left sided peripheral nerve block (a needle injects numbing medication near specific nerves in shoulder region, blocking pain signals). The “APE” indicated, “ ... Informed Consent [Physician educates a Pt about risks, benefits, and alternatives of procedure] [AMD 1] have discussed the planned anesthesia care with the patient and/or legal representative, including the following: the nature and purpose of the planned anesthesia; the risks, benefits and side effects of the planned anesthesia; alternatives for the planned anesthesia and their associated risks, benefits, and side effects ... The patient and/or legal representative demonstrated understanding of the information provided. After careful consideration, the patient and/or legal representative agreed to proceed with the planned anesthesia care ...”. During an interview on 1/30/25 at 12:04 with Anesthesia Medical Doctor (AMD) 1, AMD 1 stated, she recalled Pt 6’s wrong sided nerve block on 12/2/25. AMD 1 stated, she (AMD 1) was the anesthesia provider for Pt 6’s surgery on 12/2/25. AMD 1 stated the planned anesthesia for Pt 6’s surgery was general anesthetic combined with a nerve block. AMD 1 stated, before starting the nerve block, RN 10 conducted a time-out procedure, during which the surgical site was confirmed aloud. AMD 1 stated, she could not see the surgeon’s skin marking for the surgical site because it was below the shoulder, where she had inserted the needle. AMD 1 stated she administered a nerve block on Pt 6’ right shoulder [non-operative side] AMD 1 stated, she should have double checked the surgeon’s skin marking before administering the nerve block to Pt 6’s right shoulder. During a telephone interview on 1/30/25 at 3 p.m. with Medical Doctor (MD) 2, MD 2 stated he recalled performing Pt 6’s surgery on 12/2/24. MD 2 stated, he was Pt 6’s Orthopedic Surgeon (Specialist physician for treating bones, joints, muscles, tendons, and ligaments) for her shoulder surgery. MD 2 stated, Pt 6’s surgery was planned for the left shoulder, and the Anesthesia Provider administered a nerve block on the right shoulder. MD 2 stated no one from the Risk Management Department had talk to him about the incident and he was not aware of any root case analysis conducted. During an interview on 1/31/25 at 10:07 a.m. with the Director of Risk Management (DRM), the DRM stated the Risk Management department received an IRIS (Incident Response Improvement System) report and investigated the incident. The DRM stated the hospital legal department reviewed the incident to decide if it needed to be reported to California Department of Public Health (CDPH-a state agency that works to promote the health of California residents) The DRM stated, based on the review, the hospital determined the incident did not meet the CDPH reporting criteria for an adverse event. The DRM stated a root cause analysis was not conducted. The DRM stated nerve block was not considered a surgery, however agreed the nerve block was given in the Operating Room (OR-dedicated space in the hospital where surgical procedures are performed) as part of the surgery process. The DRM stated a time-out (a brief pause in the surgical procedure to verify critical information and ensure patient safety) was completed to verify information and ensure patient safety. The DRM stated the nerve block was not a stand-alone procedure and did not carry some risk to Pt 6. The DRM stated the hospital did not conduct a root cause analysis (RCA- the process of discovering underlying causes of a problem to prevent recurrence) but completed actions items and held safety meetings about the incident. The DRM stated in retrospect, the anesthesia procedure was part of the surgical process. During a review of the facility’s policy and procedure (P&P) titled, “Adverse Event Reporting to the California Department of Health Services,” dated 1/3/22, the P&P indicated, “To comply with the mandated reporting requirements of Health and Safety Code 1279.1 (b). To support the improvement of patient safety and quality improvement initiatives ... Adverse event includes any of the following: Surgery performed on a wrong body part that is inconsistent with the documented informed consent for that patient ... It shall be the policy of [hospital name] to report an adverse event, as define within Health Safety Code 1279.1, to the California Department of Public Health (CDPH) no later than five days after the event has been detected; or, if the event is an ongoing urgent or emergent threat to the welfare, health, or safety of patients ... not later than twenty-four (24) hours after the adverse event has been detected ... In addition, the regulations specify the hospital is subject to an onsite investigation when CDPH determines that an adverse event or complaint is an ongoing threat of imminent danger of death or serious bodily harm. It is also our policy to investigate the source of the event, initiate any mitigation actions that may be indicated and cooperate fully with the CDPH throughout the process. All adverse events which may be considered reportable as defined by this policy shall be reported to the Supervisor/Manager immediately by involved staff and an Incident Reporting Intranet System (IRIS) completed within 24 hours ...It will be the responsibility of the Risk Manager to develop and submit the initial report to the CDPH, as well as serve as liaison with the agency during subsequent investigation process ...””

“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: 40644 Based on interview and record review, the hospital failed to ensure the physician ordered Order Set titled, “Insulin Orders for Non-Pregnant Adult” (pre-written physician orders instructing the nurse as to what medication to give and what to do if the patient’s blood glucose is too low) provided safe directives for nursing staff when two registered nurses (RN 5 and RN 6) followed physician orders which resulted in one of 44 patients (Pt 1) having fluctuating blood glucose levels, resulting in a Code Blue (cardiac arrest.) This failure resulted in Patient (Pt) 1 experiencing very low blood sugar and may have contributed to Pt 1’s death. Findings: During a review of the hospital’s Facility Reported Incident (FRI) submitted to the California Department of Public Health on 12/2/24, the FRI indicated, “ ...On 11/19/24, a 79-year-old male patient ... was admitted to the cardiac progressive care unit (CPCU) unit. On 11/21/24, patient underwent a right hip [surgery], tolerated procedure well, and was transferred back to CPCU at 1813 PM (6:13 p.m.) At 2028 PM (8:28 p.m.) [insulin glargine - a long-acting insulin] 10 units subcutaneously (a shot) was administered per physician order. At 2231PM (10:31 p.m.), patient’s blood sugar was checked, resulted at 47 and he was given Dextrose 50% (D50) 50 mL IV (IV - into the vein) per order. At 2241 PM (10:41 p.m.), patient’s blood sugar was rechecked and resulted at 138 ...At 0324 AM (3:24 a.m.), Monitor Tech notified RN that SpO2 (oxygen and heart rate monitor) was reading “no pulse.” RN immediately responded ...Code Blue was called, and CPR (chest compressions and other life-saving measures) was initiated ... On 11/25/24, patient had a sudden change in mentation (mental activity) and stopped following commands with GCS 10 (Glasgow Coma Scale - measures the level of consciousness) decreasing to 7. During a review of hospital document titled, “History & Physical (H&P)” dated 11/19/24, the H&P indicated Pt 1 was sent to the hospital on 11/19/24 by his orthopedic (bone) doctor because he had a hip fracture (broken hip) and needed surgery. The H&P indicated Pt 1 was a “ ...79 y.o. (year old) male patient with a history of diabetes mellitus 2 (disease that causes blood sugar to rise too high and drop too low) with nephropathy (kidney disease,) retinopathy(eye disease,) hypertension,(high blood pressure) dyslipidemia, (high cholesterol,) coronary artery (heart vessel) disease ... End Stage Renal Disease (kidneys were failing, and blood sugar is difficult to control) ... anemia (body doesn’t have enough healthy blood cells.)” During an interview on 1/30/25 at 11:00 a.m. with RN 6, RN 6 stated she was the nurse for Pt 1 on 11/21/24 on the day shift (7 a.m. to 7:30 p.m.) RN 6 stated that during the handoff report from RN 23 at 7:00 a.m. on 11/21/24 (the process of giving information about the patients’ care and needs to the nurse who will be taking over care) RN 23 told her that Pt 1 was NPO (not eating or drinking anything) because he was going to surgery that day to have his hip repaired. RN 6 stated Pt 1 had an Order Set titled “Subcutaneous (given into the skin - a shot) Insulin Orders for Non-Pregnant Adult” was for managing the patient’s blood sugar level, and if the blood sugar level dropped below 70 mg/dl (milligrams per deciliter, a measurement - Normal range of blood sugar is 70-99 mg/dl.) RN 6 stated she was also informed by RN 23 that Pt 1 was a dialysis patient (meaning the patient undergoes a process of filtering the blood because the kidneys do not function normally) and his last dialysis treatment was yesterday morning (11/20/24.) Pt 1’s blood sugar was 53 on 11/21/24 at 5:00 a.m. and RN 23 gave the first dose of 10 ml (milliliters, a liquid measurement) of D50 (D50 - 50% dextrose solution - a concentrated sugar solution given into the vein to quickly raise the sugar level in the blood) and at 5:35 a.m. and when RN 23 rechecked, it was 156, so no further action was needed according to the Order Set. RN 6 stated when she checked on Pt 1 that morning, on 11/21/24 around 7:00 a.m., he was alert and talking to her. RN 6 stated she checked Pt 1’s blood sugar at around 11:00 a.m., and it was 66 mg/dl, mg/dl, so she gave the second dose of D50 because that is what the Order Set instructed her to do. RN 6 stated on 11/21/24 at 11:38 a.m. MD (Medical Doctor) 5 was notified that Pt 1’s blood sugar was 66 mg/dl. D50 was given per the Order Set and when rechecked the blood sugar was 212 mg/dl. RN 6 stated she told the doctor Pt 1 had a low blood sugar at 5:00 a.m. and again at 11:00 a.m. and that D50 was given each time. RN 6 stated the Order Set did not instruct her to call the doctor, but she believed the doctor would want to know that the patient’s blood sugar was fluctuating. Pt 1’s surgery was scheduled for 4:00 p.m. and before the patient was placed on a gurney to be transported to surgery RN 6 stated that she checked the blood sugar again, and it was again below 70 mg/dl, so she gave another 10 ml of D50 per the Order Set instructions, the 3rd dose of the day, and told the nurse from surgery to recheck Pt 1’s blood sugar in 10 minutes. RN 6 stated the nurse in surgery did recheck and Pt 1’s blood sugar and it was above 100 ml/dl, so no further action was needed according to the Order Set. RN 6 stated that Pt 1 returned from surgery at about 6:30 p.m., right before shift change. RN 6 stated she told the oncoming night nurse (RN 5) about the incidents of low blood sugar and that Pt 1 had received three doses of 10 mls (milliliters, a liquid unit of measure) of D50 and that he just drank 4 ounces of apple juice between the time that he returned from surgery at 6:30 p.m. and when report started at about 7:00 p.m. RN 6 stated Pt 1 had not had anything to eat during her shift from 7:00 a.m. to 7:30 p.m. except the apple juice right after surgery., and pt had been NPO since yesterday (11/19/24 at 4:23 p.m., more than 24 hours before surgery.) During an interview on 1/30/25 at 8:39 a.m. with RN 5, RN 5 stated she was the nurse assigned to Pt 1 on 11/21/24 on the night shift. RN 5 stated Pt 1 had surgery during the day shift and was back in his room before her shift started at 7:00 p.m. RN 5 stated she received a hand-off report from RN 6 that Pt 1 had surgery during the day and his blood sugar levels had been up and down, and he had received 3 doses of D50, one at around 5:00 a.m. one at around 11:00 a.m., and another around 4:00 p.m. right before the patient went in for surgery. RN 5 stated she explained to Pt 1 what each of his medications were for before giving them, including the insulin glargine (long-acting insulin) and gave the 10 units insulin glargine shot at 8:28 p.m. RN 5 stated the Order Set indicated specifically not to hold the insulin glargine even if blood sugar is low or if the patient is NPO. RN 5 stated Pt 1 was scheduled to have his blood sugar checked at 11 p.m., so she did a fingerstick at 10:30 p.m. and it showed a blood sugar level of 47 mg/dl, a very low level. RN 5 stated she gave D50 according to the physician’s Order Set. RN 5 stated Pt 1’s blood sugar came up to 138 mg/dl within 10 minutes after receiving the D50. RN 5 stated she did not call the doctor because the Order Set did not instruct her to call as long as the blood sugar comes back up after receiving D50. RN 5 stated Pt 1 rested comfortably the rest of the evening, and that she “looked in on him” several times. RN 5 stated Pt 1 had a routine blood draw by a phlebotomist (person who draws blood) at 3:03 a.m. and the phlebotomist did not report any concerns about Pt 1 to her. RN 5 stated she received a call from the Monitor Tech (the person who was watching Pt 1’s heart and respiration monitor outside his room) stating Pt 1’s monitor was reading, “no pulse.” RN 5 stated she went to the room and found Pt 1 unresponsive and without a pulse, and she called a Code Blue (process to call a team of medical professionals to try to revive a patient.) RN 5 stated Pt 1’s blood sugar was less than 10 mg/dl, and he was given more D50 during the Code Blue, and his heart started to beat again, then he was transferred to Intensive Care Unit. During an interview and record review on 1/29/25 at 10:59 a.m. with Nurse Manager (NM) 1 and the Director of Inpatient Services (DIS), NM 1 stated they did a Root Cause Analysis (RCA- a process of investigating the reasons why errors happen to try to keep them from happening again) on this case and determined there were some things that needed to change. NM 1 stated the Order Set for Subcutaneous (given into the skin - a shot) Insulin Orders for Non-Pregnant Adult wasn’t clear, and changes were made to the Order Set because of the incident with Pt 1. NM 1 stated there was a lack of critical thinking skills from nursing, and the doctor should have been called during the day to discuss what could be done about Pt 1’s blood sugar that kept dropping a few hours after he received the D50. NM 1 stated, “We were chasing the Blood Sugar. Giving repetitive doses of D50 should have raised a flag.” The DIS stated that this incident required urgent education to all nurses and doctors, and changes to the Order Set. The DIS stated there have been changes to the Order Set in this facility as well as other facilities managed by this organization. During an interview on 1/30/25 at 11:30 a.m. with a Pharmacist (Pharm 1,) Pharm 1 stated he was familiar with the situation of Pt 1’s blood sugar dropping after receiving multiple doses of D50. Pharm 1 stated the insulin glargine, also called basal insulin, was given “per protocol” as was the D50 that was given when Pt 1’s blood sugar was below 70 ml/dl. Pharm 1 stated when an order for medication is received in the pharmacy, the pharmacist reviews the individual orders, including reviewing relevant laboratory results, the patient’s height, weight, and age, and other medications the patient is on to make sure the medications don’t interfere with each other. During an interview with the Director of Pharmacy (DP), the DP stated the hospital has an Order Set Committee, and committee decides how often each Order Set should be reviewed. DP stated the Order Set for Insulin Orders for Non-Pregnant Adult was reviewed in 2023. The DP stated all Order Sets are reviewed by the Pharmacy and Therapeutics Committee, which she attends. The DP stated the Pharmacy Department did not monitor the use of D50 in the past, but now they are monitoring its usage to serve as another safety check, a change that has been put into place since and because of the incident with Pt 1. During an interview on 1/31/25 at 11:00 a.m. with MD 1, MD 1 stated he has worked at this hospital for about 2 years and has been a hospitalist (doctor who sees patients who are admitted to a hospital) for over 20 years. MD 1 stated he admitted Pt 1 and ordered the insulin glargine as part of the Order Set. MD 1 stated he has the ability to customize the Order Set. MD 1 stated for Pt 1, he came in for elective surgery (not an emergency surgery.) MD 1 stated when he first admitted Pt 1, his blood sugar was “almost 400.” Pt 1 wasn’t scheduled for the surgery for a day or two, and so he ordered meals for the patient and expected him to be eating. MD 1 stated he takes into account the patient’s age, weight, and he knew that Pt 1 had end-stage renal disease. MD 1 stated it was his “clinical judgement call” to use the Order Set and to select the insulin glargine dose. MD 1 stated he ordered a diet for Pt 1 on 11/20/24 and was not notified that Pt 1 was not eating the day prior to the surgery or that the patient had been having drops in his blood sugar levels requiring repeated doses of D50 on 11/21/24. During a review of Order Set ... titled “insulin glargine (brand name) injection 10 units nightly” the order indicated it was started on 11/19/24 at 4:22 p.m. by MD 1. The order indicated, “Admin instructions: Basal insulin should not be held based on pre-dose blood glucose level or meal status.” The document indicated the order was reviewed by Pharmacist 2 (RPH 2). The document indicated, “Diet NPO - DIET EFFECTIVE NOW, Starting on Tuesday, 11/19/24 at 1623 (4:23 p.m.) until specified.” During a review of hospital document titled, “flowsheets,” the flowsheet indicated on 11/20/2024 at 12:12 p.m. Pt 1 drank 240 ml (about 8 ounces) of liquid and ate 50% of his meal. The flowsheet did not indicate what foods or beverages Pt 1 ate or drank. The flowsheet indicated on 11/20/24 at 4:22 p.m. Pt 1 drank 180 ml (about 6 ounces) and at 50% of his meal. There is no documentation of any more food or beverages during the evening of 11/20/24 or in the morning. The flowsheet indicated on 11/21/24 at 8:00 a.m. patient was NPO. During a review of nursing note by RN 5, the note dated 11/22/2024 3:53 a.m. indicated, “0318: Received call from cardiac monitoring about patient’s oxygen sensor not reading. Writer went in to check on patient. Found patient unresponsive, cool to touch. No pulse. 0319: Writer started compressions and emergency activated. 0320: Activated code blue. Code blue team at bedside. 0342: Code blue ended. Patient transferred to higher level of care in ICU 0351: Called son [name] to update on patient. No answer. Left voicemail.” During a review of hospital document titled, “Progress Notes” dated 11/22/24 at 2:33 p.m. by Nurse Practitioner (NP) 1, NP 1’s note indicated, “Assessment: Acute Hypoxic Respiratory Failure” Occurred due to PEA (PEA - Pulseless Electrical Activity, which is a cardiac arrest rhythm that occurs when a person’s heart stops but there is still electrical activity.) Intubated (breathing tube inserted down his throat and connected to machine to breathe for patient) .... Suspect PEA due to hypoglycemia.” During a review of physician note dated 12/2/2024 by MD 4, the note indicated, “Death note: Patient expired peacefully on comfort care with family at bedside at 0603 a.m. ...” During a review of a professional reference from the Cleveland Clinic Journal of Medicine, “Managing diabetes in hemodialysis patients: Observations and recommendations” retrieved from www.ccjm.org on February 10, 2025, the article indicated, “ESRD significantly alters glycemic control, the results of hemoglobin A1c testing, and the excretion of antidiabetic medications. The various and opposing effects of ESRD and dialysis can make blood glucose levels fluctuate widely, placing patients at risk of hypoglycemia-and presenting a challenge for nephrologists and internists.” During a review of the professional reference from Academic Life in the Emergency Department, Dec 31, 2014, retrieved from https://www.aliem.com/d50-vs-d10-severe-hypoglycemia-emergency-department/ titled, “D50 vs D10 for Severe Hypoglycemia in the Emergency Department - Drawbacks of D50, the article indicated, “1. Rebound hypoglycemia: After administration of D50 there is an excess amount of glucose available, leading to increased uptake and utilization by the tissues, which suppresses both gluconeogenesis and glycogenolysis. Without continued administration of dextrose-containing fluids, this may result in rebound hypoglycemia.”

“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: 47205 Based on observation, interview, surveillance video review and record review, the hospital failed to ensure nurses followed policies and procedures (P & P) when: 1. Nurses in the emergency department (ED- area of the hospital that provides immediate care for severe injuries and illnesses 24/7 without appointments) did not document skin integrity assessments and wound care interventions for 11 of 12 patients (Pt 2, 3, 4, 7, 8, 9, 38, 39, 40, 41, and 42) who were determined to need inpatient services and were holding in the ED in accordance with hospital P&P “Pressure Injury Risk Assessment, Prevention, Staging and Treatment” dated 9/13/24. These failures resulted in Pt 2, 3, 4, 7, 8, 9, 38, 39, 40, 41, and 42 experiencing avoidable new pressure ulcer or avoidable worsening of identified pressure ulcer and could negatively affect patients’ overall health and wellness and could contribute to a longer hospital stay. 2. Nurses in Labor and Delivery unit (L&D, area of the hospital where babies are born and pregnant patients are treated) failed to conduct daily check of the Crash Cart (a mobile medical unit stocked with essential supplies and medication for use in emergency situations) for supplies and equipment on 1/5/25 and 1/10/25 in accordance with hospital P&P titled, “Code Blue -Medications & Crash Carts (CB),” dated 6/14/2024. These failures had the potential for essential supplies and equipment to be unavailable or malfunctioning in a medical emergency and possibly not address the emergent needs of patients. 3. Nurses failed to document an incident involving taser (a handheld, battery-powered device that delivers an electric shock to temporarily disable or restrain a person) use on Pt 43. Security Officer personnel used the taser on Pt 43 on 2/2/25 and nursing staff observed and were aware of the incident. There were no entries in the medical record documenting the use of the taser, or the personnel using the taser. The medical record did not include an entry from a physician or from Registered Nurse (RN) 13 regarding an assessment of the patient’s condition following the taser use, according to the hospital Policy and Procedure P&P, titled, “Standard of Practice Emergency Department”. These failures to document the taser use and subsequent medical assessment, created a significant risk to Pt 43’s safety, and the potential harm of not identifying and documenting post-taser medical evaluations or complications such as cardiac arrhythmias (irregular hear-rhythms), burns or musculoskeletal (network of muscles, bones, joints, ligaments, and tendon) injuries. Findings: 1. During a concurrent observation and interview on 1/28/25 at 10:12 a.m., in the ED with ED Director (EDD) of the unit, the ED was observed to be very busy, with many patients of all ages on gurneys or hallway beds as well as in rooms. EDD stated the unit was currently experiencing high volumes of ED patients coming to the ED, and inpatients waiting in the ED for an inpatient bed assignment. During the tour, patients were observed to be waiting, eating, sitting on gurneys interacting with the one visitor allowed at bedside and/or receiving infusions of IV medications. Pt 41 and Pt 42 were observed to be holding in a hallway gurney. During a concurrent interview and record review on 1/28/25 at 11:21 a.m., with Clinical Supervisor (CS) 7 and EDD, the Electronic Health Records (EHR) for Pt 41 and Pt 42 was reviewed. Pt 41’s “ED Pt Care Timeline” dated 1/28/25, indicated, “ ...TT 65:45 (hours:minutes) ...” EDD explained “TT” represented the time [the patient Pt) spent in the ED before being moved to an inpatient admission bed. EDD stated ED nurses are trained to provide appropriate level of care to inpatients holding in the ED for an inpatient bed assignment. During an interview on 2/3/25 at 10:08 a.m. with the ED Manager (EDM) 2, EDM 2 stated the initiation of the “ED Inpatient (EDIN) team” began April 2024. EDM 2 stated EDIN was initiated to relieve the need for an ED RN to be floated into an inpatient care assignment. EDM 2 stated the EDIN staff includes Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Patient Care Technicians (PCTs) recruited into EDIN. EDM 2 stated nurses hired into the EDIN may have prior experience in caring for the inpatient population. EDIN staff receive orientation with inpatient nurses to ensure they are competent to deliver the inpatient care level ordered by the provider. EDM 2 stated he was hired into a night shift manager position on June 2024, and was later assigned to manage EDIN and EDIN staff in September 2024, because of his prior experience in leading a similar unit in another state. EDM 2 stated he reports to the EDD. EDM 2 stated the ED is EDIN staff’s “home base” and staff are considered part of the ED team. EDM 2 stated EDIN staff or Float Pool staff are assigned to care for inpatients in the ED, if there are was not enough EDIN or Float Pool staff to care for the number of inpatients holding in the ED, ED staff are assigned to fill the need. EDM 2 stated EDIN staff does not float to the ED to care for ED patients or go up to the units with the admitted patient. EDM 2 stated EDIN staffs an EDIN Clinical Supervisor (CS) to oversee EDIN staff working in designated zones in the ED. During concurrent interview and record review on 2/3/25 at 10:15 a.m., of the facility “ED Map” dated 3/28/2022, with EDM 2, EDM 2 referenced the ED Map and indicated there was a more current version, but he could still provide basic details as he explained the ED layout. Review of the ED layout indicated the ED was configured in a rectangle with designated color-coded zones, such as green, yellow and red zones. The color code of the zone corresponded to the level of services the patient needed in the ED with green the least complex care and red, the most complex care. EDM 2 stated inpatients are routinely moved into the Green and Yellow-West Zones. EDM 2 stated sometimes inpatients are moved into the Yellow East Zone where they may be mixed in with ED patients temporarily, while waiting for either an inpatient admission bed or to be moved into the Green or Yellow -West Zone. EDM 2 stated inpatients are not routinely held in the Red Zone. EDM 2 stated the goal is to group inpatients into a designated area to facilitate their care. During concurrent observation, interview and record review on 2/3/25 at 10:40 a.m., with ED Manager (EDM) 2 and ED Registered Nurse (RN) 17 in the ED, RN 17 stated she was assigned to care for ED inpatients today, and normally works in the ED. ED RN 17 stated she was the primary RN for Pt 39 and reviewed Pt 39’s EHR. ED RN 17 stated Pt 39’s EHR “IP Charting [where nurses document care of the inpatient waiting in the ED and IP stands for In Patient] indicated Pt 39 was placed on an overlay (air overlay cradles the body, providing protection and treatment for pressure ulcers) was performed on 2/2/25 at 11:00 a.m., with a nursing assessment of Pt 39’s skin documented on 2/2/25 at 4:59 p.m. Pt 39’s Braden Scale Score (BSS- a numerical value used to assess a patient’s risk of developing pressure ulcers. A lower score indicates a higher risk. The BSS is calculated by evaluating six factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A total score ranging from 6 (high risk) to 23 (low risk): 19-23: No risk, 15-18: Mild risk, 13-14: Moderate risk 10-12: High risk, 9 or less: Very high risk) was 19. RN 17 stated as an ED RN, she floats into EDIN as needed. RN 17 stated the EDIN and Float Pool staff were not sufficiently staffed today to take care of all the EDIN patients waiting for an inpatient bed. RN 17 stated in reviewing the prior shifts documentation she would have expected the nurse to first assess and learn the patients BSS, then implement interventions (turning, waffle overlay, etc.) according to the skin saving “bundle” [grouped interventions based on BSS] corresponding to the patients BSS and skin care needs. RN 17 stated the potential harm to the patient is a missed care need or risk and implementing the wrong intervention, which could lead to patient harm. During a record review of the hospital’s Facility Reported Incident (FRI) submitted to the California Department of Public Health (CDPH) on 1/14/25, the FRI indicated Pt 2 had a “...wound nurse consultation...revealed that patient’s evolving deep tissue injury (DTI-suspected deep tissue injury is when the surface of the skin looks like a stage I or II sore, but underneath the surface, it’s a stage III or IV sore) to [buttocks] have been determined as stage III pressure injury (these sores have gone through the second layer of skin into the fat tissue. The sore looks like a crater and may have a bad odor. It may show signs of infection: red edges, pus, odor, heat, and/or drainage. The tissue in or around the sore is black if it has died)...” During record review of Pt 2’s EHR [documents provided by the hospital], on 2/6/25 Pt 2’s “Face Sheet (FS)” dated 2/2/25 was reviewed. The FS indicated, Pt 2 was a “...29-year-old ... admitted on 1/1/25 for Altered Mental State (AMS- a change in mental function, such as a change in awareness, attention, or consciousness) and Seizures (SZ- when there’s a burst of abnormal electrical activity in the brain, which can cause temporary changes in movement, behavior, or awareness. SZs can range from minor to severe, and can involve convulsions or loss of consciousness) and discharged on 1/10/25 with Home Health (Home health care includes a wide range of health and social services delivered in your home to treat illness or injury) care.” During record review of Pt 2’s EHR, on 2/6/25 Pt 2’s “History & Physical [H&P- an assessment from physician including medical history and exam],” dated 1/1/25, was reviewed. The H&P indicated Pt 2 “...presented to the ED for taking multiple tablets of baclofen (a muscle relaxing medication) and DUI (Driving Under Influence [of a substance]) and under Police Custody... 29 years old... history of ...obesity (obese- abnormal or excessive fat accumulation that presents a risk to health), hypothyroidism (a condition where the thyroid gland doesn’t produce enough thyroid hormones), and MS (Multiple Sclerosis-a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control)...” During record review of Pt 2’s EHR, on 2/6/25 Pt 2’s ED Timeline, dated 2/2/25 was reviewed. Pt 2’s ED Timeline indicated, “...TT: 86:02 [Pt 4 remained in the ED on a hallway gurney until admission bed transfer]...on 1/1/25 at 18:50 (6:50 p.m.)...” During a record review of the complaint submitted to CDPH on 12/16/24, the complaint indicated Pt 3 “... a resident of a local skilled nursing facility (SNF- a long-term healthcare facility)admitted on April 2024 at 128 lbs. then discharged on May 2024 at 141 lbs., then admitted on 8/16/2024 back to SNF at 123 lbs. from this facility [hospital]. His weight when admitted to this facility [hospital] on 8/11/24 was 143 lbs. Weight loss appears to have occurred at the hospital. There are two stage 2 decubitus noted on the Patient also upon arrival to the SNF. Nothing was noted on the hospital records or treatment plan sent to the SNF by this facility [hospital]. Nothing indicated on the hospital records stated that he was admitted to hospital with any signs of decubitus (pressure injury or bedsore) either. Admission was due to seizure activity. At this time it appears that both the significant weight loss and decubitus occurred while he was at the hospital from 8/11/24 to today, 8/16/2024...” During record review of Pt 3’s EHR on 2/6/25 Pt 3’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 3’s “...Admit Reason (s) Seizure Disorder...ED Arrival Date/Time: 8/11/24, 12:44 (p.m.)...Date/Time First Inpatient: 8/11/24, 16:32 (4:32 p.m.)...Discharge Date/Time 8/15/24, 18:52 (6:52 p.m.)...Dispo [disposition- the destination of the patient after hospital discharge]: To Another SNF for Skilled Nursing Care...” During record review of Pt 3’s EHR, on 2/6/25 Pt 3’s “H&P,” dated 11/22/24, was reviewed. The H&P indicated Pt 3 was a “...75-year-old...patient with a history of Diabetes mellitus (high blood sugar disease), Hypertension, Mental retardation...Seizures, and Thyroid disease...” During record review of Pt 3’s EHR, on 2/6/25 Pt 3’s ED Timeline, dated 1/31/25 was reviewed. Pt 3’s ED Timeline indicated, “...TT: 29:27 [Pt 3 remained in the ED until admission bed transfer]...on 8/11/24 at 16:36 (4:36 p.m.)...” During a record review of the hospital’s FRI submitted to CDPH on 12/13/24 indicated Pt 4 was an “ ...83-year-old patient admitted...on 11/22/24 for acute kidney injury (AKI-where your kidneys suddenly stop working properly) and UTI- (Urinary Tract Infection- an infection in the urinary system). Hospitalization complicated by severe agitation requiring restraints, fluctuating mentation (mental activity)/dementia- (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Patient was noted with a deep tissue injury to sacrum area on 11/28/24, wound consult was placed. Sacral (a large, triangular bone at the base of the spine) wound has evolved into an unstageable full thickness pressure injury (when the stage is not clear), and the right gluteus (any of the large muscles of the buttocks) has evolved into a partial thickness injury that has new epithelialization (the process of becoming covered in epithelium (a layer of cells covering all the surfaces of the body), which helps the body to repair damage) and is resolving.) ...” During record review of Pt 4’s EHR [documents provided by the hospital on 2/6/25 Pt 4’s FS dated 1/31/25, the FS indicated, “...ED Arrival Date/Time: 11/22/23 11:16 (a.m.)...Date/Time First Inpatient: 11/22/224, 16:59 (4:59 p.m.)...Discharge Date/Time: 12/12/24, 14:48 (2:48 p.m.)...Dispo: To Another Facility or SNF...” During record review of Pt 4’s EHR, on 2/6/25 Pt 4’s “H&P” dated 11/22/24, was reviewed. The H&P indicated Pt 4 was an “...83-year-old...patient with a history of hypertension (high blood pressure) and dementia...brought in by ambulance due to concern for abnormal kidney function on recent labs...” During a record review of Pt 4’s EHR, on 2/6/25, Pt 4’s “ED Timeline” dated 1/31/25, was reviewed. The Timeline indicated, “...TT: 103:29...[Pt 4 remained in the ED on a hallway gurney for 22 hours before being moved into a room in the ED. Pt 4 remained on a gurney until admission bed transfer]...on 11/26/24 at 18:45 (6:45 p.m.)...” During a record review of the hospital’s FRI submitted to CDPH on 1/21/25 indicated Pt 7 was a “...31 y.o. (year-old) pt BIBA (brought in by ambulance) post (after) ground-level fall. Imaging studies revealed a right femoral neck fracture (a break in the bone that connects the femoral head (ball of the hip) to the femoral shaft (thigh bone) and pt was admitted 1/4/2025 for surgical intervention. Wound consultation on 1/15/2025 has revealed that the patient’s evolving DTI to the left aspect (area) of the coccyx (tail bone) has opened and is now an unstageable pressure injury...” During a concurrent interview and record review on 1/30/25 at 1:15 p.m., with the CPCU Nurse Manager (NM 2), EHR records for Pt 7 was reviewed. NM 2 Manager stated CPCU staff are expected to conduct a new admit dual skin verification (2 nurses required to assess and attest to their findings), to take pictures of any skin concerns, it is NM 2’s expectation that the new admit will have pictures of coccyx and heels, even if no concern is assessed, unless patient refuses. NM 2 stated the preventive care turning/repositioning, pressure relieving overlay, do not require an order, nurse follows hospital P&Ps. Any concerns are to be reported to the provider for possible orders. NM 2 stated some interventions are nurse driven [meaning the nurse can begin preventative skin care) and can be started as soon as it is assessed. NM 2 stated while inpatients are holding in the ED, the EDD Leaders are responsible for the oversight of these inpatients. NM 2 stated after review of patient 7’s record, it did not indicate skin interventions were done, or done consistently while patient was waiting in the ED. During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 7’s “...Admit Reason (s): Closed Right Hip Fracture...ED Arrival Date/Time: 1/4/25, 3:15 (a.m.)...Dater/Time First Inpatient: 1/4/25, 07:47 (a.m.)...Discharge Date/Time: 1/23/25, 14:33 (2:33 p.m.)...Dispo: Home with Home Hlth (Health) Service...” During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s “H&P” dated 1/4/25 was reviewed. The H&P indicated, Pt 7’s “...on [brand name blood thinner]...for thrombus (blood clot)...Past Medical History:...Dialysis daily via PD Cath (Peritoneal Dialysis Catheter- a treatment for kidney failure that uses the lining of the abdomen (peritoneum) as a filter to remove waste products and excess fluid from the blood)...End Stage Renal Disease (ESRD-a medical condition in which a person’s kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life)...Hypertension...Lupus (disease where the body’s defense system attacks healthy cells and tissues, causing damage to many parts of the body)...” During record review of Pt 7’s EHR, on 2/6/25 Pt 7’s ED Timeline, dated 1/31/25 was reviewed. Pt 7’s ED Timeline indicated, “...TT: 42:25 [Pt 4 remained in the ED on a hallway gurney until admission bed transfer]...on 1/4/25 at 19:42 (7:42 p.m.)...” During a record review of the hospital’s FRI submitted to CDPH on 1/29/25 indicated Pt 8 was “...an 88 y.o. male who presented to the ED 1/9/25 with AMS, cough, abdominal (stomach) pain, nausea, vomiting, and chest pain. On 1/24/25 nurses and provider assessed patient had Stage 3 pressure injury to coccyx (tail bone) ...” During record review of Pt 8’s EHR, on 2/6/25 Pt 8’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 8’s “...Admit Reason (s): Altered Mental Status...ED Arrival Date/Time: 1/9/25, 18:46 (6:46 p.m.)...Dater/Time First Inpatient: 1/10/25, 08:19 (a.m.)...Discharge Date/Time: 1/25/25, 14:30 (2:30 p.m.)...Dispo: To Another SNF for Skilled Nursing Care...” During record review of Pt 8’s EHR on 2/6/25 Pt 8’s “H&P” dated 1/10/25 was reviewed. The “H&P” indicated, Pt 8 “[past medical] history of hypertension, CVA (Cerebrovascular Accident- (or stroke- a medical condition characterized by the sudden interruption of blood flow to the brain, leading to the death of brain cells) , Parkinson’s disease (a brain disorder that causes unintended or uncontrollable movements), and dementia...” During record review of Pt 8’s EHR, on 2/6/25 Pt 8’s ED Timeline, dated 1/31/25, was reviewed. Pt 8’s ED Timeline indicated, “...TT: 40:32 ...[Pt 8 remained in the ED on a hallway gurney for 24 hours before being moved into a room in the ED. Pt 8 remained on a gurney until admission bed transfer]...on 1/11/25 at 11:18 (a.m.)...” During a record review of Pt 9’s “H&P,” dated 1/25/25, the “H&P” indicated, Pt 9 was a 75-year-old brought in by ambulance from home due to family concern of AMS. Patient 9 arrived at the ED on 1/25/25 at 11:56 a.m., and was admitted to the hospital on 1/25/25 at 5:26 p.m. for acute metabolic encephalopathy (brain is affected by lack of oxygen causing confusion), severe sepsis, and thrombocytopenia (low platelets-cell fragments in blood crucial to blood clotting). Pt 9 was moved to the Cardiac Progressive Care Unit (CPCU - a hospital unit providing care for patients with heart related conditions recovering from a critical stage) on 1/27/25 at 3:07 p.m.. Pt 9 had a Glasgow Coma Scale (GCS - a brain, spinal cord, and nerve assessment tool used to measure a person’s level of consciousness after a brain injury, a higher score indicating a higher level of consciousness) of 11 (moderate brain injury), she was bed bound since September 2024. During a record review of Pt 9’s “Physician Order [PO]1,” dated 1/25/25 at 5:26 p.m., the “PO 1” indicated, Pt 9 was admitted to the hospital as an inpatient on 1/25/25 at 5:26 p.m. During a concurrent interview and record review on 1/30/25 at 11:22 a.m. Pt 9’s “Wound Flowsheet Summary [WFS],” dated 1/25/25 to 1/28/25 was reviewed. The “WFS” indicated a skin assessment was completed on 1/25/25 at 7:30 p.m. The “WFS” indicated Pt 9 had “broken skin to coccyx area” documented in the skin integrity cell. The “WFS” indicated Pt 9’s BSS was 12, CS 6 stated a BSS of 12 was considered a high risk for skin breakdown. The “WFS” indicated no special mattress, or preventative dressing was documented for Pt 9. CS 6 stated Pt 9 should have been placed on a low air loss mattress and should have had a bordered dressing on her wound, when the nurse’s assessment indicated Pt 9 had a high risk for skin breakdown. The “WFS” indicated on 1/26/25 at 7:59 a.m. Pt 9’s “BSS” was 9. CS 6 stated a score of 9 was a severe risk for developing a pressure injury. The “WFS” indicated Pt 9 did not have another skin assessment completed until 1/27/25 at 11:27 a.m. Pt 9 went 27.5 hours without having a skin assessment documented by ED nurses. CS 6 stated on 1/26/25 Pt 9’s night shift nurses should have documented a skin assessment. The “WFS” indicated on 1/27/25 at 3:30 p.m. upon arrival from the ED to the inpatient CPCU Pt 9 had a skin assessment completed. The “WFS” indicated, Pt 9 had skin integrity documentation of a skin abrasion (scrape), bruising, infiltration (fluid leaking into tissues), redness, weeping (fluid leaking out), and a wound. The “WFS” indicated, skin integrity locations were the abdomen, breast, face, hand, cervical (neck) spine, arm, and coccyx. CS 6 stated nurses in the CPCU staged Pt 9’s coccyx wound a stage 2. CS 6 stated while Pt 9 was holding in the ED the only documented skin integrity (state of skin and its ability to function as a protective barrier) issue was a wound to the coccyx. CS 6 stated beginning skin interventions early and following the policy to protect skin were important to care for the patients skin and to prevent patients from getting sicker. During a concurrent observation and interview on 2/3/25 at 10:32 a.m. in Pt 9’s hospital room, Pt 9 was observed lying on her back in the hospital bed with her eyes open. Pt 9 was an Armenian speaking patient, and an interpreter was at bedside for interpretation. Pt 9 did not make eye contact or respond when greeted. Pt 9’s Family Member (FM 1) was at bedside. Pt 9 was not interview-able, due to her cognitive impairment (a decline in one or more mental functions, such as memory, attention, and reasoning). Pt 9’s FM 1 did not speak English, and responses were received through the interpreter. FM 1 stated Pt 9 was in the ED for three (3) days. FM 1 stated Pt 9 was very sick when she arrived at the hospital. FM 1 stated the physician started Pt 9 on antibiotics. FM 1 stated, Pt 9 only had a small healing wound to the lower back, near her bottom when she arrived to the ED. FM 1 stated, Pt 9 had a new wound to her back, and stomach, when she was moved to the CPCU from the ED. During a record review of Pt 9’s “Wound Care Consult Note [WCCN],” dated 2/2/25, the “WCCN” indicated Pt 9’s nurse entered a wound nurse consultation for a PI (Pressure Injury) to the sacrum (tail bone) on 1/28/25 at 2:24 p.m. On 1/29/25 at 8:12 a.m. Pt 9 had a Wound Care Specialist (WCS) consultation assessment completed. The WCS documented, “ ... Patient consulted for an open partial thickness wound [Stage 2] to the right aspect of the sacrum ... Wound is friction [skin rubbed against a surface] related. Wound Care Recommendations: ... Reduce/relieve pressure ... between bony prominences [bones are close to the skin] and the support surface ... Please re-consult Wound Care Specialist for new skin/wound symptoms, complications and/or deterioration [become worse]. During a concurrent observation and interview on 2/3/25 at 11:23 a.m., with Pt 38 and ED RN 15 in ED patient room Y-12 (Yellow zone, room 12), Pt 38 was lying on his back, with head propped up on a gurney (a bed on a frame with wheels that is used for moving people who are sick or injured), high-flow oxygen (high-flow oxygen therapy system includes those that supply a flow that meets or exceeds the patient’s inspiratory flow demand) was in place along with IV (intravenous- administered into a vein or veins) catheter (a thin, flexible tube that’s inserted into a vein to provide fluids, medications, or blood transfusions) and IV antibiotics (drug used to treat infections caused by bacteria and other microorganisms) being administered. Pt 38 stated he was admitted for “pneumonia and came to the ED for trouble breathing.” Pt 38 stated he was not offered a hospital bed, a toothbrush or clean towel to at minimum wipe his hands and face clean. Pt 38 stated because he needed staff assistant to get out of the gurney (oxygen and IV tubing and cardiac monitor connections) he was not getting out of the gurney much. It was observed there was no television or restroom in the private room. Pt 38 stated staff offered a bedside commode, and he used it despite feeling “embarrassed” at staff having to clean up his stool after he used the bedside commode (portable toilet). Pt 38 stated his father brought him a wet paper towel (from towel dispenser at a small sink in the room and that is what he used to clean his face and hands. Pt 38 stated he had not been updated on when an inpatient bed might be assigned. Pt 38 stated a visit from the doctor indicated he might be discharged 2/4/25 and not be moved at all. RN 15 stated Pt 38 had orders to remove the high flow oxygen and continue with IV antibiotics. RN 15 stated she took care of Pt 38 on 2/3/25. RN 15 stated she had not offered to order a hospital bed or provided opportunities for Pt 38 to take care of his hygiene needs (brush teeth, bathe, etc.). During record review of Pt 38’s EHR on 2/6/25 Pt 38’s “FS” dated 2/1/25, was reviewed. The FS indicated, Pt 38’s “...Admit Reason (s) Sepsis: (your body’s extreme reaction to an infection)...ED arrival Date/Time: 2/1/25, 05:14 (a.m.)...Date/Time First Inpatient: 2/1/25, 11:55 (a.m.)...” During record review of Pt 38’s EHR [documents provided by the hospital], on 2/6/25 Pt 38’s “H&P” dated 2/1/25, was reviewed. The H&P indicated, Pt 38 “a 22-year-old...super morbidly (defined as being 100 lbs. (pounds) or more over ideal body weight) obese...brought in to the ED by ambulance for difficulty breathing and cough. Pt 38 was admitted to the hospital on 2/1/25 at 11:55 a.m. ...for severe Sepsis and Pneumonia (inflammation (swelling) and fluid in your lungs caused by a bacterial (relating to or caused by bacteria (small germs (tiny organisms, or living things, that can infect you and make you sick)...[Pt 38] has no known medical conditions...” During record review of Pt 39’s EHR, on 2/6/25 Pt 39’s “FS” dated 2/3/25 was reviewed. The FS indicated, Pt 39’s “...Admit Reason (s): Dysphagia (difficulty swallowing)...ED Arrival Date/Time: 2/2/25, 00:36 (12:36 p.m.)...Date/Time First Inpatient: 2/2/25, 03:46 (a.m.)...” During record review of Pt 39’s EHR, on 2/6/25, Pt 39’s “H&P” dated 2/2/25 was reviewed. The H&P indicated, Pt 39 was a “...49-year-old, with past medical history of uncontrolled DM, multiple diabetic foot infections, L (Left) TMA (Trans metatarsal amputation-surgical procedure that removes part of the foot), R (Right) BKA (Below the knee amputation-surgical procedure that removes part of the leg), and drug abuse...presented to the ED due to choking episode...” During record review of Pt 40’s EHR, on 2/6/25 Pt 40’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 40’s “...Admit Reason (s): Altered Mental Status...ED Arrival Date/Time: 1/9/25, 18:46 (6:46 p.m.)...Dater/Time First Inpatient: 1/10/25, 08:19 (a.m.)...Discharge Date/Time: 1/25/25, 14:30 (2:30 p.m.)...Dispo: To Another SNF for Skilled Nursing Care...” During record review of Pt 40’s EHR on 2/6/25, Pt 40’s “H&P” dated 1/28/25 was reviewed. The H&P indicated, Pt 40 was “...a 79-year-old, with history of recurrent stage IV lung adenocarcinoma (lung cancer) ...with bone mets (bone metastases- bone metastasis occurs when cancer cells spread from their original site to a bone) in the ribs, s/p resection radiation in the past, COPD (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe)...presented to the hospital due to short of breath cough generalized weakness, poor oral intake...” During record review of Pt 40’s EHR, on 2/6/25 Pt 40’s ED Timeline, dated 1/29/25, was reviewed. Pt 40’s ED Timeline indicated, “...TT: 30:35 ...[Pt 40 remained in the ED on a gurney until admission bed transfer]...on 1/11/25 at 11:18 (a.m.)...” During a record review of Pt 40’s EHR, the EHR indicated the first documented Head to Toe (a physical exam that evaluates a patient’s entire body to assess their health) assessment was on 1/28/25 at 8:00 p.m., the EHR indicates the BSS was 19 with skin “intact...bruising to [pt] back. On 1/29/25 at 7:00 a.m., a pillow was documented for “proper alignment.” On 1/29/25 at 8:00 a.m., turns every 2 hours and overlay were documented/implemented. Turns were inconsistently documented with first turn (after first head to toe assessment) documented at 2:48 a.m. on 1/29/25 (or 6 hours later). On 1/30/25 at 11:34 p.m., photos of Pt 40 taken per unit expectation on arrival with documentation of left buttock impairment. During record review of Pt 41’s EHR, on 2/6/25 Pt 41’s “FS” dated 1/31/25 was reviewed. The FS indicated, Pt 41’s “...Admit Reason (s): AMS...ED Arrival Date/Time: 1/26/25, 22:16 (10:16 p.m.) ...Date/Time First Inpatient: 1/27/25, 08:19 (a.m.)...” During record review of Pt 41’s EHR on 2/6/25, Pt 41’s “H&P” dated 1/27/25 was reviewed. The H&P indicated, Pt 41 was “...83-year-old...with past medical history of dementia, CVA..., atrial fibrillation (a-fib- a heart condition that causes an irregular heartbeat), hypertension, congestive heart failure (CHF- chronic condition where the heart muscle is weakened and cannot pump blood effectively)...appears ill and frail...likely septic...UTI...” During record review of Pt 41’s EHR, on 2/6/25 Pt 41’s ED Timeline, dated 1/29/25, was reviewed. Pt 41’s ED Timeline indicated, “...TT: 65:45 ...[Pt 41 remained in the ED on a gurney]...” During a record review of Pt 41’s EHR, the EHR indicated the first documented Head to Toe assessment was on 1/26/25 at 11:46 p.m., the EHR indicates the BSS was 13 with skin “Present on Admission; Redness ...coccyx, foot, heel...” Turns were inconsistently documented with first turn (after first head to toe assessment) documented at 4:11 p.m. on 1/27/25 (or greater than 5 hours later). On 1/27/25 at 4:11 p.m., a waffle overlay was documented. On 1/30/25 at 8:20 p.m., photos of Pt 41 taken per 3 CPCU unit expectation on arrival with documentation of impairment “...Intact, Redness, Excoriation...[to] Toe, abdomen, coccyx, buttocks, thigh, perianal [areas]...” During record review of Pt 42’s EHR, on 2/6/25 Pt 42’s “FS” dated 1/29/25 was reviewed. The FS indicated, Pt 42’s “...Admit Reason (s): Syncope (another word for fainting or passing out....ED Arrival Date/Time: 1/27/25, 16:32 (4:32 p.m.)...Date/Time First Inpatient: 1/28/25, 08:20 (a.m.)...” During a record review of Pt 42’s EHR, on 2/6/25 Pt 42’s “H&P” date 1/29/25 was reviewed. The H&P indicated, Pt 42 was an “...89-year-old, with history of Sjogren syndrome (a chronic autoimmune disorder that happens when the immune system attacks the glands that make moisture in the eyes, mouth, and other parts of the body)...chronic kidney disease...hypertension...” During a record review of Pt 42’s EHR, the EHR indicated the first documented Head to Toe assessment was on 1/28/25 at 8:04 a.m., the EHR indicates the BSS was 20 with skin “intact.” Pillows and pressure relief overlay documented by Patient Care Technician (PCT) on 1/28/25 at 6:19 a.m. Pt 42 was transferred to the inpatient unit on 1/28/29 at 6:40 p.m. On 1/29/25 at 2:37 a.m., inpatient nurse documentation of “Plan of Care Signed” note indicated “...Skin check completed with secondary nurse. Redness noted to abdominal and groin fold. Blanchable redness to coccyx. Foam dressing applied. Educated patient to reposition throughout shift to prevent further skin breakdown...” During an interview on 2/4/25 1:23 p.m., with the EDD, the EDD stated she has been the EDD since April 2024. The EDD stated she is aware of the results of the patient record reviews and the gaps in documentation of skin management and prevention, specifically care to prevent and ensure no further worsening of existing wounds while in-patients are waiting in the ED for an admission bed. he EDD stated once the patient is admitted the nurse has 24-hrs to document the admission documentation, per policy. EDD stated historically, nurses have waited until admission orders are placed to begin the inpatient assessments. The EDD’s current expectation is that on arrival, if risk factors are identified a risk assessment should be completed with the patient getting the intervention for risk as assessed. EDD stated nurses should not wait until an admit order, if the assessment of the patient warrants the intervention, the patient should get that intervention. EDD acknowledges that more work needs to be done to ensure that the education is real-time and relevant for the patient population. EDD stated staging and bundles implementation is challenging to the staff in the ED, and education is ongoing. EDD stated there are hospital resources the nurse can tap into such as guidance from CSs, and policies and procedures. EDD stated with wounds and skin, it is nurse driven care, they can add order for wound consult and order specialty beds be delivered to the ED for patient use as indicated along with other interventions to ensure the patient is on the right surface for their BSS. The EDD stated she and the leadership team in the ED continue to provide staff education and participate in auditing and monitoring to ensure ED staff are retaining the new information/education. EDD stated staff in the ED will be expected to improve documentation and attend training (formal wound classes offered to staff) to supplement their current knowledge of how to care for and manage patient skin while they are waiting in the ED. The EDD stated implementation of a turn team in the ED has proven effective in managing those with risk and full assistance required to maintain skin integrity. During an interview on 2/5/25 at 9:39 a.m., with Chief Nursing Officer (CNO), a summary of the observations and interview with Pt 38 were provided. The CNO stated “we failed [in meeting Pt 38’s care]” and he developed breakdown of skin that he did not have when he came to the hospital. We are looking to improve and we are not there yet.” CNO stated she was aware of the gaps in care and documentation identified during record reviews. CNO stated leadership will now need to look at if the skin risk needs to be assessed while the patient is an ED pt to ensure that skin integrity measures are implemented timely no matter the admission status. The CNO stated her expectation for nurses is they follow hospital policy and procedures. CNO stated the purpose of following P&Ps is to ensure resources are available to nurses to keep patients safe and provide quality care. During an interview on 2/7/25 at 10:17 a.m. with the CNO stated, LNs were expected to assess the patient’s skin within 24 hours after admission and then once per shift. The CNO stated skin integrity interventions were chosen based on nurse skin assessments. The CNO stated the longer nurses delayed skin care interventions, patients were more at risk for hospital acquired pressure injuries (HAPI). The CNO stated HAPIs result in patient harm. Therefore, skin interventions were important to prevent skin breakdown. During a review of the hospital P&P titled “Pressure Injury Risk Assessment, Prevention, Staging and Treatment” dated 9/13/24 on 2/6/25, the P&P indicated “ ... PURPOSE A. To provide staff with a valid and reliable pressure injury risk assessment tool for admitted patients. B. To provide guidelines for the prevention of pressure injury development in the adult and adolescent (14-17 years of age) population. C. To provide guidelines for systematic staging, assessment, and treatment of pressure injuries. D. To implement wound management strategies to optimize the healing potential and prevent deterioration of existing pressure injuries. ...POLICY: A. All patients shall be assessed upon admission, then every shift, and with condition changes using the Braden Scale for Predicting Pressure Sore Risk. B. Prevention measures are to be applied based on the assessed level of risk according to the Braden Scale for Predicting Pressure Sore Risk. C. Patients with a subscale identified as a score of 1 or 2 are considered at risk for developing pressure injuries. The nurse will identify and implement an individualized plan of care that addresses the interventions appropriate to reduce the risk factors. D. Upon identification of a suspected pressure injury, whether present on admission or hospital-acquired, the RN shall photograph, describe and document the injury location on the appropriate section of the electronic health record (EHR). The pressure injury will be staged by a RN and they will complete an Incident Reporting Intranet System (IRIS) report. E. Notify the Clinical Supervisor and/or WS of all unstageable, stage 3, or stage 4 pressure injuries as soon as possible after discovery. F. Notify the provider of any skin breakdown and of any significant changes to the pressure injury. G. All pressure injury treatment requires a provider order. H. Obtain a nutritional consult for any patient with a stage 2 or greater pressure injury. I. The RN may implement all aspects of the policy. The licensed vocational nurse (LVN) may implement any portion of the policy as directed by the RN/provider and within their scope of practice. A patient care technician (PCT) may implement all preventive measures in care as directed by the nurse. PROCEDURE: A. Risk Assessment... 1. Use the “Braden Scale Risk Assessment tool” to identify patients at risk for pressure injury as part of the initial admission patient assessment. Subsequent Braden Risk assessments are completed each shift. 2. The initial skin assessment upon admission and/or transfer from another unit will be conducted by an RN and a secondary licensed staff [RN or LVN] member. 3. Refine the assessment by including these additional risk factors: a. Fragile skin b. Existing pressure injury of any stage, including those injuries that have healed or are closed. c. Impairments in blood flow to extremities from vascular disease, diabetes or tobacco use. 4. Develop a plan of care based on the areas of risks, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, positioning, and the support surface. If the risk is from malnutrition, address this problem, etc... B. Prevention (All patients regardless of score) 1. Skin Care a. Inspect all of the skin following admission and document the assessment in the medical record within 24 hours of admission. b. Re-assess the skin routinely per the “Standards of Practice Documentation Grid.” c. Assess pressure points, including under equipment contact sites, and also over bony prominences, such as the sacrum, coccyx, buttocks, heels, ischium (the lower, back part of the hip bone, known as the pelvic bone), trochanters (a bony prominence on the upper part of the femur (thigh) bone, near the hip joint), elbows, and under medical devices. d. When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent (near to) skin. Moistening the skin assists in identifying changes in color. e. Cleanse the skin promptly after episode of incontinence. f. Use skin cleansers that are pH balanced for the skin. g. Avoid positioning patient on an area of erythema (abnormal redness of the skin or mucous membranes) or pressure injury. h. Initiate standard pressure injury prevention(s) per Braden scoring. Interventions may include the following in the “Prevention by Risk Levels” section below (Procedure, section C), and also within the “Wound Bundle reference grid.”...2. Nutrition...3. Moisture Control...4. Pressure Reduction-Positioning...Friction and Shearing Reduction...C. Prevention by Risk Levels...Not at Risk - greater than 18 if no subscale scores of 1 or 2... If the patient scores a 1 or 2 .... implement any of the following interventions... E. Document finding in the EHR... 2. Photograph on discovery, weekly and with significant changes...3 if new pressure injury noted; initiate same pressure injury prevention measures as treatment, obtain a wound consult...4 IRIS (hospital event reporting application)...” During a review of the hospital’s “P&P” titled, “Pressure Injury Risk Assessment, Prevention, Staging and Treatment,” dated 9/13/24, the P&P indicated, “ ...All patients shall be assessed upon admission, then every shift, and with condition changes using the Braden Scale for Predicting Pressure Sore Risk ... Upon identification of a suspected pressure injury ... The pressure injury will be staged by an RN, and they will complete an Incident Reporting Intranet System (IRIS) report ... Develop a plan of care based on the areas of risks, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, positioning, and the support surface. If the risk is from malnutrition, address this problem, etc. ... Inspect all of the skin following admission and document the assessment in the medical record within 24 hours of admission ... Re-assess the skin routinely per the Standards of Practice Documentation Grid ... Initiate standard pressure injury prevention(s) per Braden scoring ... Pressure Reduction-Positioning ... Turn and position all patients ... Staging/Treatment ... Stage all pressure injuries according to amount of tissue loss ... Document finding in the EHR [Electronic Health Record] ... If new pressure injury noted; initiate same pressure injury prevention measures as treatment, obtain a wound consult ...”. During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility’s policy and procedure (P&P) titled, “Pressure Injury Assessment, Prevention, Staging and Treatment”, dated 09/13/24, Section III part A. indicated, Patient’s with a total score of nine or less are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk, for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear. During a review of facility’s policy and procedure (P&P) titled, “Standard of Practice for Emergency Department”, dated 9/23/24, the “P&P” indicated “ ...Maintain and/or improve skin integrity during hospitalization ...through appropriate nursing interventions ... Reposition patient every 2 hours or more frequently ... Obtain a physician’s order for the use of pressure relieving devices when warranted ... Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device ...” During a review of a professional reference titled, “Implementation of Pressure Injury Prevention (PIP) Strategies in Acute Care,” dated May/June 2022, (retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9093720/pdf/wocn-49-211.pdf) the professional reference indicated, “ ... In 2019, the Agency for Healthcare Research and Quality reported that HAPI rates are rising, while all other hospital-acquired conditions are decreasing ... there is room for improvement in the implementation of some of the most basic PI prevention strategies including repositioning, heel elevation, layers of bed linens, nutritional support, and moisture management. Future research should seek to build on the current study by focusing on prospective and longitudinal studies evaluating risk factors and prevention practices in acute care settings to better understand the occurrence of HAPIs in this population as well as provide insight into the potential occurrence of unavoidable PIs (Pressure Injuries)...” The American College of Emergency Physicians policy statement titled, “Boarding of Admitted and Intensive Care Patients in the Emergency Department,” revised February 2023, retrieved 2/19/25 from https://www.acep.org/siteassets/new-pdfs/policy-statements/boarding-of-admitted-and-intensive-care-patients-in-the-emergency-department.pdf, indicated, “ ... Optimal utilization of the emergency department (ED) includes the timely evaluation, management, and stabilization of all patients. Once admitted, patient care is most effectively and safely delivered on inpatient units. Boarding of admitted patients in the ED represents a hospital-wide failure and contributes to lower quality of care, decreased patient safety, reduced timeliness of care, reduced patient satisfaction, an increased number of patients leaving without being seen, and increased mortality. Additionally, it directly contributes to ED crowding due to the resultant loss of bed and resource capacity. ED crowding and its negative impacts on patients are due to misaligned health care economics and financial pressures on hospitals ...” The Joint Commission Journal on Quality and Patient Safety article titled, titled “No More Useless Band-aids that Fail to Solve America’s Emergency Department Boarding Crisis,” dated 12/2023 retrieved 2/19/25 from https://www.jointcommissionjournal.com/article/S1553-7250(23)00234-9/fulltext indicated, “The causes of boarding as well as many proposed solutions have been well described. However, the suggestions are band-aid solutions such as changing ED workflow, surgical schedule smoothing, and alternate care sites, and none of them will alleviate boarding and its harms. Boarding is the manifestation of a dysfunctional health care system with misaligned financial incentives. It is a direct consequence of the United States’ patchwork, profit-driven health care system, not attributable to any single hospital or health care organization. The Journal of Academic Emergency Medicine article titled, “The Association Between Length of Emergency Department Boarding and Mortality” retrieved 2/19/25 from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2011.01236.x, indicated, “ ...ED boarding occurs when insufficient hospital capacity is available for admitted patients to be transferred to inpatient beds. The result is that admitted patients remain in the ED, sometimes for long periods. The concern is that due to competing demands by other patients and general system overload, boarders do not receive the same level of care that they would in inpatient beds. Several recent articles have identified safety issues with boarding, including adverse events, higher rates of ventilator-associated pneumonia, higher mortality rates for intensive care unit (ICU) patients per se, and for admissions overall. There are also higher rates of medication errors and preventable adverse events ...” While daily admissions from the ED will vary somewhat, the typical number can be easily determined from the ED’s historical records. Beds could easily be reserved for these anticipated admissions, and remaining beds could be allocated to elective admissions. Predicting the daily admission needs for the ED to function and serve the community is not a difficult task. We lack the will to do this, not the ability to make it happen. The lack of will arises from hospital administrators having no incentive to reserve space for ED admissions when they can allocate beds to elective admissions that generate higher profit. In both for-profit and not-for-profit ...” hospitals-which account for the overwhelming majority of annual acute inpatient admissions in the United States-the C-suite is tasked with remaining fiscally solvent. To do so, they favor patients with the kinds of insurance and the kinds of medical conditions that provide lucrative reimbursement for short lengths of stay. In following this strategy, admitted ED patients are queued up in the ED, occupying rooms and halls that need to be available to the patients in the ED waiting room. Consequently, our healthcare system caters better to a regional patient in need of advanced oncology therapy, organ transplant, or complex surgery than a local community member who presents to the ED with pneumonia or congestive heart failure who may find that emergency medical services cannot take them to their preferred hospital because its ED is diverting due to saturation. Boarding is a driver of ambulance diversion and leads to further inequities and disparities.15-21 Our healthcare system does not value care of the most vulnerable.22 While many factors contribute to the lack of acute inpatient psychiatric stabilization beds, a reimbursement system that undervalues such care is a major factor.23 Individuals suffering a mental health crisis experience some of the most egregious prolonged boarding in EDs awaiting acute inpatient psychiatric beds.24-27 2. During a concurrent interview and record review on 1/28/25 at 10:25 a.m. with Nurse Manager (NM) 5 in L&D, the “L&D Crash Cart Check Sheet (CCC, a sheet for daily check of the presence of essential supplies and function of equipment is recorded)”, dated January 2025, was reviewed. The “CCC” indicated the checklist columns for all equipment and supplies for 1/5/25 and 1/10/25 were blank. NM 5 stated, “ ... It looks like they [staff who were to check the cart] missed it ...” and stated the cart should have been checked daily. During an interview on 2/5/25 at 9:42 a.m. with the Chief Nursing Officer (CNO), the CNO stated the expectation was for Crash Cart Checks to be performed daily on every Crash Cart. The CNO stated if Crash Carts were not checked daily, the supplies or equipment needed in an emergency might be unavailable and could result in a negative patient outcome (harm or death). During a review of the “CB”, the “CB” indicated, ’ ... External crash cart checks [items on the outside of the cart], including defibrillator [a device that applies an electrical charge to the heart to restore a normal heartbeat] battery checks ...are to be completed at least every 24 hours ... Crash Cart Checks ... Perform external checks, including defibrillator testing, at least every 24 hours ... Document these checks using the Crash Cart Check Sheet, if the unit is closed [no patients or staff on the unit], document ‘unit closed’ on the check sheet ... Document crash cart checks on the Crash Cart Check Sheet ...” 3. During a review of Pt 43’s “Emergency Department Provider Notes [EDPN- assessment from physician including medical history and exam]” dated 2/1/25, the “EDPN” indicated Pt 43 was admitted on 2/1/25 at 10:16 p.m. for Psychiatric 5150 Danger to Self [a state law that allows law enforcement and mental health professionals to detain someone for 72 hours for a mental health evaluation and treatment] (found by police walking barefoot through traffic with bleeding on face and hands and holding onto rose with thorns). Pt 43 had abrasions (scrapes) to the face, both hands and both feet. Pt 43 had a flat affect (absent display of emotions), and poor eye contact. Pt 43’s visit diagnosis was bizarre (very strange or unusual) behavior and closed displaced fracture (bone break not through the skin) of fifth metacarpal (connects the pinkie finger to the palm) bone of left hand. During a review of Pt 43’s “ED Care Timeline [EDCT],” dated 2/1/25 to 2/2/25, the “EDCT” indicated, Pt 43 was moved to the SCU [Special Care Unit- is a locked unit within the Emergency Department (ED) where patients who are in a psychiatric or behavioral emergency and do not require complex medical treatments are placed] on 2/1/25 at 10:16 p.m. The “EDCT” indicated, on 2/1/25 at 10:41 p.m. a head-to-toe assessment was completed by LNs indicating Pt 43 had cuts and redness to both hands, his face, his left knee, and left foot. The “EDCT” indicated, at 11:30 p.m. “ ... ED Notes: Writer and secondary RN entered SCU and attempted to clean pt’s open wounds. Pt refused care, pt states “I like the wounds how they are, I like to walk around barefoot, I don’t want them cleaned. I have a right to say no ...” The “EDCT” indicated, on 2/1/25 at 11:33 p.m. Pt 43 was a flight risk (attempt to leave unit) and during Pt 43’s psychiatric assessment he was withdrawn (avoiding interaction), preoccupied (distracted), and guarded (cautious). The “EDCT” indicated, Pt 43’s general attitude was suspicious, and he was a low risk for violence on the violence assessment tool (tool used to assess risk for violence). The “EDCT” indicated, on 2/1/25 from 11:45 p.m. to 2/2/25 at 1:30 a.m. documented under “Continuous Observation” Pt 43 was awake, lying down, and quiet or awake lying down talking to staff. The “EDCT” indicated, on 2/2/25 at 1:19 a.m. an ED Note by RN 13: “ ... Writer attempted to initiate splint [medical device used to support and immobilize an injured body part] application process. Pt refused splint application. Writer explained benefits and risk of ignoring medical treatment and application of medical equipment. Pt states that he is going to hell regardless so there is no point “it is what it is” ... MD notified. Awaiting orders and further plan of care ...” The “EDCT” indicated, on 2/2/25 1:45 a.m. Pt 43 was “... Awake; Abusive to staff; Agitated (uneasiness, nervous); Evidence of harmful behavior (verbal or actions) (Patient assaulted officer. Pt being placed in four-point [both wrists and ankle] restraints [preventing movement of body and limbs]) ...”. The “EDCT” indicated, on 2/2/25 at 1:48 a.m. orders were placed for violent restraints, and 5 milligram (mg- a unit of measurement) haloperidol (medication used to treat agitation, and irritability) injection (a shot with a needle to give medication), 50 mg diphenhydramine (medication causes sedation) injection and 2 mg lorazepam (medication to treat anxiety and nervousness) injection were ordered. The “EDCT” indicated, 2/2/25 at 2:46 a.m. an ED note addendum documented by Registered Nurse (RN) 13 “ ...Writer witnessed pt [Pt 43] approached SCU door, security officer opened the door and spoke to pt. Pt assaulted [make a physical attack on] security officer at this time and officer was able to close the door at this time. Pt hitting body against door and barricaded [blocked] himself against the door. Code assessment was called overhead at this time, MD was also notified. Pt began to escalate [increase rapidly] in behaviors, became increasingly agitated. Security stepped in to carry out 4-point restraint orders. Pt restrained to gurney; bed wheels unlocked. Restraints applied on wrist. Prior left-hand injury at admission, restraint applied to lower wrist, hand in neutral position resting on the gurney. Medication orders were also carried out. Pt still agitated at this time ...”. The “EDCT” indicated, 2/2/25 at 4:15 a.m. Pt 43’s vital signs were taken by a Certified Nursing Assistant (CNA). The “EDCT” indicated, the next complete patient assessment was documented on 2/2/25 at 8:00 a.m. by a RN. The “EDCT” did not contain any reference to the use of a taser on Pt 43 and did not contain a head-to-toe assessment of Pt 43 by RN 13 after the taser strike. During a review of Pt 43’s “EDPN Continued”, dated 2/2/25 no time on documentation, the “EDPN Continued” indicated, “ ... The following face to face evaluation was performed within 1 hour of the patient being placed in restraints. Unable to obtain review of systems due to patient condition. The behavioral assessment indicates danger to self, danger to others, violent. I reviewed and assessed patient’s history, drugs and labs if available and determined that there are no immediately reversible conditions. The patient’s medical and behavioral condition and reaction to the intervention continued attempts or displays of harmful behaviors. I have determined the need to continue the restraint or seclusion ...” Pt 43’s medical record did not contain any reference of taser use and did not contain any “EDPN” with an assessment by a physician after the taser strike. During a telephone interview with RN 13 on 2/4/25 at 3 p.m. RN 13 stated, she was Pt 43’s primary nurse on the night of 2/1/25 and morning of 2/2/25. RN 13 stated, she remembered the incident when Pt 43 was tased. RN 13 stated, four officers went into the room and surrounded the patient. RN 13 stated, one officer had their taser drawn before they entered the room, as soon as the officer lowered the taser, Pt 43 grabbed his legs and RN 13 saw the taser fire. RN 13 stated, she looked at Pt 43’s skin after the incident and he had dried blood, but there were no taser prongs stuck in his skin. RN 13 stated Pt 43 “may or may not have been tased”. RN 13 stated, she saw the taser deployed, but did not see where the prongs struck Pt 43, or see any prong removed from Pt 43. RN 13 stated, she did not document the taser use, and the officers did not tell her where Pt 43 was struck with the prongs. RN 13 stated, she administered the ordered medications after Pt 43 was restrained on the gurney. RN 13 stated, Pt 43’s physician did not come and assess the patient after the taser strike. RN 13 stated, she did not complete a head-to-toe assessment on Pt 43 after the incident, but his respirations remained equal and unlabored (breathing normally). During an interview on 2/4/25 at 3:40 p.m. with Emergency Department Manager (EDM) 1, EDM 1 stated, there was no documentation in Pt 43’s medical record indicating Pt 43 was tased. EDM 1 did not say why RN 13 did not document the taser strike to Pt 43. During a concurrent observation and interview on 2/5/25 at 7:39 a.m. with SO1, SO1 had no bruising around her left eye. SO1 had a bandage to the back of her left hand. SO1 stated, her left eye was still tender to the touch. SO1 stated, her left hand still had two small puncture wounds. SO1 stated, she worked the overnight shift on 2/1/25 to 2/2/25 and recalled the incident with Pt 43. SO1 stated, she saw Pt 43 approach the door and he knocked. SO1 stated, Pt 43 was mumbling, so she opened the door a crack, and Pt 43 struck her with his palm through the door crack. SO1 stated, she pulled the door closed and called the SWC to report the incident and get additional officers to the area. SO1 the SWC told the officers if Pt 43 attacked anyone, “I’m going to pop him (clarified this meant he would tase Pt 43)”. SO1 stated, the SWC removed his taser from the holster, turned the taser camera on, and pointed the taser at Pt 43. SO1 stated, the SWC fired the taser at Pt 43. SO1 stated, one of the taser prongs hit her left hand and she informed the SWC she had been hit. SO1 stated, she did not know if the other prong hit Pt 43. SO1 stated, she removed the wire and prong from her hand and continued restraining Pt 43. SO1 stated she was then seen as a patient in the ED where the physician bandaged her hand and sent her for a Computed Tomography (CT - medical imaging procedure using X-Rays and a computer to create detailed pictures inside the body). During an interview on 2/5/25 at 8:06 a.m. with SO2, SO2 stated, he recalled the events from the overnight shift on 2/1/25 p.m. to 2/2/25 a.m. with Pt 43. SO2 stated, the plan was to enter the room two officers per door. SO2 arrived to the SCU area and Pt 43 was sitting on the floor, with his arms up and hands balled into fists next to his head. SO2 stated, the SWC “said something about a taser” but SO2 could not hear him because of the background noise around the unit. SO2 stated, SO1 and the SWC entered the door on the North and the SWC had his taser drawn. SO2 stated, him and SO3 entered through the West door. SO2 stated, after all officers entered the room and began surrounding Pt 43, Pt 43 grabbed for the SWC’s leg and the SWC fired the taser at Pt 43. SO2 stated, he assumed the taser hit Pt 43. SO2 stated, he heard SO1 announce twice she was hit by a taser prong. SO2 stated, SO1 removed the prong from her hand. SO2 stated, the officers continued applying restraints to Pt 43’s arms and legs. SO2 stated he was aware Pt 43 had a fracture in his hand, and he was trying not to manipulate (move around) his hand too much. SO2 stated he was applying the restraints to Pt 43’s arms and Pt 43’s hand was bleeding. SO2 stated, he could not see clearly where Pt 43 was hit by the taser prong. During an interview on 2/5/25 at 8:24 a.m. with SO3, SO3 stated, he responded to the SCU when he heard the call for officer response over the radio. SO3 stated the SWC told him to go get restraints. SO3 stated the officers were given directives to open both doors at the same time and approach the patient. SO3 stated, the four security officers entered the SCU and the SWC had his taser drawn. SO3 stated Pt 43 had gone silent. SO3 stated the SWC fired his taser hitting Pt 43 with one prong in his midsection and the other prong hit SO1 in her left hand. SO3 stated, he did not recall who removed the taser prong from Pt 43’s midsection. During an Interview on 2/5/25 at 8:51 a.m. with SOM, the SOM stated, the taser should not have been removed from the holster before Pt 43 grabbed the SWC’s leg. The SOM stated, the SWC did not follow hospital Policy and Procedure in many ways during the incident. The SOM stated, when a taser was discharged a clinical assessment of Pt 43 should have been done. The SOM stated the SWC did not notify RN 13 the taser hit Pt 43, which led to RN 13 not completing a clinical assessment and not notifying the physician. The SOM stated the SWC did not take photographs the site where Pt 43 was hit by the taser as policy dictated. During a review of the hospital’s P&P titled, “Standard of Practice Emergency Department,” dated 9/23/24, the P&P indicated “ ... STANDARD OF PRACTICE: Safety, Medication, IV Therapy, Infection Control. The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: ... Adhere to all established [Name of Hospital] policies/procedures ... Intervene appropriately to correct unsafe situations ... Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order ... Documentation on the Emergency Department Electronic Health Record (EHR) will reflect assessment of the patient’s status and needs ... system specific assessment at the onset of patient treatment with ongoing assessment dependent upon patient condition and response to treatment ... Advise the physician of any alterations in the patient’s psychological and/or physiological condition ...”. During a review of the hospital’s P&P titled, “Documentation in the Health Record,” dated 6/14/2018, the P&P indicated, “ ... PURPOSE ... To provide a complete record of patient care and patient progress ... To facilitate communication among care providers and enhance continuity of care ... To provide a legal record of patient care ... All care providers caring for the patient are to document within their scope of practice/job description ... All patient care and activities are to be documented at the time care is provided ...”. During a review of the hospital’s Policy and Procedure (P&P) titled, “Taser Usage,” dated 1/8/25, the P&P indicated, “ ... The use of a TASER by security staff is considered a law enforcement action, not a health care intervention The purpose of this policy is to establish guidelines for the deployment and use of the a TASER by Security Services Staff ... [Name of hospital] does not support the use of a TASER by any hospital staff as a means of achieving a clinical objective, including but not limited to, subduing a patient in order to place that patient in restraints or seclusion ... Deploy/Deployment - The removal of a device from its carrying holster for display or use. The actual application or discharge of a tool or device, such as the TASER, is not required to be considered deployment ... Application - The firing of projectile probes regardless if contact with an individual is made or the application of a drive stun to an individual ... Tactical Deployment ... Prior to discharging the TASER, the officer shall loudly announce “TASER” when the circumstances allow, to notify everyone that the TASER is being fired ... AFTER DISCHARGE RESPONSIBILITIES ... [Name of hospital] will contact local law enforcement and request that the person is taken into law enforcement custody ... The identification of the utilized TASER shall be identified in the documentation. ... After the subject has been taken into custody/control, security staff shall: ... Ensure the person’s injuries are promptly examined by clinical staff and any embedded probes are Removed ... Appropriate photographs should be taken to document the incident and any injuries that may have been sustained from the use of a TASER ... After each TASER deployment, the shift supervisor and manager shall review all documentation to evaluate the appropriateness for the deployment. All TASER deployment reviews shall be completed by the Use of Force Review Board as defined by the Use of Force policy ...”. During a review of a professional reference titled, “Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study,” dated 2/16/23, the professional article indicated, “ ... Documentation is a standard way of keeping ongoing patient care information. It is the relevant facts of routine health information and patient care plans, such as professionals’ evaluation and judgement about the patients, evaluation charts, tests, reports, subjective notes or professionals’ reflections ... Documenting routine practices is essential for the continuity of patient care, ... communication among healthcare professionals and better patient diagnoses and treatments ... it should be patient-focused, accurate, relevant, clear, permanent, confidential and timely ... Poor documentation practice affects patient management, continuity of patient care and medicolegal [medical and legal] issues, which arise from incomplete and inadequate documentation, lack of accuracy and poor quality. It leads to adverse patient outcomes, medication errors and patient deaths. Distorted health information may influence health professionals’ decision-making capabilities due to inappropriate and misleading documentation practices ...”. During a review of a professional reference titled, “Heart attack from a Taser: What You Need to Know,” dated 3/20/23, (retrieved from https://www.healthline.com/health/heart-attack/heart-impact-from-taser), the professional article indicated, “ ... Aside from the risk of a taser encounter leading to serious arrhythmia and cardiac arrest (heart stops beating), one other effect can be an injury from falling. A person who experiences the taser strike may fall to the ground and hit their head or injure another body part ... a tasers darts can lodge in the skin, and medical professionals must remove them carefully ... Tests may include an electrocardiogram (a record or display of a person’s heartbeat) to assess the heart’s electrical activity and other cardiac (heart) monitoring ... Aside from the risk of a taser encounter leading to serious arrhythmia and cardiac arrest, one other effect can be an injury from falling. A person who experiences the taser strike may fall to the ground and hit their head or injure another body part ...”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49884 Based on observations, interviews and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures, CDC and clinical standards of practice for infection control when: 1. The Nursery Unit (an area in the hospital where newborn babies are cared for) soiled utility room (a room designated to store waste products, soiled items, and used medical equipment) cabinet stored an open package of unused disposable diapers and an unused package of baby wipes. The Inpatient Surgical Unit (an area in the hospital where patients who require surgery are cared for) soiled utility room cabinet stored two unused white specimen buckets (a container used to store and transport patient specimens removed from surgery for laboratory testing). The Outpatient Endoscopy Unit (an outpatient center that serves patient needing endoscopic procedure- allows doctor to see inside the body without a performing major surgery) soiled utility room cabinet stored four unopened containers of a spill control product (a material designed to contain and absorb liquid spills). The Peri-Operative Unit (is a hospital unit that provides care to patients before, during, and after surgery) soiled utility room cabinet stored a plastic bag containing new unopened cleaning supplies including, two bottles of a rust remover product, one bottle of a liquid cleanser, and several scrubbing pads. 2. The Outpatient Surgical Unit clean supply room two packages of tissue traps (disposable collection devices used in surgery, tissue and fluids are vacuumed into container for disposal), and a package of sterile gloves inside a blue container were found on the floor between the wire racks which stored clean and sterile operating room supplies. These failures resulted to significantly increasing the potential risk for cross contamination (the transfer of harmful bacteria from one place, object, or person to another with harmful effect) which could harm patients. 3. RN 12 failed to perform hand hygiene during Pt 26’s surgery prior to entering the Operating Room (OR), upon donning and doffing gloves, and touching both Patient 26 and OR equipment/areas. This failure was a serious breach of aseptic technique (germ free condition) and significantly increases the risk for Pt 26 for an infection due to the potential contamination transfer from RN 12’s hands to Pt 26 and the sterile environment (free of germs). 4. Intravenous lines (IV) infusing medications were not labeled with a date to be changed for four of 46 patients (Pt - patients 30, 32, 45, and 46). This failure had the potential to put Pt 30, Pt 32, Pt 45, and Pt 46 at risk of infection from contaminated IV lines. Findings: 1. During a concurrent observation and interview on 1/28/25 at 11 a.m. with Nurse Manager (NM) 6 in the Nursery Unit soiled utility room, the cabinet stored an open package of unused disposable diapers and unused baby wipes. Nurse Manager (NM) 6 stated the diaper and wipes should not have been stored in the soiled utility room and were not suitable for patient use any longer due to the risk of infection by cross contamination (the spread of harmful bacteria or viruses form one place or thing to another) that could spread infection. During a concurrent observation and interview on 1/28/25 at 2:25 p.m. with NM 7 in the Inpatient Surgical Department soiled utility room, the cabinet stored two white specimen buckets. NM 7 stated the specimen buckets was unused and should not be stored in the soiled utility room. NM 7 stated, anything stored in the soiled utility room was considered dirty. During a concurrent observation and interview on 1/28/25 at 2:50 p.m. with NM 10 in the Outpatient Endoscopy Department soiled utility room, the cabinet stored four unopened containers of a foam spill control product. NM 10 stated, anything in the soiled utility room was considered dirty. NM 10 stated, using products from the soiled utility room for patients had a potential risk for cross contamination and could result to an infection. During a concurrent observation and interview on 1/28/25 at 3:30 p.m. with Clinical Supervisor (CS) 3 in the Peri-Operative Department soiled utility room, the cabinet stored a plastic bag with new unopened cleaning supplies including, two bottles of a rust remover product, one bottle of a liquid cleanser, and several scrubbing pads. CS 3 stated, the items should not be stored in the soiled utility room cabinets. CS 3 stated the items were now considered contaminated and should not be used. CS 3 stated, using the products had the potential for cross contamination. During an interview on 2/4/25 at 1:04 p.m. with the Director of Infection Prevention (DIP), the DIP stated, supplies intended for patient use should not be stored in a soiled utility room because the soiled utility room was a dirty area, and the hospital needed to ensure items used for patients were clean. During an interview on 2/5/25 at 9:43 a.m. with the Chief Nursing Officer (CNO), the CNO stated once patient care items are in the soiled utility room, the items were considered dirty and not suitable for patient use due to the risk for infection. During the review of professional reference titled, “What is the difference between a clean and dirty utility room? (WID)”, dated 9/4/18, the “WID” indicated, “ ... ‘Dirty’ doesn’t refer to visible mess. It simply means a patient has come into contact with the item, so it either needs to be made sanitary for the next use or disposed of completely. When items from the clean utility room are sent to a patient, the dirty utility room (or sluice room) is where the used items end up, in order to be cleaned or disposed of. Generally, these will be containers which have been used to collect and hold human waste. If waste items aren’t managed correctly, adhering to thorough infection control guidelines, they can become a serious HCAI [Healthcare-associated infection, infection resulting from a healthcare intervention] risk. So, this is where the reference to ‘dirty’ comes into play - potentially, these utensils can harbor microbes which are extremely dangerous if allowed to spread ...”. 2. During a concurrent observation and interview on 1/28/25 at 2:33 p.m. with the Director of Operations (DO) and The Director of Supply Chain (DSC), in the Outpatient Surgery Department supply room, two packages of tissue traps, and a packaged of sterile gloves inside a blue container, were found on the floor between the wire racks which stored packaged clean and sterile operating room supplies. The DO stated, the supplies should not be on the floor. The DSC stated, supplies should not be used in the operating room for patient surgeries after being on the floor. The DSC stated the reason not to use surgical supplies from the floor was to prevent the spread of infection. During an interview on 2/4/25 at 1:06 p.m. with Infection Prevention Manager (IPM), the IPM stated, the OR supplies found on the floor should not be used in the OR for patients and should be discarded. The IPM stated, the OR supplies found on the floor could carry microorganisms into the patient’s OR environment and had the potential to cause an infection. During an interview on 2/5/25 at 9:40 a.m. with the CNO, the CNO stated, her expectations was for clean supplies should be stored in a way that protects from contamination and should not be on floor. The CNO stated, clean supplies found on the floor should not be use on patients and should be discarded. During a review of the professional reference titled, “The role of the surface environment in healthcare-associated infections”, dated August 2013, the professional reference indicated, “ ...Hospital surfaces are frequently contaminated with important healthcare-associated pathogens (bacteria). Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider’s hands or gloves that may result in patient-to-patient transmission of nosocomial (originating from the hospital) pathogens ...” During a review of the professional reference titled, “Good Storage and Distribution Practices for Medical Products”, (retrieved from https://www.who.int/publications/m/item/trs-1025-annex-7) dated 6/17/20, the professional reference indicated, “ ...Storage and distribution are important activities in the supply chain management of medical products ... Storage areas should be of sufficient capacity to allow orderly storage of the various categories of medical products ... Storage areas should be appropriately designed, constructed, maintained or adapted. They should be kept clean and there should be sufficient space and lighting ... Materials and medical products should be stored off the floor, away from walls and ceilings, protected from direct sunlight and suitably spaced, to permit ventilation, cleaning and inspection ... Materials and medical products should be handled and stored in such a manner as to prevent contamination, mix-ups and cross-contamination ...” During a review of the professional reference titled, “Keeping it Sterile: Fundamentals of Sterile Storage,” (retrieved from https://www.ormanager.com/keeping-it-sterile-fundamentals-of-sterile-storage/) dated 7/20/23, the professional reference indicated, “ ... Using sterile items in surgery is a fundamental practice, not a rudimentary one that can or should be taken for granted. Put simply, using unsterile items can result in a patient infection. If sterile storage conditions are not appropriate, the items can become contaminated. Such contamination may go undetected, rendering items unsafe and unusable. Therefore, healthcare facilities must take action to create an environment that properly protects sterile packages. This includes securing a proper sterile storage environment and developing policies and procedures to help ensure sterile packages are safely stored and handled ... Sterile packages should be handled with care and positioned so they are not crushed, bent, compressed, or punctured. Sterile items should never be stored on floors ...” 3. During an observation on 1/31/25 at 4:47 p.m. in OR 1, RN 12 was assigned as the Circulating RN (manages the overall flow of a surgical procedure and ensure patient safety) for Pt 26’s surgery. RN 12 entered the OR and did not perform hand hygiene prior to donning (put on) gloves and was observed collecting and preparing surgical supplies for Pt 26 surgical procedure. RN 12 with gloved hands touch Pt 26’s legs and positioned on to the stirrups (devices that position a patient’s legs), RN 12 moved a small portable table which hold surgical instruments and surgical supplies closer to Pt 26. RN 12 placed the packaged of antiseptic skin prep (a cleaning solution used to decrease surgical site infection) on the surgical stand and open the package. RN 12 moved the trash container closer to the surgical area and the trash lid was used as a tabletop. RN 12 doffed (removed) her gloves and did not perform hand hygiene and proceeded to open the plastic package of a sterile gloves and donned sterile gloves. RN 12 cleaned and disinfect Pt 26’s surgical site with betadine (an antiseptic used to prevent infection), and after disinfecting the surgical site RN 12 doffed her sterile gloves and did not perform hand hygiene. RN 12 reached to her pocket for her phone, pushed the buttons, and returned the phone to her pocket. RN 12 was typing on the computer with ungloved hands, and after proceeded to donned sterile gloves without performing hand hygiene. RN 12 plugged a tube with irrigation fluids for Pt 26’ surgery, and after went back to typing on the computer with gloves, then touched the light control switch on the wall. After Pt 26’s surgery was completed, RN 12 doffed her gloves and donned new gloves without performing hand hygiene, and transported Pt 26 to the Post Operative Unit. During review of Pt 26’s “History & Physical (H&P- an assessment from physician including medical history and exam),” dated 1/27/25, the “H&P” indicated, Pt 26 was a female presenting to the physician’s office with a chief complaint of preoperative exam for a scheduled surgery on 1/31/25. Pt 26’s scheduled surgery was an operative dilation and curettage (D&C-small instruments are used to open the lower narrow part of the womb, hysteroscopy (an exam of the inside of the womb, with a narrow telescope with a light and camera). During an interview on 1/31/25 at 5:25 p.m. with RN 12, RN 12 stated, RN 12 stated “I forget sometimes” to do hand hygiene between glove changes. RN 12 stated it was important to remember to clean hands by performing hand hygiene to not give the patient an infection. During an interview on 1/31/25 at 5:28 p.m. with the Director of Surgery (DS), the DS stated, applying hand sanitizing gel before and after gloving was important, to prevent infection. During an interview on 2/4/25 at 1:15 p.m. with the IPM, the IPM stated, the expectation for OR staff to perform hand hygiene, before touching a patient, after touching a patient, before putting on gloves and after taking off gloves. The IPM stated, hands could potentially be contaminated at any time. The IPM stated, performing hand hygiene prevents introducing microorganisms to the patients. During a review of the hospital’s Policy and Procedure titled, “Hand Hygiene,” dated 4/14/22, the P&P indicated, “ ...The purpose of this policy is to promote effective hand hygiene practices and reduce the transmission of microorganisms amongst patients, personnel and visitors ... Hand hygiene - A general term referring to any action of hand cleansing ... Hand hygiene is the single most important means of preventing the spread of infection and is to be performed in any interaction where transmission of microorganisms is possible ... At [Name of Hospital] the expectation is that all healthcare personnel will perform hand hygiene following World Health Organization (WHO) guidelines ... Indications for hand hygiene:1. Before and after touching the patient 2. Before handling an invasive device for patient care, regardless of whether or not gloves are used 3. Before donning sterile or non-sterile gloves 4. After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings 5. If moving from contaminated body site to another body site during care of the same patient 6. After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient 7. After removing sterile or non-sterile gloves ... Hand hygiene can be accomplished by hand washing with soap and water or using an alcohol-based hand rub ... Use of gloves ... The use of gloves does not replace the need for hand hygiene by either hand rubbing or handwashing. ... When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to either another body site (including non-intact skin, mucous membrane or medical device) within the same patient or the environment ...”. During a review of professional reference from the CDC titled, “Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, the professional reference indicated, “ ... Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with Handwashing with water and soap (e.g., plain soap or with an antiseptic). Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) ... Cleaning your hands reduces: The potential spread of deadly germs to patients. The spread of germs, including those resistant to antibiotics ... Know when to clean your hands ... Immediately before touching a patient ... Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices ... Before moving from work on a soiled body site to a clean body site on the same patient ... After touching a patient or patient’s surroundings ... After contact with blood, body fluids, or contaminated surfaces ... Immediately after glove removal ...” 4. During a concurrent observation and interview on 1/28/25 at 10:45 a.m. with the Inpatient Cardiovascular Services Director (ICSD) and RN 22 in Intensive Care Unit (ICU), observed RN 22 caring for Pt 32 at bedside. Observed intravenous (IV) tubing infusing an antibiotic. The tubing had a sticker attached that indicated tubing was to be changed “Saturday” but not a date. There was a line on the sticker that indicated, “date” but no date was filled in. I asked RN 22 how she knew if it needed to be changed this coming Saturday, or if it should have been changed last Saturday. RN 22 stated this information is shared nurse-to-nurse during shift change. The ICSD stated they have been discussing whether the labels should have a date or not and stated this is “going to Professional Practice Council for discussion.” During a concurrent observation and interview on 1/28/25 at 10:49 a.m. with the ICDS and RN 21 in the Intensive Care Unit (ICU), observed RN 21 caring for Pt 30 at bedside. RN 21 was in the room changing the IV line for propofol (a powerful anesthetic and sedative.) Observed CRRT was also in process (Continuous Renal Replacement Therapy is a type of dialysis - dialysis does the work of the kidneys when a patient has a serious kidney disease or injury) and fentanyl (a powerful pain reliever) was infusing. All the IV tubing lines were labeled with stickers indicating the day of the week the line was to be changed, but not a date. RN 21 said, “that’s how we do it. Different days have different colored labels, so it makes it easy to see what lines you need to change on your shift.” She said some lines have to be changed every day, and others can go longer. During a concurrent observation and interview on 2/3/25 at 10:55 a.m. with the Clinical Supervisor (CS) 2 in the Intensive Care Unit (ICU), we entered the room of Pt 45. Observed one bag of IV fluid labeled Lactated Ringers (replaces fluids and electrolytes). There was a sticker on the IV tubing that indicated, “change Saturday” with no date to indicate if it should have been changed last Saturday or if it needs to be changed next Saturday. Observed one bag of piperacillin/ tazobactam (an antibiotic) with a sticker on the IV tubing that indicated, “Change Sunday” with no date to indicate if it should have been changed last Saturday or if it needs to be changed next Sunday. Observed one bag labeled vancomycin (an antibiotic) with a sticker on the IV tubing that indicated, “change Thursday” with no date to indicate if it should have been changed last Thursday or if it needs to be changed next Thursday. CS2 stated labeling with just the day and not the date is the current practice. During a concurrent observation and interview on 2/3/25 at 10:59 a.m., entered the room of Pt 46 with CS 2. Observed one bag of fentanyl with sticker on the IV tubing that indicated, “Change Wednesday” with no date to indicate if it should have been changed last Wednesday or if it needs to be changed next Wednesday. Observed one bag labeled dexmedetomidine which CS 2 stated was a sedative. There was a sticker on the IV tubing that indicated, “change Wednesday” with no date to indicate if it should have been changed last Wednesday or if it needs to be changed next Wednesday. During an interview on 2/3/25 at 11:05 a.m. with the ICU Manager (NM3), NM3 stated the lines are to be labeled with a sticker indicating the day the tubing is to be changed, not the date. NM3 stated this is their practice, and he believed this was consistent with their policy. During an interview on 2/4/25 at 1:03 pm with the Director of Inpatient Safety and Infection Prevention (DIP) the DIP stated it is important for IV lines to be changed because it could put the patient at risk of an infection. The DIP stated some IV lines need to be changed more often for some medications, so an actual date on the label is important to make it clear when the line is due to be changed. During an interview on 2/5/25 at 9:38 a.m. with the CNO, the CNO stated she was aware that there are different practices for labeling IV tubing in the hospital. The CNO stated, “IV tubing labels should have a date on them. I expect nurses to follow the policy.” During a review of hospital policy titled, “Intravenous Tubing Changes, Intermittent Infusion Devices & IV Sites,” dated 06/14/2024, the policy indicated, “ ... V. PROCEDURE ... C. Label new IV tubing with date to be changed.””

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 49884 Based on interview and record review, the hospital failed to ensure prevention of surgical errors for one of three patients, Patient (Pt) 6, when Pt 6 was consented for a left reverse total shoulder arthroplasty (shoulder joints replaced with artificial parts, reversing the normal ball and socket structure) surgery and Anesthesia Medical Doctor (AMD) 1 ordered a left shoulder nerve block (a procedure that numbs the nerves in the shoulder area, providing pain relief) and did not verify correct surgical site in accordance with the hospital’s policy and procedure (P&P) titled “Universal Protocol - Procedural Areas” before performing a right shoulder nerve block. Medical Doctor (MD) 2 informed the family of the error of the nerve block to the wrong side and obtained consent to perform the left shoulder arthroplasty with local anesthesia to the left shoulder and Pt 6 under general anesthesia. These failures led to Pt 6 receiving the wrong-side nerve block to the right shoulder and avoidable pain and suffering and non-use of the right shoulder. This failure resulted in Pt 6 being under general anesthesia longer than expected, potentially causing inadequate post-operative pain relief, the need to administer opiates (strong pain medication) for pain, possibly unnecessarily; and the error required an unplanned overnight hospital stay. Findings: During a concurrent interview and record review on 1/29/25 at 2:23 p.m. with Nurse Manager (NM) 7, Patient 6’s “History & Physical (H&P- an assessment from a physician including medical history and exam),” dated 12/2/25 was reviewed. The “H&P” indicated, Pt 6 was 71 years old and presented to the hospital on 12/2/24 for surgery. The “H&P” indicated, Pt 6’s medical condition requiring surgery was, primary osteoarthritis (degenerative joint disease that affects the cartilage that cushions the ends of bones) of left shoulder, and left glenohumeral (ball and socket joint that connects the upper end of arm bone to the socket of shoulder blade) arthritis (inflammation of joints).The “H&P,” indicated Pt 6, “ ... is indicated for reverse total shoulder arthroplasty [a surgical procedure that replaces the shoulder joint with artificial parts, reversing the normal ball-and-socket structure]. [Pt 6] was explained the risks, benefits, and alternatives ... The patient is consented [gave permission] for left reverse total shoulder arthroplasty ...”. NM 7 stated the operating physician spoke with the patient in the pre-operative unit (are in the hospital where patients are prepared for surgery) to answer any questions, ensure all consents have been signed, and mark the surgical site with a skin marker. During a review of Pt 6’s “Anesthesia Preprocedure Evaluation [APE- assess a patient’s medical history and current condition to determine if they can tolerate anesthesia (a medical intervention that prevents pain during procedures) for surgery],” dated 12/2/24 at 8:16 a.m., the “APE” indicated, Anesthesia Medical Doctor (AMD) 1 completed a physical exam of Pt 6 on 12/2/24 at 8:16 a.m. The “APE” indicated Pt 1’s anesthesia plan was general anesthesia (medication causing loss of feeling and awareness like a deep sleep), a left sided interscalene block (an injection of medication that numbs the bundle of nerves that extend to the upper arms, hands and shoulders), and a left sided peripheral nerve block (a needle injects numbing medication near specific nerves in shoulder region, blocking pain signals). The “APE” indicated, “ ... Informed Consent [AMD 1] have discussed the planned anesthesia care with the patient and/or legal representative, including the following: the nature and purpose of the planned anesthesia; the risks, benefits and side effects of the planned anesthesia; alternatives for the planned anesthesia and their associated risks, benefits, and side effects ... The patient and/or legal representative demonstrated understanding of the information provided. After careful consideration, the patient and/or legal representative agreed to proceed with the planned anesthesia care ...”. During a review of “Orders,” dated 11/25/25, the “Orders” indicated, “ ... Anesthesia Services per Assessment and Plan ... Ordering Provider: [Medical Doctor (MD) 2] ... Written ... 12/2/24 0755 [7:55 a.m.] ...”. During a review of “Anesthesia Orders [AO],” dated 12/2/25, the “AO” indicated, “ ... Peripheral Nerve Block ... Ordering Provider: AMD 1 ... 12/2/24 0820 [8:20 a.m.] ... Indications ... at surgeon’s request and post-op pain management ...”. During a review of Pt 6’s “Progress Note [PN],” dated 12/2/25 at 2:06 p.m., the “PN” documented by MD 2 indicated, “ ... Upon entering the OR [Operating Room], after the nerve block had been performed, I was notified that the block had inadvertently [accidentally] been completed on the contralateral [opposite] side. After thorough discussion with the attending anesthesiologist, it was decided that a nerve block would not be performed on the ipsilateral [same side of body as surgery] shoulder due to risk of phrenic nerve palsy [when the nerve that controls the diaphragm (controls breathing) is incapable of movement] and need for continued ventilation [machine assisted breathing] after the completion of the surgery. I discussed the issue with the patient’s son prior to prepping [cleaning the surgical site to remove germs] and draping [putting a sterile barrier around surgical site] the patient and he expressed understanding of the error that was made. I discussed that we would still proceed with the planned procedure on the left shoulder and keep the patient overnight as both of her upper extremities (arms) would have limited use and she would need increased help with personal hygiene, feeding herself, and completing ADLs (activities of daily living, dressing, bathing, eating). He expressed understanding of the plan and I re-entered the OR around 1130 am to continue prepping and draping for the procedure on the left shoulder. The procedure on the left shoulder commenced at 1157 am ...” During a review of Pt 6’s “Anesthesia Progress Note [APN],” dated 12/2/25 at 2:50 p.m., the “APN” indicated, “ ... Spoke with patient’s son to explain that interscalene peripheral nerve block was placed on right side instead of left. Explained that patient will have limited use of right arm during period of block, and the duration is typically 12-24 hours ...”. During a concurrent interview and record review on 1/29/25 at 2:30 p.m. with NM 7 Pt 6’s “Timeout Universal Protocol [TUP],”, dated 12/2/25, was reviewed. The “TUP” indicated, Pt 6’s anesthesia time out (a brief pause in an operation to confirm the patient, procedure, and site) was on 12/2/25 at 11:16 a.m. The “TUP” indicated the timeout type was an anesthesia block, and the procedure was a left arthroplasty reverse total shoulder with MD 2. The “TUP” indicated, the timeout questions were, correct patient, correct site, correct side, correct position, correct procedure, and site marked. The “TUP” indicated, a “Yes” response to all time out questions. The “TUP” indicated, the OR staff present for the anesthesia block time out were, AMD 1, RN 10, Surgical Technician (ST) 2, and a Medical Doctor Resident. NM 7 stated during the time-out, all OR staff were expected to stop all activities and focus on the time-out process. NM 7 stated the time-out questions are asked verbally and directed to everyone in the room. NM 7 stated each staff member should provide a verbal confirmation before the procedure or surgery begins, to ensure everyone pauses and listens to the time-out to prevent wrong site procedures. During an interview on 1/30/25 at 12:04 with Anesthesia Medical Doctor (AMD) 1, AMD 1 stated, she recalled Pt 6’s wrong sided nerve block on 12/2/25. AMD 1 stated, she (AMD 1) was the anesthesia provider for Pt 6’s surgery on 12/2/25. AMD 1 stated the planned anesthesia for Pt 6’s surgery was general anesthetic combined with a nerve block. AMD 1 stated, before starting the nerve block, RN 10 conducted a time-out procedure, during which the surgical site was confirmed aloud. AMD 1 stated, she could not see the surgeon’s skin marking for the surgical site because it was below the shoulder, where she had inserted the needle. AMD 1 stated an ultrasound (US-machine that uses sound waves to create real-time pictures of internal organs and tissues and displays them on a screen) machine was used during the nerve block procedure. AMD 1 stated a less preferred (Per AMD 1’s the screen is more difficult to read) US machine was initially set up in the OR on Pt 6’s right side (non-operative side). AMD 1 stated, during the process of starting the general anesthesia, the technician brought in the preferred US machine and placed at the foot of the bed on Pt 6’s left side (operative side). The less-preferred US was then removed from the operating room. AMD 1 stated, she asked RN 10 to move the US machine closer because she could not see the screen. AMD 1 stated RN 10 then moved the US machine to Pt 6’s left shoulder. AMD 1 stated, RN 10 prepped Pt 6’s right shoulder and she (AMD 1) performed a nerve block. AMD 1 stated, later MD 2 entered the OR and noticed no needle mark on Pt 6’s left shoulder, AMD 1 stated she realized the wrong shoulder had been blocked. AMD 1 stated, administering a nerve block to Pt 6’s left shoulder after having administered one to the right shoulder was not possible due to the risk of phrenic nerve damage (occurs when the nerve that controls the respiratory muscle are damage, making it difficult to breath). AMD 1 stated Pt 6’s family decided to proceed with the surgery, and MD 2 used a local anesthesia (temporarily blocks pain to an area) to Pt 6’s left the shoulder for the surgery. AMD 1 stated, Pt 6 was already asleep for the nerve block, and she did not think it added much time to the general anesthesia. AMD 1 stated, she should have double checked the surgeon’s skin marking before administering the nerve block to Pt 6’s right shoulder. During a telephone interview on 1/30/25 at 3 p.m. with MD 2, MD 2 stated he recalled performing Pt 6’s surgery on 12/2/24. MD 2 stated, he was Pt 6’s Orthopedic Surgeon (Specialist physician for treating bones, joints, muscles, tendons, and ligaments) for her shoulder surgery. MD 2 stated, Pt 6’s surgery was planned for the left shoulder, and he marked Pt 6’s left arm. MD 2 stated the mark was large enough to be visible. MD 2 stated, he entered the OR and observed Pt 6 was intubated and under general anesthesia, however, the left shoulder was not prepped for surgery. MD 2 stated, he inquired with the OR team about the nerve block, when he noticed there was no mark on the operative shoulder [left shoulder] from the injection. MD 2 stated, typically, there should be a visible mark such as redness or a small drop of blood, where the needle entered. MD 2 stated, he looked at Pt 6’s left shoulder and commented to AMD 1 she “didn’t even leave a mark” when she did the nerve block. MD 2 stated, AMD 1’s face lost all color, she looked at RN 10 and said she blocked the wrong shoulder. MD 2 stated AMD 1 pulled down Pt 6’s gown from the right arm and saw no MD skin pen mark and looked at the left arm and saw the MD site marking. MD 2 stated, administering a nerve block to Pt 6’s left shoulder after AMD 1 administered one to the right shoulder was not possible due to the risk of phrenic nerve damage. MD 2 stated this condition could lead to post operative respiratory depression (loss of the ability to breathe). MD 2 stated the alternative plan to continue with the left shoulder surgery was to administer a local anesthesia and for Pt 6 to be admitted for observation. MD 2 stated, he contacted Pt 6’s family, who agreed to proceed with the surgery using local anesthesia and for Pt 6 to remain in the hospital overnight for observation. MD 2 stated, he preferred and requested a nerve block for Pt 6’s type of surgery because it gave superior post operative pain relief and reduces opiate consumption in the first 24 hours after surgery. MD 2 stated, due to the lack of a nerve block, Pt 6 potentially could have a higher opiate (strong pain medication) consumption. During an interview on 1/30/25 at 3:27 p.m. with Registered Nurse (RN) 10, RN 10 stated, he recalled the surgical case involving Pt 6. RN 10 stated, he was Pt 6’s circulating nurse (nurse who works in OR to manage patient care and safety) during her surgery. RN 10 stated, when a nerve block was performed, the surgical staff had to position the room and move all equipment to the patient’s non-operative side. RN 10 stated, the anesthesiologist used an US machine to guide the needle for the nerve block procedure. RN 10 stated, the US machine was initially set up on the patient’s non-operative side, when the room was prepared for Pt 6 surgical case. RN 10 stated, AMD 1 requested a different US machine, and the exchange occurred before he (RN 10) entered the operating room with Pt 6. RN 10 stated Pt 6 was moved into the OR on a gurney. RN 10 stated the new US machine was set up on Pt 6 operative side and he did not realize the US machine was positioned in the incorrect place and should have been on the non-operative side. RN 10 stated, AMD 1 administered general anesthesia and intubated Pt 6 on the gurney. RN 10 stated during the procedure, he was standing at the bottom of the gurney, and Pt 6’s extremities were covered with blankets. RN 10 stated from where he was standing prevented him from seeing the surgical site marking on Pt 6 left shoulder. RN 10 stated he performed a time-out from his position, confirming the surgery was a total left shoulder procedure and the anesthesia was a left shoulder block. RN 10 stated after the nerve block was performed, Pt 6 was moved onto the OR table and positioned for surgery. RN 10 stated, before Pt 6 was prepped for surgery MD 2 entered the OR and observed Pt 6’s left shoulder and inquired about the nerve block due to the absence of needle marks from the nerve block. RN 10 stated, he noticed AMD 1’s face turned white, and AMD 1 told MD 2 she blocked the wrong shoulder. RN 10 stated he reported the incident to his manager in real-time and filed an incident report. RN 10 stated, he should have pulled the blanket down lower to reveal the surgical site marking and could have prevented the error. RN 10 stated, he did not see the Intravenous (IV) lines (a thin flexible tube attached to a pump inserted into a vein to deliver fluids) or Blood Pressure (BP) lines coming off the right arm. RN 10 stated, the IV and BP cuff would not be placed on Pt 6 operative side. RN 10 stated, seeing the lines on Pt 6 right shoulder side should have been an indicator Pt 6 should not have been blocked on the right shoulder. During an interview on 1/31/25 at 3:46 p.m. with the Director of Surgery (DS), the DS stated, his expectation for OR staff was to conduct the time-outs according to the policy. The DS stated, OR staff are expected to ensure the surgical consent was signed and accurate. The DS stated, OR staff should double-check the type of surgery and the operative site, especially if there was a site marking. The DS stated he expected OR staff to pause all activities in the OR, verify site markings, and listen to the time-out information. The DS stated if any information was incorrect, they should speak up. The DS stated a time-out should occur before anesthesia and before the surgical incision begins. During an interview on 2/5/25 at 9:38 a.m. with the Chief Nursing Officer (CNO), the CNO stated, OR staff were expected to follow the hospital’s Universal Protocol P&P when a timeout was being announced. The CNO stated OR staff should visualize the skin marking when the side and site are announced during the time-out. During a review of hospital P&P “Universal Protocol (UP- a set of guidelines for healthcare professionals that aims to prevent surgical errors) - Procedural Areas,” dated 12/19/23, the P&P indicated, “ ... PURPOSE ... To provide guidance to peri-procedural [time before, during, or after a medical procedure] personnel for verifying the correct patient, procedure, and site during operative or other invasive procedures ... To provide guidance for improving team communication through a culture of safety in order to reduce the incidence of medical errors ... The Universal Protocol must be followed on all procedures that require an informed consent. This includes all invasive/operative procedures, and all procedures done under Procedural Sedation whether invasive or noninvasive ... The Universal Protocol is composed of the following elements:1. Pre-Procedure verification. 2. Marking the site, when applicable 3. Procedural Briefing 4. Time Out. 5. Debriefing ... Site Marking ... The site is to be marked at or adjacent to the incision site at a location that will be visible after the patient is prepped and draped, when anatomically and technically possible ... Time Out ...The Time Out is a standardized process that is performed with the healthcare team and used throughout the hospital before all operative/invasive procedures ... The healthcare team involved in the procedure must pause to conduct a final verbal and audible verification of all safety elements listed below. This pause is referred to as a Time Out ... The Time Out involves the immediate members of the procedure team, including the individual performing the procedure and other active participants who will be participating in the procedure from the beginning ... Conduct the Time Out immediately before the procedure begins with the patient properly positioned, prepped and draped ... All activities are to be suspended for the duration of the Time Out, ... so that all members of the team are focused on elements of the Time Out. ...Time Out addresses and verbally confirms among all team members the following elements ... Correct patient ...Confirmed with two identifiers (per Patient Identification policy) ... Correct procedure and laterality (when applicable) as consented ... Site marked (when applicable) ...”. During a review of professional reference titled, “When Left Is Right and Right Is Wrong: A Case Report of Two Near-Miss Wrong-Sided Peripheral Nerve Blocks,” (retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9217577/) dated 6/15/22, the professional reference indicated, “ ... Wrong-sided peripheral nerve blocks occur with a surprisingly high frequency despite being described as a “never event.” Timeout procedures are performed and documented, yet timeout omission is rarely cited as a contributing factor for wrong-sided blocks ... Author Recommendations ...Reduce time pressure to perform regional blocks by stressing the importance of quality over on-time starts when nerve blocks are involved ... Be aware of environmental cues by making mental notes of patients with bilateral injuries ...Visualize the procedure mark immediately prior to performing nerve block. Occasionally, a separate block mark may be needed if surgical mark is far from the nerve block site ...Place separate procedure marks when multiple blocks (i.e., front/back blocks) are performed on the same patient. Visualize both marks during the initial timeout ...After repositioning, institute a pause point to confirm that the second procedural mark is visible before performing the second block ...”. During a review of professional reference titled, “Lasting effects of general anesthetics on the brain ...” (retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC6443620/) dated 3/11/19, the professional reference indicated, “ ...General anesthetics are commonly used in major surgery. To achieve the depth of anesthesia for surgery, patients are being subjected to a variety of general anesthetics, alone or in combination. It has been long held an illusory concept that the general anesthesia is entirely reversible, and that the central nervous system is returned to its pristine state once the anesthetic agent is eliminated from the active site. However, studies indicate that perturbation (departing from established course) of the normal functioning of these targets may result in long-lasting ... undesirable effects. The ... aging brain may be vulnerable to anesthesia. An important mechanism for anesthesia-induced developmental neurotoxicity (damage to the brain, spinal cord or nerves from brain and spinal cord) ... Exposure to anesthesia to the aged brain can be a risk of the long-lasting impairments of cognitive (the mental process of gaining knowledge) function ...”.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 37529 Based on observation, interview, and record review, the facility failed to have an effective governing body (GB) that is legally responsible for the conduct of the hospital when: 1. The hospital did not follow established policies and procedures (P&P) to provide the level of care ordered by the physicians for Patient (Pt)1, Pt 2, Pt 3, and Pt 4 in the Emergency Department (ED) who had inpatient physician’s orders. 1a. Pt 1, a 70-year-old (y/o) brought in by ambulance (BIBA)to the emergency department (ED) for symptoms of stroke and admitted as an inpatient on 8/23/24 on stroke protocol and was not prioritized a bed in the hospital and remained in the ED on a gurney until 8/27/24, totaled of 101 hours. Pt 1 had generalized pain from laying on the gurney (a bed with wheels primarily used for short term to transport patients in the hospital). Pt 1 had right side weakness and license nurses did not conduct stroke assessment and did not implement interventions for utensil use and assistance for eating and ambulation in going to the bathroom. The license nurses did not read and document Pt 1’s telemetry cardiac strip (a recording of patient’s heart electrical activity) every four hours. The license nurses did not administer Pt 1’s asthma medications in a timely manner and did not provide an incentive spirometry (a handheld device that helps patients takes slow, deep breaths to improve lung function). The license nurses did not document Pt 1’s nutritional intake and output. (refer to A398) 1b. Pt 2, a 86-year-old male was BIBA to the ED on 7/2/24 at 6:32 pm for left lower lobe pneumonia (PNA- lung infection) and was admitted as an inpatient on 7/3/24 at 7:15 a.m. and was not prioritized for an inpatient bed. Pt 2 had an inpatient order and remained in the ED until 7/3/24 at 8 p.m. before transferred to inpatient floor. Pt 2 stayed in the ED hallway on the gurney for approximately 25 hours. Nurses did not develop and implement nursing care plan for pneumonia. Nursing staff were not aware of Pt 2’s oxygen saturation decline and was not consistently monitored by nurses. On 7/11/24 nurses did not perform respiratory assessment prior to discharge to a Skilled Nursing Facility (SNF) at approximately. 9:30 a.m. Nurses did not notify the physician of the respiratory status of Pt 2 upon discharge. (Refer to A398) 1c. Pt 3, a 87 year old with a history of dementia, came by ambulance to the ED on 9/15/24 for chest pain and cough, was admitted later the same day on 9/15/24 with possible pneumonia, was not prioritized for a bed in the hospital and remained in the ED until 9/19/24 when he was moved to a bed on the med-surg unit, after spending 104 hours on a gurney in the ED hallway. During his ED stay, Pt 3 who had a skin breakdown on his head and coccyx noted on admission, did not have his care plan interventions implemented for nutrition, did not get a pressure relief mattress pad placed on his gurney until 9/17/24, and did not have his heels elevated off the gurney mattress until he was moved to the med surg unit on 9/19/24. The hospital nursing staff did not follow the hospital P&P’s for patient assessment, care planning, implementing interventions, and skin assessment. (Refer to A398) 1d. Pt 4, a 77-year-old BIBA to ED after choking on food which required a laryngoscope (a thin tube device used to examine the larynx) retrieval of the food by Emergency Medical Services (EMS). Pt 4 stayed in the ED for three days and the license nurses skin assessment was incomplete and did not describe the location, size, and description of each wound. The license nurses in the ED did not implement interventions to relieve pressure on feet and heels not until Pt 4 was transferred to the medical surgical inpatient unit. The license nurses in the ED did not document Pt 4’s nutritional intake in the ED. (Refer to A398) The hospital license nurses did not follow the hospital’s policies and procedures for patient assessment, documentation in the electronic healthcare record, develop, implement and evaluation of care plans, follow stroke protocol, pressure injury risk assessment, staging and prevention, pain management, Standards of Practice for Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, and Emergency Department. Because of the serious actual harm to Pt 1 related to the decline of health in the ED and not appropriately treating the stroke; serious actual harm to Pt 2 related to not adequately assessing and treating respiratory illness; serious actual harm to Pt 3 related to not addressing and treating skin ulcers; and serious potential harm to Pt 4 related to unrelieved pain, aspiration of food and developing pressure injuries; and serious potential harm to each patient for not being prioritized for inpatient bed once determined to need admission an Immediate Jeopardy (IJ) situation was called on 09/26/2024 at 9:25 a.m. under CFR 482.23(b)(6) tag A-0398 Nursing Services with Chief Nursing Officer (CNO) and other hospital leaders. The IJ template was shared with CNO and an explanation was given to submit a Plan of Removal that addressed the IJ situation. Version 1 of the PoR was submitted on 09/26/2024 at 5:08 p.m. and was unacceptable. Version 3 was acceptable on 09/30/2024 at 1:40 p.m. and was acceptable. The PoR addressed the following nursing elements: nursing inservices and education and return demonstration, inpatient placement prioritization process, policy review and monitoring, following hospital policies and procedures in accordance with the needs of patients in the ED and patients admitted to the hospital but remain in the ED. The survey team validated implementation of the actions on the PoR and the IJ was removed on 09/30/2024 at 4:40 p.m. in the presence of the CNO. 5. 2. The hospital failed to ensure Clinical Institute Withdrawal Assessment for Alcohol (CIWA- a scale used in the assessment and management of alcohol withdrawal) protocol was followed for three of three sampled patients (Pt 36, Pt 37, and Pt 38) when license nurses did not follow the frequency of patient assessment, monitoring, and documentation according to the CIWA protocol. (Refer to A398) 3. The hospital failed to ensure patient’s rights were considered for Pt 15, Pt 24, Pt 26, and Pt 28 with limited English proficiency (LEP) when the nurse did not document on the EHR the method of communication used and the interpreter waiver to decline the used of the hospital interpreter service were not completed. (refer to A117). 4. The hospital failed provide a care in a safe environment for Pt 32, Pt 41, and Pt 42 with a Columbia Suicide Severity Rating Scale (CSSRS- a suicidal ideation and behavior rating scale which measures the intensity and severity of ideation, behavior and lethality) of high risk for suicide and the one on one sitter (a qualified staff member assigned to constantly observe a patient who is at high risk for suicide to immediately help redirect patient from engaging in harmful acts) assigned was monitoring several other patients at the same time and did not provide constant direct supervision to monitor suicidal behavior to prevent suicidal attempts. (Refer to A144) 4. The hospital failed to provide a safe setting for the care of Pt 5 and nurses did not recognize and act on a change of condition and did not implement nursing care in accordance with hospital policies and procedures. (Refer to A144) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe manner.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37529 Based on observation, interview, and record review, the hospital failed to protect and promote each patient’s rights when: 1. For four of six sampled patients (Pt 15, Pt 24, Pt 26, and Pt 28) licensed nurses did not document the method of communication used and the interpreter waiver was not completed for patients with limited English proficiency and prefers family member to interpret. (Refer to A117) 2. Three of six sampled patients (Patient (Pt) 32, Pt 41, and Pt 42) and the license nurses assessed Pt 32, Pt 41, and Pt 42’s Columbia Suicide Severity Rating Scale (CSSRS- a suicidal ideation and behavior rating scale which measures the intensity and severity of ideation, behavior and lethality) as high risk for suicide and the one on one sitter (a qualified staff member assigned to constantly observe a patient who is at high risk for suicide to immediately help redirect patient from engaging in harmful acts) assigned was monitoring several other patients at the same time and did not provide constant direct supervision to monitor suicidal behavior to prevent suicidal attempts. (Refer to A144) 3. Nurses did not recognize and take action on the change of condition for Pt 5 and nurses did not follow policies nad procedures meant to provide care in a safe setting. (Refer to A144) 4. The Grievance process was not followed for one of three patients sampled (Pt 2). (Refer to A-0118) The cumulative effect of these systemic problems resulted in the hospital’s inability to provide quality healthcare in a safe setting.”

“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: 37529 Based on observation, interview and record review, the hospital failed to have a well-organized and effective nursing service when: 1. Pt 1, a 70-year-old (y/o) brought in by ambulance (BIBA)to the emergency department (ED) for symptoms of stroke and admitted as an inpatient on 8/23/24 on stroke protocol and was not prioritized a bed in the hospital and remained in the ED on a gurney until 8/27/24, totaled of 101 hours. Pt 1 had generalized pain from laying on the gurney (a bed with wheels primarily used for short term to transport patients in the hospital). Pt 1 had right side weakness and license nurses did not conduct stroke assessment and did not implement interventions for utensil use and assistance for eating and ambulation in going to the bathroom. The license nurses did not read and document Pt 1’s telemetry cardiac strip (a recording of patient’s heart electrical activity) every four hours. The license nurses did not administer Pt 1’s asthma medications in a timely manner and did not provide an incentive spirometry (a handheld device that helps patients takes slow, deep breaths to improve lung function). The license nurses did not document Pt 1’s nutritional intake and output. (refer to A398) 2. Pt 2, a 86-year-old male was BIBA to the ED on 7/2/24 at 6:32 pm for left lower lobe pneumonia (PNA- lung infection) and was admitted as an inpatient on 7/3/24 at 7:15 a.m. and was not prioritized for an inpatient bed. Pt 2 had an inpatient order and remained in the ED until 7/3/24 at 8 p.m. before transferred to inpatient floor. Pt 2 stayed in the ED hallway on the gurney for approximately 25 hours. Nurses did not develop and implement nursing care plan for pneumonia. Nursing staff were not aware of Pt 2’s oxygen saturation decline and was not consistently monitored by nurses. On 7/11/24 nurses did not perform respiratory assessment prior to discharge to a Skilled Nursing Facility (SNF) at approximately. 9:30 a.m. Nurses did not notify the physician of the respiratory status of Pt 2 upon discharge. (Refer to A398) 3. Pt 3, a 87 year old with a history of dementia, came by ambulance to the ED on 9/15/24 for chest pain and cough, was admitted later the same day on 9/15/24 with possible pneumonia, was not prioritized for a bed in the hospital and remained in the ED until 9/19/24 when he was moved to a bed on the med-surg unit, after spending 104 hours on a gurney in the ED hallway. During his ED stay, Pt 3 who had a skin breakdown on his head and coccyx noted on admission, did not have his care plan interventions implemented for nutrition, did not get a pressure relief mattress pad placed on his gurney until 9/17/24, and did not have his heels elevated off the gurney mattress until he was moved to the med surg unit on 9/19/24. The hospital nursing staff did not follow the hospital P&P’s for patient assessment, care planning, implementing interventions, and skin assessment. (Refer to A398) 4. Pt 4, a 77-year-old BIBA to ED after choking on food which required a laryngoscope (a thin tube device used to examine the larynx) retrieval of the food by Emergency Medical Services (EMS). Pt 4 stayed in the ED for three days and the license nurses skin assessment was incomplete and did not describe the location, size, and description of each wound. The license nurses in the ED did not implement interventions to relieve pressure on feet and heels not until Pt 4 was transferred to the medical surgical inpatient unit. The license nurses in the ED did not document Pt 4’s nutritional intake in the ED. (Refer to A398) The hospital license nurses did not follow the hospital’s policies and procedures for patient assessment, documentation in the electronic healthcare record, develop, implement and evaluation of care plans, follow stroke protocol, pressure injury risk assessment, staging and prevention, pain management, Standards of Practice for Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, and Emergency Department. Because of the serious actual harm to Pt 1 related to the decline of health in the ED and not appropriately treating the stroke; serious actual harm to Pt 2 related to not adequately assessing and treating respiratory illness; serious actual harm to Pt 3 related to not addressing and treating skin ulcers; and serious potential harm to Pt 4 related to unrelieved pain, aspiration of food and developing pressure injuries; and serious potential harm to each patient for not being prioritized for inpatient bed once determined to need admission an Immediate Jeopardy (IJ) situation was called on 09/26/2024 at 9:25 a.m. under CFR 482.23(b)(6) tag A-0398 Nursing Services with Chief Nursing Officer (CNO) and other hospital leaders. The IJ template was shared with CNO and an explanation was given to submit a Plan of Removal that addressed the IJ situation. Version 1 of the PoR was submitted on 09/26/2024 at 5:08 p.m. and was unacceptable. Version 3 was acceptable on 09/30/2024 at 1:40 p.m. and was acceptable. The PoR addressed the following nursing elements: nursing inservices and education and return demonstration, inpatient placement prioritization process, policy review and monitoring, following hospital policies and procedures in accordance with the needs of patients in the ED and patients admitted to the hospital but remain in the ED. The survey team validated implementation of the actions on the PoR and the IJ was removed on 09/30/2024 at 4:40 p.m. in the presence of the CNO. 5. The hospital failed to ensure Clinical Institute Withdrawal Assessment for Alcohol (CIWA- a scale used in the assessment and management of alcohol withdrawal) protocol was followed for three of three sampled patients (Pt 36, Pt 37, and Pt 38) when license nurses did not follow the frequency of patient assessment, monitoring, and documentation according to the CIWA protocol. (Refer to A398) 6. The hospital failed to ensure P&P for Intake and Output (I&O) was followed for one of one sampled patient (Pt 25) when Pt 25 had a physician order for Intake and Output (a medical measurement of the fluids and food that enters and exits the body) and license nurses did not document Pt 25’s I&O in the Electronic Healthcare Record (EHR- a digital version of a patient’s medical history and demographics that can be accessed by authorized healthcare providers). (Refer to A398) 7. The hospital failed to ensure P&P and Professional Standards of Practice for pain management was followed for seven of seven sampled patients (Pt 8, Pt 15, Pt 19, Pt 29, Pt 32, Pt 40, and Pt 55) when license nurses did not assess and re-assess Pt 8, Pt 15, Pt 19, Pt 29, Pt 32, Pt 40, and Pt 55’s level of pain after pain medication was administered. (Refer to A398). 8. The hospital failed to ensure P&P for telemetry cardiac monitoring (TCM-a portable device used to continuously monitor patient’s heat activity) was followed for five of five sampled patients (Pt 15, Pt 27, Pt 28, Pt 35, and Pt 41 when the license nurses did not read and document Pt 15, Pt 27, Pt 28, Pt 35, and Pt 41 telemetry cardiac strip every four hours. (Refer to A398). 9. The hospital failed to ensure physician’s order and P&P was followed for one of one sampled patient (Pt 23) when license nurses failed to administer Patient Pt 23’s diltiazem (a medication that relaxes the blood vessels in the body and lowers the heart rate) drip (continuous intravenous infusion) on 8/28/24 at the rate ordered by the physician and failed to document Pt 23’s heart rate (HR) and blood pressure (BP) when titrating (increasing or decreasing the dose of) the drip according to the facility’s policy and procedure. (Refer to A398) 10. Nurses did not follow the prescribed dose for nitrogylcerin for Pt 13. (refer to A405). The cumulative effect of these systemic problems resulted in the facility’s inability to ensure the provision of quality health care in a safe setting.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 41166 Based on interview and record review the hospital failed to ensure that safe pharmaceutical services had been provided and meet the needs of each patient as evidenced by: The hospital failed to develop and implement systems to ensure the safe use of medications when 6 of 7 patients (Patients 4, 5, 6, 8, 9, 10) were not accurately monitored for sedation (sleepiness) adverse effects after being administered IV (intravenous- into the vein) opioids. (Refer to A-500) The cumulative effect of this systemic problem resulted in the facility’s inability to ensure the provision of quality health care, in compliance with the Condition of Pharmaceutical Services.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 37529 Based on observation, interview, and record review the hospital failed to reduce the factors that lead to a preventable hospital readmission when: 1.Pt 2 was admitted on 7/2/24 with diagnosis of pneumonia (lung infection) and was discharged on 7/11/24 and returned 6 hours later in respiratory distress. (Refer to A-0821) 2. Pt 25 was seen in the emergency department on 9/23/24 for elevated heart rate, low blood pressure, and positive urine test and discharged 6 hours later and then returned 19 hours later with elevated heart rate, fever, generalized weakness and with a urinary tract infection. (Refer to A-0821) These failures resulted in Pt 2 being readmitted, intubated, and eventually passing away on 8/8/24 and Pt 25 returning to the hospital and being admitted and treated.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 42321 Based on observation, interview, and record review the hospital failed to reduce the factors that lead to a preventable hospital readmission when: 1.Pt 2 was admitted on 7/2/24 with diagnosis of pneumonia (lung infection) and was discharged on 7/11/24 and returned 6 hours later in respiratory distress. (Refer to A-0821) 2. Pt 25 was seen in the emergency department on 9/23/24 for elevated heart rate, low blood pressure, and positive urine test and discharged 6 hours later and then returned 19 hours later with elevated heart rate, fever, generalized weakness and with a urinary tract infection. (Refer to A-0821) These failures resulted in Pt 2 being readmitted, intubated, and eventually passing away on 8/8/24 and Pt 25 returning to the hospital and being admitted and treated.”

“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: 37529 Based on interview and record review, the hospital failed to ensure patient’s rights were considered for four of six sampled patients (Pt 15, Pt 24, Pt 26, and Pt 28) when the nurse did not document the preferred language of communication used and the interpreter waiver was not completed for patients with limited English proficiency and prefered family member to interpret in accordance with hospital policy and procedure. These failures had the potential for patients whose preferred language was other than English to not receive and fully understand procedures and/or education provided to them and could result in negative health outcomes. Findings: 1. During a review of Pt 15’s Patient Demographics (PD-document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 9/24/24, the PD indicated Pt 15 was a 68-year-old male admitted to the hospital on 9/16/24 at 6:47 p.m., with a Diagnoses of Urinary tract infection (UTI-a bacterial infection that affects the bladder, urethra, and kidneys) and Spanish speaking. During a concurrent interview and record review on 9/23/24, at 1:48 p.m., with the Director of Emergency Department (DED), Pt 15’s Emergency Department Patient Care Timeline (EDPCT- a record of key times in a patient’s encounter in the Emergency Department)) and History and Physical (H&P-a comprehensive assessment of a patient’s health that includes medical history, physical exam, and demographics) dated 9/16/24 were reviewed. The EDPCT indicated, “ ...there was no documentation in the Risk Assessment, the Communication Barrier, and availability of Interpreter ...” The H&P indicated “ ...that History was provided by: RN and was necessary due to language barrier ...” The DED stated family member could be used for Interpretation for simple things like the need to go to the bathroom but not for admission, surgical consents, and medical importance. The DED stated the standards was for the nurse to document who interpreted for the patient and the level of ability to interpret. The DED stated a tiered staff (certified medical interpreters trained professionals who can translate health information correctly) or a family member could interpret for the patient. During a concurrent interview and record review on 9/25/24, at 7:46 a.m., with Registered Nurse (RN) 1, Pt 15’s EDPCT and H&P dated 9/17/24 was reviewed. The EDPCT indicated RN 1 was the nurse assigned to Pt 15 on 9/16/24. The H&P indicated, “ ...assumed care ... Pt Spanish speaking. Interpreter obtained by son at bedside ...” RN 1 stated she speaks Hmong and English. RN 1 stated Pt 15’s son was at bedside and interpreted for Pt 15. RN 1 stated she was not aware the interpreter waiver needed to be completed before allowing son to interpret. RN 1 stated it was important to use the best way to effectively communicate with the patient to ensure understanding between the nurse and the patient for better treatment and care. During a concurrent interview and record review on 9/25/24, at 12:34 p.m., with RN 2, Pt 15’s EDPCT was reviewed. The EDPCT indicated RN 2 assessed Pt 15 in the Triage Area (the sorting of sick or injured patients according to severity). RN 2 stated she only speaks English. RN 2 stated when patients needed an interpreter, the family member, or a tiered staff member was always available to interpret for the patient. RN 2 stated she did not document the interpreter used and method to communicate for Pt 15. RN 2 stated the expectation was for the nurses to document the method of communication for non-English speaker. RN 2 stated the potential outcome for not using the interpreter services was for miscommunication to occur and missed vital information. During a review of the Policy and Procedure (P&P) titled, “Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired “, dated 6/14/24, the P&P indicated. VI. DOCUMENTATION: B. Requesting staff members document in the patient’s EHR [Electronic Health Record -a digital version of a patient’s medical history that can be accessed by all healthcare providers involved in patient’s care] if an interpreter or device is/ was used for the following 1. a) Name of the interpreter, including i. interpreter used (first and last name) ii. Interpreter agency, as appropriate iii. Time iv. Date ...2. If the requesting staff member is a tiered bilingual staff, can document in their notes or the interpreter flow sheet that they themselves interpreted. 2. During a review of Pt 24’s PD dated 9/24/24, the PD indicated Pt 24 was a 79-year-old female admitted to the hospital on 9/16/24 at 7:55 p.m., with a diagnosis of Closed Head Injury. Pt 24’s language was Hmong and discharged home on 9/16/24 at 9:45 p.m. During a concurrent interview and record review on 9/24/24, at 1:54 p.m., with the Educator Medsurg (EM) and the Director of Emergency Department (DED). The EDPCT and the H&P dated 9/16/24 were reviewed. The DED stated Pt 24’s H&P indicated the H&P was obtained from Pt 24’s family member. The DED stated the EDPCT did not indicated the nurse completed the interpreter services waiver and did not document the method of communication to patient. The DED stated the nurse should have completed the interpreter services waiver to use the family as patient interpreter and not the hospital interpreter services. 3. During a review of Pt 26’s PD dated 9/24/24, Patient 26’s PD indicated a 63-year-old female admitted to the hospital on 9/17/24 at 10:19 a.m., with an Admission Diagnosis of Symptomatic Cholelithiasis (a condition where hard deposits in the gallbladder cause pain or other symptoms). Pt 26’s language was Punjabi, and Pt 26 was discharged home on 9/19/24 at 2:55 p.m. During a concurrent interview and record review on 9/24/24 at 2:20 p.m., with the DED, Pt 26’ H&P dated 9/17/24. The H&P indicated Pt 26 was in the Emergency Department for abdominal and back pain and was accompanied with her family member who interpreted for Pt 26. The interpreter waiver was not completed by the nurse. The DED stated the interpreter waiver should have been completed to ensure Pt 26 understands she was using her family member as an interpreter and not using the hospital interpreter services. The DED stated it was important to have an interpreter to ensure Pt 26 had a clear understanding of the situation. 4. During a review of Pt 28’s PD, the PD indicated a 59-year-old female admitted to the hospital on 9/19/24 at 1:58 p.m., with an Admission Diagnosis of Bacteremia (the presence of viable bacteria in the circulating blood) and was discharged on 9/20/24 at 4:50 p.m., to another acute care hospital. Pt 28’s language was Spanish. During a review of Pt 28’s Interpreter Flowsheet dated 9/22/24 p.m., the Interpreter Flowsheet indicated Pt 28 needed an interpreter with no documentation of the interpreter type, interpretation method, interpreter name, interpreter session type, interpretation provider, and interpretation location. During a review of Pt 28’s EDPCT dated 9/24/24. The EDPCT indicated Pt 28’s Risk Assessment did not indicate the Communication Barrier, and an interpreter was used. During an interview on 9/26/24, at 1:30 p.m., with RN Quality Management Coordinator (RQMC) the RQMC stated, Pt 15, Pt 24, Pt 26, and Pt 28 interpreter waiver should have been completed by the nurse and placed in the patient’s electronic health record but was not. During a review of the facility’s Policy and Procedure (P&P) titled, “Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired “, dated 6/14/24, the P&P indicated, “PURPOSE: A. To define the communication system that is used for patients who have Limited English Proficiency (LEP) ... B. To provide guidelines for coordinating timely response in meeting the assessed special language needs of individual patients ... C. To comply with Americans with Disabilities (ADA), Title VI of the Civil Rights Act of 1964 and Health and Safety Code of California ... 1. Health and Safety Code of California requires licensed general acute care hospitals to provide language assistance services to patients with language or communication barriers ... Community Medical Centers (CMC) has contractual agreements that define expectations and response time and those vendors are the only language contract services that must be used E .... Upon testing and training, such a staff member is assigned a one or two badge buddy, depending on their scope of competency in the given targeted language F. Language Service Line: Language services are available via phone 24 hours a day, 7 days a week ... G. Non-English or LEP: Those individuals whose native language is other than English and who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers ... III. POLICY: It is the policy of Community Medical Centers (CMC) to provide equal access to and equal participation in health care interactions for persons ...L. In the event that the patient prefers to use a friend or a family member to interpret on their behalf one of the following waivers must be signed and scanned into the patient’s EHR. Waive interpreter- English or waive interpreter- Spanish ...V. PROCEDURE: A. c. Once language preference is determined: III. If a person chooses to utilize family members or friends for interpretation, that patient will sign the appropriate waiver VI. DOCUMENTATION: A. Staff member verifies if an interpreting services waiver has been signed by patient ...””

“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: 50446 Based on interview and record review, the hospital failed to ensure patient’s rights were considered for four of six sampled patients (Pt 15, Pt 24, Pt 26, and Pt 28) when the nurse did not document the preferred language of communication used and the interpreter waiver was not completed for patients with limited English proficiency and prefered family member to interpret in accordance with hospital policy and procedure. These failures had the potential for patients whose preferred language was other than English to not receive and fully understand procedures and/or education provided to them and could result in negative health outcomes. Findings: 1. During a review of Pt 15’s Patient Demographics (PD-document providing demographic information about the patient to include name, date of birth, admission date, emergency contact and more), dated 9/24/24, the PD indicated Pt 15 was a 68-year-old male admitted to the hospital on 9/16/24 at 6:47 p.m., with a Diagnoses of Urinary tract infection (UTI-a bacterial infection that affects the bladder, urethra, and kidneys) and Spanish speaking. During a concurrent interview and record review on 9/23/24, at 1:48 p.m., with the Director of Emergency Department (DED), Pt 15’s Emergency Department Patient Care Timeline (EDPCT- a record of key times in a patient’s encounter in the Emergency Department)) and History and Physical (H&P-a comprehensive assessment of a patient’s health that includes medical history, physical exam, and demographics) dated 9/16/24 were reviewed. The EDPCT indicated, “ ...there was no documentation in the Risk Assessment, the Communication Barrier, and availability of Interpreter ...” The H&P indicated “ ...that History was provided by: RN and was necessary due to language barrier ...” The DED stated family member could be used for Interpretation for simple things like the need to go to the bathroom but not for admission, surgical consents, and medical importance. The DED stated the standards was for the nurse to document who interpreted for the patient and the level of ability to interpret. The DED stated a tiered staff (certified medical interpreters trained professionals who can translate health information correctly) or a family member could interpret for the patient. During a concurrent interview and record review on 9/25/24, at 7:46 a.m., with Registered Nurse (RN) 1, Pt 15’s EDPCT and H&P dated 9/17/24 was reviewed. The EDPCT indicated RN 1 was the nurse assigned to Pt 15 on 9/16/24. The H&P indicated, “ ...assumed care ... Pt Spanish speaking. Interpreter obtained by son at bedside ...” RN 1 stated she speaks Hmong and English. RN 1 stated Pt 15’s son was at bedside and interpreted for Pt 15. RN 1 stated she was not aware the interpreter waiver needed to be completed before allowing son to interpret. RN 1 stated it was important to use the best way to effectively communicate with the patient to ensure understanding between the nurse and the patient for better treatment and care. During a concurrent interview and record review on 9/25/24, at 12:34 p.m., with RN 2, Pt 15’s EDPCT was reviewed. The EDPCT indicated RN 2 assessed Pt 15 in the Triage Area (the sorting of sick or injured patients according to severity). RN 2 stated she only speaks English. RN 2 stated when patients needed an interpreter, the family member, or a tiered staff member was always available to interpret for the patient. RN 2 stated she did not document the interpreter used and method to communicate for Pt 15. RN 2 stated the expectation was for the nurses to document the method of communication for non-English speaker. RN 2 stated the potential outcome for not using the interpreter services was for miscommunication to occur and missed vital information. During a review of the Policy and Procedure (P&P) titled, “Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired “, dated 6/14/24, the P&P indicated. VI. DOCUMENTATION: B. Requesting staff members document in the patient’s EHR [Electronic Health Record -a digital version of a patient’s medical history that can be accessed by all healthcare providers involved in patient’s care] if an interpreter or device is/ was used for the following 1. a) Name of the interpreter, including i. interpreter used (first and last name) ii. Interpreter agency, as appropriate iii. Time iv. Date ...2. If the requesting staff member is a tiered bilingual staff, can document in their notes or the interpreter flow sheet that they themselves interpreted. 2. During a review of Pt 24’s PD dated 9/24/24, the PD indicated Pt 24 was a 79-year-old female admitted to the hospital on 9/16/24 at 7:55 p.m., with a diagnosis of Closed Head Injury. Pt 24’s language was Hmong and discharged home on 9/16/24 at 9:45 p.m. During a concurrent interview and record review on 9/24/24, at 1:54 p.m., with the Educator Medsurg (EM) and the Director of Emergency Department (DED). The EDPCT and the H&P dated 9/16/24 were reviewed. The DED stated Pt 24’s H&P indicated the H&P was obtained from Pt 24’s family member. The DED stated the EDPCT did not indicated the nurse completed the interpreter services waiver and did not document the method of communication to patient. The DED stated the nurse should have completed the interpreter services waiver to use the family as patient interpreter and not the hospital interpreter services. 3. During a review of Pt 26’s PD dated 9/24/24, Patient 26’s PD indicated a 63-year-old female admitted to the hospital on 9/17/24 at 10:19 a.m., with an Admission Diagnosis of Symptomatic Cholelithiasis (a condition where hard deposits in the gallbladder cause pain or other symptoms). Pt 26’s language was Punjabi, and Pt 26 was discharged home on 9/19/24 at 2:55 p.m. During a concurrent interview and record review on 9/24/24 at 2:20 p.m., with the DED, Pt 26’ H&P dated 9/17/24. The H&P indicated Pt 26 was in the Emergency Department for abdominal and back pain and was accompanied with her family member who interpreted for Pt 26. The interpreter waiver was not completed by the nurse. The DED stated the interpreter waiver should have been completed to ensure Pt 26 understands she was using her family member as an interpreter and not using the hospital interpreter services. The DED stated it was important to have an interpreter to ensure Pt 26 had a clear understanding of the situation. 4. During a review of Pt 28’s PD, the PD indicated a 59-year-old female admitted to the hospital on 9/19/24 at 1:58 p.m., with an Admission Diagnosis of Bacteremia (the presence of viable bacteria in the circulating blood) and was discharged on 9/20/24 at 4:50 p.m., to another acute care hospital. Pt 28’s language was Spanish. During a review of Pt 28’s Interpreter Flowsheet dated 9/22/24 p.m., the Interpreter Flowsheet indicated Pt 28 needed an interpreter with no documentation of the interpreter type, interpretation method, interpreter name, interpreter session type, interpretation provider, and interpretation location. During a review of Pt 28’s EDPCT dated 9/24/24. The EDPCT indicated Pt 28’s Risk Assessment did not indicate the Communication Barrier, and an interpreter was used. During an interview on 9/26/24, at 1:30 p.m., with RN Quality Management Coordinator (RQMC) the RQMC stated, Pt 15, Pt 24, Pt 26, and Pt 28 interpreter waiver should have been completed by the nurse and placed in the patient’s electronic health record but was not. During a review of the facility’s Policy and Procedure (P&P) titled, “Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired “, dated 6/14/24, the P&P indicated, “PURPOSE: A. To define the communication system that is used for patients who have Limited English Proficiency (LEP) ... B. To provide guidelines for coordinating timely response in meeting the assessed special language needs of individual patients ... C. To comply with Americans with Disabilities (ADA), Title VI of the Civil Rights Act of 1964 and Health and Safety Code of California ... 1. Health and Safety Code of California requires licensed general acute care hospitals to provide language assistance services to patients with language or communication barriers ... Community Medical Centers (CMC) has contractual agreements that define expectations and response time and those vendors are the only language contract services that must be used E .... Upon testing and training, such a staff member is assigned a one or two badge buddy, depending on their scope of competency in the given targeted language F. Language Service Line: Language services are available via phone 24 hours a day, 7 days a week ... G. Non-English or LEP: Those individuals whose native language is other than English and who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers ... III. POLICY: It is the policy of Community Medical Centers (CMC) to provide equal access to and equal participation in health care interactions for persons ...L. In the event that the patient prefers to use a friend or a family member to interpret on their behalf one of the following waivers must be signed and scanned into the patient’s EHR. Waive interpreter- English or waive interpreter- Spanish ...V. PROCEDURE: A. c. Once language preference is determined: III. If a person chooses to utilize family members or friends for interpretation, that patient will sign the appropriate waiver VI. DOCUMENTATION: A. Staff member verifies if an interpreting services waiver has been signed by patient ...””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 37529 Based on interview and record review the facility failed to follow its policy/process on prompt resolution of patient grievances for one of three sampled patients (Patient (Pt) 2) when Pt 2 spouse filed a grievance and because Pt 2 passed away the hospital felt it did not have to follow up on the grievance filed. This failure to follow up resulted in Pt 2’s spouse not receiving a response to her grievance and did not provide her a resolution to her issues she reported with her husband’s care. Findings: During a concurrent interview and record review on 9/19/24, at 10:30 a.m. with Vice President of Quality Outcomes (VPQO) and Patient Relations Specialist (PRS), the grievance process was reviewed for a complaint filed by Pt 2’s spouse on 8/19/24. The “Complaints & Grievances” external report provided on 9/18/24 was reviewed, it indicated on 8/19/24 a complaint/grievance was filed for Pt 2 for the following areas of concern “Care/Treatment, Dietary, Discharge” and provided a date “Closed by Patient Relations” of 8/28/24, this was confirmed with the VPQO and PRS. PRS stated the hospital process for complaints and grievances is that when they receive a phone call “we listen to the concerns for the patient and put the information into their IRIS (Incident Reporting Intranet System- where all complaints and findings will be documented) and reach out to each department that was involved in the care of the patient that there were complaints about, we speak with the clinical supervisor about the concerns. The Clinical supervisor will then follow up with the patient to clarify all concerns and investigate the issues. The manager of the department is also tasked so they are aware of what is going on in their unit”. The PRS stated if the patient is no longer in the hospital the complaint/grievance will still be sent via the IRIS to the departments and their leadership will investigate the areas of concern. At that time an acknowledgement letter is sent out to the complainant and within 30 days a resolution letter is sent. The PRS stated the four elements that must be on the resolution letter are the concerns the patient has, department findings, date of completion of the investigation, and a contact persons name if they have further questions. The PRS stated we have had patients that have not been happy with that letter in the past and have had to escalate it up to risk management and they follow up with the patient and their families. During an interview on 9/19/24 at 10:40 a.m. with the PRS, the PRS reviewed the notes that were taken for the complaint Pt 2 Spouse filed on 8/19/24. PRS stated Pt 2’s Spouse provided a timeline of Pt 2’s care through out his stay starting 7/2/24. In this grievance Pt 2’s Spouse stated she did not feel her husband was ready to be discharged on 7/11/24 to a SNF but the physician did and if he had not been discharged early since he turned around and came right back that he may still be here with them. The PRS stated each area of Pt 2’s Spouse complaint was tasked out and investigated, ED said no negligent care, 5 North found no issues with the discharge and no refusal of care noted but a resolution letter was not sent out because the patient was deceased, and we only send letters to patients and not their spouses. During an interview on 9/19/24 at 10:45 a.m. with the VPQO, the VPQO stated the hospital sent out an initial letter to Pt 2’s spouse on 8/19/24 thanking her for making them aware of her concerns. The VPQO stated we do not send out resolution letters to patients who have passed away and then stated it is not part of our policy to send out resolution letters to spouses only to the patients. The VPQO stated no resolution letter was sent for this complaint, but he is reviewing the policy to see if they need to make changes and plan to take it to committee to get it updated. The VPQO stated there should be a letter for closure for the family member. During an interview on 10/2/24, at 11:12 a.m., with the Director of Risk Management, Regulatory and Patient Safety (DRM), the DRM stated the risk department became aware of the issue with Pt 2’s discharge on 7/11/24 on 9/18/24. DRM stated once there was an issue her department started to investigate “looking for any gaps or follow up” that needed to be reviewed and noted that Pt 2’s spouse had filed a complaint prior to 9/18/24 about Pt 2’s discharge on 7/11/24. DRM stated, “we noted there were some potential gaps with care at discharge, O 2 (oxygen saturations) had been trending down on the day of discharge and the spouse had reported concerns to the nurse about the patient [Pt 2] not being ready for discharge, this was not escalated at that time and the patient was discharged to a SNF (skilled nursing facility) and came back within 6 hours and needed to be readmitted”. DRM stated MD 6 was sent to peer review (The process of Medical Staff office assigning peer to peer, meaning MD to MD, review of the situation.) on 9/19/24 by risk management because there were concerns that Pt 2 may not have been ready for discharge on 7/11/24. During a review of the facility’s policy titled, “Patient and Patient’s Representative Complaint & Grievance” dated 6/28/23, indicated, “I. PURPOSE A. to meet patients’ reasonable expectations of care and services in a timely, reasonable, and consistent manner. B. To outline the process to receive, investigate, evaluate, and respond to written or verbal complaints or grievances concerning patient care or services by [name of hospital system] ... III. POLICY A. Issues that qualify as grievances include: 1. Complaints that involve allegations of abuse or neglect, endanger, or potentially endanger the patient and issues relating to the hospitals compliance with Centers for Medicare and Medicaid (CMS) hospital Conditions of Participation. 2. Situations where patients or the patient’s representative call or write to [name of hospital system] after discharge from hospital or from a clinic visit about concerns related to care or services, who were not able to resolve their concern during their stay or who did not wish to address their issue during their stay. 3. Situations where the patient or patient’s representative request the complaint be handled as a formal complaint or grievance or when the patient requests a written response from [name of hospital system]. 4. Situations where the issue cannot be resolved at the point of service and is referred to [name of hospital system] administration for later resolution ... C ... 4. Referral to Quality Improvement Organization (QJO): a. Quality Improvement Organization are Centers for CMS contractors charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting. Medicare beneficiary concerns submitted after discharge regarding a quality of care or premature discharge issues will be referred to case management and or internal peer review as appropriate. In the event that the beneficiary does not agree with the resolution, the beneficiary will be informed of his or her right to contact the QJO and provide the contact information. IV. PROCEDURE A. Complaints and Grievances Received Regarding Patient Care. 1. When possible, Complaints are resolved as soon as possible by the person receiving the complaint. 2. If the concerns cannot be resolved by the person receiving the complaint, the chain of command is followed until the complaint can be addressed. The supervisor on duty for the point of service (POS) is contacted. If the supervisor is not available, contact the manager; If the manager is not available, contact the director. 3. A grievance form will be available to the patient to document the nature of the issue or concerns. If the patient needs assistance in completing the form, assistance will be provided by [hospital name] staff. 4. If the situation endangers or potentially endangers the patient, such as neglect, abuse, risk management is to be contacted immediately. 5. Complaints where suit has been threatened or are treated as intent and referred to risk management immediately. 6. Complaints that involve the medical staff are referred to peer review for follow up using the incident reporting Internet system (IRIS). B. Grievance received will be responded to as follows. 1. If Patient Relations does not speak directly to the patient or patient’s representative, a written acknowledgment will be sent to the patient within seven business days to acknowledge receipt of the grievance. 2. A letter will be sent within 30 business days from the date [hospital name] received the grievance to the patient in their preferred language. 3. Grievances will be documented in IRIS and forwarded to Area management for investigation and resolution. a. Point of service leadership or designee will document their findings in IRIS. b. The letter to the patient will have the following elements: i. Name of hospital contact person. Ii. Steps taken on behalf of the patient to investigate the grievance. iii. The results of the grievance process. iv. Date of completion of the grievance process. C. Complaints against physicians. 1. Complaints by the patient or patient’s representative received regarding physicians, podiatrist, allied health professionals and dentists are to be referred to peer review. A letter will be sent to the patient in their preferred language within 30 days of the complaint. V. Documentation. A. All complaints and grievances will be reported and documented in the IRIS system. B. Patient Relations will send a letter of response to all grievances within 30 days of applicable and attached to the IRIS ...” No where in this policy does it say they do not send letters out to family of the deceased.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 42321 Based on interview and record review the facility failed to follow its policy/process on prompt resolution of patient grievances for one of three sampled patients (Patient (Pt) 2) when Pt 2 spouse filed a grievance and because Pt 2 passed away the hospital felt it did not have to follow up on the grievance filed. This failure to follow up resulted in Pt 2’s spouse not receiving a response to her grievance and did not provide her a resolution to her issues she reported with her husband’s care. Findings: During a concurrent interview and record review on 9/19/24, at 10:30 a.m. with Vice President of Quality Outcomes (VPQO) and Patient Relations Specialist (PRS), the grievance process was reviewed for a complaint filed by Pt 2’s spouse on 8/19/24. The “Complaints & Grievances” external report provided on 9/18/24 was reviewed, it indicated on 8/19/24 a complaint/grievance was filed for Pt 2 for the following areas of concern “Care/Treatment, Dietary, Discharge” and provided a date “Closed by Patient Relations” of 8/28/24, this was confirmed with the VPQO and PRS. PRS stated the hospital process for complaints and grievances is that when they receive a phone call “we listen to the concerns for the patient and put the information into their IRIS (Incident Reporting Intranet System- where all complaints and findings will be documented) and reach out to each department that was involved in the care of the patient that there were complaints about, we speak with the clinical supervisor about the concerns. The Clinical supervisor will then follow up with the patient to clarify all concerns and investigate the issues. The manager of the department is also tasked so they are aware of what is going on in their unit”. The PRS stated if the patient is no longer in the hospital the complaint/grievance will still be sent via the IRIS to the departments and their leadership will investigate the areas of concern. At that time an acknowledgement letter is sent out to the complainant and within 30 days a resolution letter is sent. The PRS stated the four elements that must be on the resolution letter are the concerns the patient has, department findings, date of completion of the investigation, and a contact persons name if they have further questions. The PRS stated we have had patients that have not been happy with that letter in the past and have had to escalate it up to risk management and they follow up with the patient and their families. During an interview on 9/19/24 at 10:40 a.m. with the PRS, the PRS reviewed the notes that were taken for the complaint Pt 2 Spouse filed on 8/19/24. PRS stated Pt 2’s Spouse provided a timeline of Pt 2’s care through out his stay starting 7/2/24. In this grievance Pt 2’s Spouse stated she did not feel her husband was ready to be discharged on 7/11/24 to a SNF but the physician did and if he had not been discharged early since he turned around and came right back that he may still be here with them. The PRS stated each area of Pt 2’s Spouse complaint was tasked out and investigated, ED said no negligent care, 5 North found no issues with the discharge and no refusal of care noted but a resolution letter was not sent out because the patient was deceased, and we only send letters to patients and not their spouses. During an interview on 9/19/24 at 10:45 a.m. with the VPQO, the VPQO stated the hospital sent out an initial letter to Pt 2’s spouse on 8/19/24 thanking her for making them aware of her concerns. The VPQO stated we do not send out resolution letters to patients who have passed away and then stated it is not part of our policy to send out resolution letters to spouses only to the patients. The VPQO stated no resolution letter was sent for this complaint, but he is reviewing the policy to see if they need to make changes and plan to take it to committee to get it updated. The VPQO stated there should be a letter for closure for the family member. During an interview on 10/2/24, at 11:12 a.m., with the Director of Risk Management, Regulatory and Patient Safety (DRM), the DRM stated the risk department became aware of the issue with Pt 2’s discharge on 7/11/24 on 9/18/24. DRM stated once there was an issue her department started to investigate “looking for any gaps or follow up” that needed to be reviewed and noted that Pt 2’s spouse had filed a complaint prior to 9/18/24 about Pt 2’s discharge on 7/11/24. DRM stated, “we noted there were some potential gaps with care at discharge, O 2 (oxygen saturations) had been trending down on the day of discharge and the spouse had reported concerns to the nurse about the patient [Pt 2] not being ready for discharge, this was not escalated at that time and the patient was discharged to a SNF (skilled nursing facility) and came back within 6 hours and needed to be readmitted”. DRM stated MD 6 was sent to peer review (The process of Medical Staff office assigning peer to peer, meaning MD to MD, review of the situation.) on 9/19/24 by risk management because there were concerns that Pt 2 may not have been ready for discharge on 7/11/24. During a review of the facility’s policy titled, “Patient and Patient’s Representative Complaint & Grievance” dated 6/28/23, indicated, “I. PURPOSE A. to meet patients’ reasonable expectations of care and services in a timely, reasonable, and consistent manner. B. To outline the process to receive, investigate, evaluate, and respond to written or verbal complaints or grievances concerning patient care or services by [name of hospital system] ... III. POLICY A. Issues that qualify as grievances include: 1. Complaints that involve allegations of abuse or neglect, endanger, or potentially endanger the patient and issues relating to the hospitals compliance with Centers for Medicare and Medicaid (CMS) hospital Conditions of Participation. 2. Situations where patients or the patient’s representative call or write to [name of hospital system] after discharge from hospital or from a clinic visit about concerns related to care or services, who were not able to resolve their concern during their stay or who did not wish to address their issue during their stay. 3. Situations where the patient or patient’s representative request the complaint be handled as a formal complaint or grievance or when the patient requests a written response from [name of hospital system]. 4. Situations where the issue cannot be resolved at the point of service and is referred to [name of hospital system] administration for later resolution ... C ... 4. Referral to Quality Improvement Organization (QJO): a. Quality Improvement Organization are Centers for CMS contractors charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting. Medicare beneficiary concerns submitted after discharge regarding a quality of care or premature discharge issues will be referred to case management and or internal peer review as appropriate. In the event that the beneficiary does not agree with the resolution, the beneficiary will be informed of his or her right to contact the QJO and provide the contact information. IV. PROCEDURE A. Complaints and Grievances Received Regarding Patient Care. 1. When possible, Complaints are resolved as soon as possible by the person receiving the complaint. 2. If the concerns cannot be resolved by the person receiving the complaint, the chain of command is followed until the complaint can be addressed. The supervisor on duty for the point of service (POS) is contacted. If the supervisor is not available, contact the manager; If the manager is not available, contact the director. 3. A grievance form will be available to the patient to document the nature of the issue or concerns. If the patient needs assistance in completing the form, assistance will be provided by [hospital name] staff. 4. If the situation endangers or potentially endangers the patient, such as neglect, abuse, risk management is to be contacted immediately. 5. Complaints where suit has been threatened or are treated as intent and referred to risk management immediately. 6. Complaints that involve the medical staff are referred to peer review for follow up using the incident reporting Internet system (IRIS). B. Grievance received will be responded to as follows. 1. If Patient Relations does not speak directly to the patient or patient’s representative, a written acknowledgment will be sent to the patient within seven business days to acknowledge receipt of the grievance. 2. A letter will be sent within 30 business days from the date [hospital name] received the grievance to the patient in their preferred language. 3. Grievances will be documented in IRIS and forwarded to Area management for investigation and resolution. a. Point of service leadership or designee will document their findings in IRIS. b. The letter to the patient will have the following elements: i. Name of hospital contact person. Ii. Steps taken on behalf of the patient to investigate the grievance. iii. The results of the grievance process. iv. Date of completion of the grievance process. C. Complaints against physicians. 1. Complaints by the patient or patient’s representative received regarding physicians, podiatrist, allied health professionals and dentists are to be referred to peer review. A letter will be sent to the patient in their preferred language within 30 days of the complaint. V. Documentation. A. All complaints and grievances will be reported and documented in the IRIS system. B. Patient Relations will send a letter of response to all grievances within 30 days of applicable and attached to the IRIS ...” No where in this policy does it say they do not send letters out to family of the deceased.”

“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: 50446 Based on observation, interview, and record review the facility failed to ensure the rights of patients to receive care in a safe environment when: 1. For three of six sampled patients (Patient (Pt) 32, Pt 41, and Pt 42) when licensed nurses assessed Pt 32, Pt 41, and Pt 42’s Columbia Suicide Severity Rating Scale (CSSRS- a suicidal ideation and behavior rating scale which measures the intensity and severity of ideation, behavior and lethality) as high risk for suicide and the one on one sitter (a qualified staff member assigned to constantly observe a patient who is at high risk for suicide to immediately help redirect patient from engaging in harmful acts) assigned was monitoring several other patients at the same time and did not provide constant direct supervision to monitor suicidal behavior to prevent suicidal attempts. These failures resulted in Pt 32, Pt 41, and Pt 42 to not receive care in a safe setting in an event of a suicidal crisis (is a situation in which a person is attempting to kill themselves or seriously planning to do so) due to lack of direct constant supervision and close proximity allowing the potential risk of delayed in immediate intervention if the patient attempts of self-harm. 2. Patient (Pt) 5 came to the Emergency Department with complaints of severe abdominal pain on 2/4/24 at 7:48 p.m., determined to have acute pancreatitis and was admitted. Pt 5 had abnormal vital signs and symptoms of alcohol withdrawal, and was started on the CIWA protocol and cardiac monitoring. Pt 5 was moved from an ED room in the red zone (higher acuity patients) to a hallway gurney in the yellow zone where he remained. Patient 5 had nausea, his abdomen was distended, and his abdominal pain was not relieved by pain medication, and his blood pressure and pulse were elevated. The nursing staff did not appreciate the seriousness of Pt 5’s condition and did not monitor Pt 5 for alcohol withdrawal symptoms in accordance with Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol orders, did not interpret telemetry strips, did not record intake and output, did not document activity, did not evaluate Pt 5 for bladder distention, did not report panic value calcium levels to the physician, did not recognize a change in Pt 5’s condition, and did not document Pt 5’s condition, or details of what occurred in the period of time leading up to the seizure and code blue on 2/6/24 at 12:39 p.m. These failures resulted in Pt 5 experiencing unrelieved pain, delayed intervention for bladder distention, untreated hypocalcemia, seizure and cardiac arrest with anoxic brain injury, and led to Pt 5’s death on 2/10/24. Findings: 1. During a review of Pt 32’s “Emergency Department Patient Care Timeline (EDPCT- a record of key times in a patient’s encounter in the Emergency Department)” dated 9/28/24, the EDPCT indicated Pt 32 arrived in the ED on 9/28/24 at 3:55 a.m. with complaint of rapid heart rate/dizziness. During a concurrent interview and record review on 9/28/24, at 3:45 p.m., with Licensed Vocational Nurse (LVN) 1, Pt 32’s EDPCT and CSSRS flowsheet dated 9/28/24 were reviewed. The EDPCT indicated Pt 32 had a physician order for Suicide Precaution (SP) which included a one-on-one sitter at bedside and a Consult to Specialist on Call (SOC- Psychiatric Emergency consult to manage suicidal ideation). The CCSRS flowsheet indicated Pt 32 was a high risk for suicide and the sitter for one-on-one observation started on 9/28/24 at 3:23 p.m. by PO 5. LVN 1 stated Pt 32 was assessed as a high risk for suicide and the SP was ordered on 9/28/24 at 3:07 p.m. During Observation on 9/28/24 at 3:55 p.m. in the ED Green Zone Special Care Unit (a custom design unit for patients with a specific health condition. SCUs re usually located in a separate space from other patients) room Green (G-02), Pt 32 was sitting up in bed with eyes closed and family member was holding Pt 32’s hand. PO 5 who was assigned as a one-on-one sitter for Pt 32 was sitting outside of Pt 32’s room, in a station located in front of Pt 32’s room looking at two monitor screens. During a concurrent observation and interview on 9/28/24 at 4:09 p.m. with Nurse Manager 6 (NM) 6 in ED Green Zone, NM 6 stated Pt 32 came to the ED for rapid heart and started making comments of suicidal ideation and the physician ordered a one-on-one sitter. NM 6 stated PO 5 was assigned to provide one on one observation to Pt 32 and was also assigned to provide one on one observation to Pt 33 and three other patients on the two monitor screens. NM 6 stated the expectation was to assign a separate sitter for Pt 32 to provide the one-on-one observation. NM 6 stated PO 5 should have not been assigned to provide one on one observation to Pt 32 while also assigned to observed four other patients. During a concurrent observation and interview on 9/28/24 at 4:12 p.m., with PO 5, PO 5 was sitting in the station located outside of Pt 32’s room facing two monitor screens. PO 5 stated she was proving one on one observation to Pt 32, Pt 33, and three other patients on the monitor screen. PO 5 stated it would be difficult to respond immediately in an event of an emergency to one of the patients she was proving one on one monitoring. During a review of Pt 32’s “Nursing Notes (NN),” dated 9/28/24, the NN indicated, “ ...I feel like hurting myself and others. I don’t feel right ... called doctor ... Patient [Pt 32] to be placed on a 1799 until she is evaluated by SOC. Charge nurse was also made aware of the situation. Patient does need a sitter.” During a review of Pt 32’s physician order (PO) titled “1799 Hold” dated 9/30/24, the 1799 hold indicated, “ ...reason for placement-Danger to Self ...” During a review of Pt 32’s “Media Information- Consultation (MIC) [SOC Consult],” dated 10/1/24, the MIC indicated: “ ...Subject- Consult Recommendations. Date and Time of Report- 9/28/24 at 7:25 p.m. Date and Time of Request- 9/28/24 at 3:08 p.m. Reason for consult: Thoughts of self-harm / harm to others. Clinical conclusion: Patient is a 36-year-old female with major depressive, generalized anxiety disorder, ... will be admitted ... experiencing severe anxiety with anxiety attacks, worsening depression, and marginal mood regulation. ... fears that something bad might happen to her, including her acting suddenly with a suicidal behavior .... Patient will benefit from adjusting her psychiatric medication and continuing 1:1 observation for the time being and can be reassessed for safety and psychiatric admission. Disposition recommendation: continue medical treatment with psychiatric recommendation. Treatment and medication recommendation: Continue 1:1 observation and medical hold (1799) status due to remote possibility of suddenly impulsive behavior. Psychiatric medication.... Re-consult access telecare psychiatry in 1-2 days or as needed ...”. During a review of Pt 33’s “EDPCT,” dated 9/28/24, the “EDPCT” indicated “Pt 33 arrived in the ED on 9/27/24 at 11:17 a.m. with arrival complaint BIBA [brought in by ambulance]/5150”. During a review of Pt 33’s “History & Physical (H&P- a comprehensive assessment of a patient’s health that includes medical history, physical exam, and demographics),” dated 9/27/24 at 11:43 a.m. the “H&P” indicated “chief complaint - psychiatric 5150 gravely disabled”. During an interview on 10/01/24, at 3:27 p.m., with Chief Nursing Officer (CNO), the CNO stated, the licensed nurse used whatever resource available to keep patient safe. The CNO stated, when Pt 32 had suicidal ideation and needed a one-on-one sitter, immediately the facility established a plan to keep Pt 32 safe, PO 5 was temporarily assigned to provided one on one monitoring to Pt 32 while looking for another sitter. The CNO stated PO 5 was already assigned as a sitter to Pt 33 whose room was next to Pt 32 and was the closest sitter available to provide one on one monitoring to Pt 32 while also monitoring three other patients on the monitor screen. The CNO stated patients who had physician’s order for one-on-one sitter and not provided a one-on-one sitter placed the patients at risk for harm. During a review of the facility’s “Patient Observer’s Job Description”, dated 9/18/2020, “ ...Job Summary: the patient observer remains in close proximity physical proximity and visual contact with assigned patients whose behavior put them at risk to harm themselves or others .... Essential accountabilities: ... stays with an assigned patient at all times and maintains communication in order to ensure that the patient doesn’t attempt any harmful actions ...complete continuous observation ... documentation as required, answers called lights and response to assigned patients’ needs accordingly ....” 49769 During an observation on 10/2/24 at 4:40 p.m. in the ED Green Zone Green Hallway (GH) room, PO was watching Pt 41 in room GH-03 and Pt 42 in room GH-02 at the same time. During a review of Pt 41’s “Electronic Health Record (HER- a digital version of a patient’s medical history that can be accessed by all healthcare providers involved in patient’s care)” dated 10/2/24, the EHR indicated Pt 41 came to the ED by way of ambulance on 10/2/24 12:36 p.m. for alcohol intoxication and suicidal thoughts. During a review of Pt 41’s “H&P” dated 10/2/24, the H&P indicated, “ ...Pt reporting to wanting to kill himself today and admitted to drinking beers and liquor today and took 3-4 oxycodone pills for his chronic pain, pt has a plan to shoot himself ... ED Treatments: [brand name]-used alone or with other medications to control seizures) ... “. During a review of Pt 42’s H&P dated 10/1/24, the H&P indicated, “... The patient is a 34 y.o. (year old) male who presents to the ED for suicidal ideation’s ... PHYSICAL EXAM: ... Psychiatric: Endorses gen SI (general suicidal ideation) ...”. During a concurrent observation and interview on 10/2/24 at 4:42 p.m. in the ED Green Zone Green Hallway with the Director of Emergency Department (DED), the DED stated Pt 41 and Pt 42 was assessed as a high risk for suicide and should be on one-on-one sitter monitoring. The DED stated the CSSRS was a tool for the license nurse to use to assess the risk of suicide by following the questionnaire instructions and determine the need to implement interventions to keep the patient safe. During a concurrent interview and record review on 10/2/24 at 4:50 p.m. with RN 6, Pt 41 and Pt 42’s “CSSRS” dated 10/2/24 were reviewed. The CSSRS indicated Pt 41 and Pt 42 was a high-risk suicidal patient. RN 6 stated she did the CSSRS questionnaire on 10/2/24 and knew Pt 41 and Pt 42 were a high-risk suicidal patient. RN 6 stated when a patient scores as a “high” on the CSSRS, the physician and the nurse supervisor (NS) should be notified and placed on one-on-one sitter monitoring for safety. RN 6 stated she did not notify the physician and the nurse supervisor on Pt 41 and Pt 42’s CSSRS high-risk suicidal score. RN 6 stated she should have notified the physician and the nurse supervisor of Pt 41 and Pt 42’s CSSRS high risk suicidal score. During an interview on 10/2/24 at 5:20 p.m. with NS 3, NS 3 stated Pt 41 and Pt 42 CSSRS were assessed by RN 6 and Pt 41 and Pt 42 scored high-risk for suicide and she was not notified by RN 6. NS 3 stated it was the responsibility of RN 6 to notify the nurse supervisor of Pt 41 and Pt 42’s CSSRS high-risk for suicide to provide the appropriate supervision and monitoring to Pt 41 and Pt 42. NS 3 stated RN 6 did not follow the hospital’s P&P and Pt 41 and Pt 42 could have hurt themselves. During an interview on 10/2/24 at 5:10 p.m. with the Director of Emergency Department (DED), the DED stated Pt 41 and Pt 42 scored high risk for suicide on the CSSRS and RN 6 did not notify the physician and the NS. The DED stated RN 6 should have notified the physician and the NS to provide a one-on-one sitter for Pt 41 and Pt 42. The DED stated PT 41 and Pt 42 was not assign a one-on-one sitter and Pt 41 and Pt 42 could have harm themselves. The DED stated RN 6 did not follow hospital P&P for high-risk suicidal patients. During an interview on 10/2/24 at 3:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated all hospital P&P were in place to ensure patient safety. The CNO stated any patient not provided appropriate supervision could hurt themselves. The CNO stated the P&P for high-risk suicidal patient to provide one on one sitter monitoring was not followed. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment”, dated 10/20/2022, the P&P indicated, “I. PURPOSE: To identify patients that are at risk for intentionally harming themselves who are presenting to (facility name) with primary behavioral health complaints. To guide nursing interventions in the care of patient at risk for intentionally harming themselves. Patient safety is the primary focus of treatment in this patient population. Treatment goals should always be to provide the highest level of safety ... II. DEFINITIONS: A. 1:1 Observation: 1 staff member is assigned to observe only 1 patient at all times, including while the patient sleeps, toilets or baths ... D. Nurse: Registered Nurse (RN) who has completed training and demonstrates competency in suicide risk assessment and intervention skills ... III. POLICY: B. Columbia Suicide Severity Rating Scale (CSSRS) Lifetime Tool will be used to screen all applicable patients for suicide risk ... H. Nursing interventions utilizing the CSSRS suicide risk score will be risk stratified based on the level of suicide risk (Low, Moderate, High) including risk assessment mitigation strategies; reassessment; patient monitoring ... L. Patients at high risk for suicide are monitored 1:1 ... IV. PROCEDURE: c. For patient who screen Moderate and/or High Risk the nurse will: i. Notify physician of patient states and monitor requirement. ii. Notify charge RN for patient placement in a safe environment ... II. High Risk 1:1 patient monitor ratio ... 2. For patients who present for other primary health concerns and also express suicidal ideation or later express suicidal ideation, the nurse will: ... b. Notify the physician ... d. Call charge nurse to arrange for monitoring ... 5. 1:1 monitoring, can only be discontinued after patient has had a minimum of and MSE [Medical Screening Exam- the process of sorting patients based on medical condition] or CSSRS reassessment is Moderate or Low Risk ... E. Outpatient Areas: ... a. Clinician will notify MD b. Initiate 1:1 monitoring ...”. The Columbia-Suicide Severity Rating Scale (CSSRS) supports suicide risk screening through a series of simple, plain-language questions. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, gauge the level of support that the person needs and to most quickly and simply identify whether a person is at risk and needs assistance. 2. During an interview on 9/30/24 10:22 a.m. with the father and mother (F 5 and M 5) of Patient (Pt) 5, the parents’ concerns about Pt 5’s care were discussed. F 5 stated their son (Pt 5) went to the ED accompanied by his close friend (BF) on 2/4/24 for worsening abdominal pain, was diagnosed with pancreatitis, and was admitted. F 5 stated Pt 5 drank alcohol daily and told the hospital staff and was being monitored for withdrawal symptoms. F 5 stated BF was at the hospital with their son and stayed in touch with them by phone. F 5 stated they planned to make the three hour trip from where they live to the hospital the next day (2/5/24) however the weather was an issue and they ended up driving to the hospital on 2/6/24. F 5 stated they spoke to BF several times during their drive and ten minutes after they hung up with BF and were getting close to the hospital, BF called back to tell them their son had just had a seizure and cardiac arrest. F 5 stated Pt 5 was moved to the ICU and was on a ventilator. M 5 stated she received a call from a nurse that night who told her they would keep him (Pt 5) for a couple of days to make sure he was ok, like there was nothing to worry about but he never regained consciousness and tests showed Pt 5 did not have brain activity. Pt 5’s parents stated at first they were told their son was without oxygen for four to five minutes, but later were told it was actually twelve minutes. Life saving measures were stopped and Pt 5 died on 2/10/24. Pt 5’s parents stated they do not know what happened to their son, why he had a seizure and why he was without oxygen which caused the brain damage. F 5 stated, “How does someone walk into the hospital with pancreatitis and end up dying like this? Why did this happen?” M 5 stated she had reviewed Pt 5’s record and looked up any words or medical terms she wasn’t familiar with in an effort to better understand what happened to her son, but the record did not provide the answers. M 5 stated they came up with a list of their questions and hoped the answers will clarify things for them. M 5 stated reading the record and looking up the medical terms has actually been a positive process for her as she tried to manage the grief. M 5 stated, “I guess they did not do an autopsy.” F 5 and M 5 stated no one at the hospital talked to them about it and they assumed an autopsy would be done to find out why their son died. F 5 stated they feel Pt 5 should have been monitored more closely and not left in the hallway in the ED. F 5 stated Pt 5 should have been moved to the ICU sooner in order to receive the care he needed, and that if he had, he would not have died. During an interview on 10/3/24 at 8:31 a.m. with Pt 5’s best friend (BF), BF stated he drove Pt 5 to the ED on 2/4/24 for worsening abdominal pain. BF stated he was with Pt 5 as much as he could be while Pt 5 was in the ED. BF stated he was in frequent contact with Pt 5’s parents who lived three hours away and were driving to the hospital 2/6/24. BF stated on 2/4/24 when Pt 5 and BF got to the ED, Pt 5 was put in his own room. BF stated Pt 5 drank alcohol daily and Pt 5 informed the hospital staff, and Pt 5 was supposed to be watched for signs of withdrawal. BF stated Pt 5 had lab tests done, imaging done and was given a lot of pain medication. BF stated Pt 5 was told he had pancreatitis. BF stated when he was in his own room the nurses were checking Pt 5 frequently. However, BF stated when he came back in the next morning he found that Pt 5 was on a gurney in the hallway. BF stated after Pt 5 was moved out of his room and into the hallway, it was totally different in that the nursing staff did not check on him like they did when he was in his own room on 2/4/24, the oxygen was not positioned properly on his face, it was halfway off at times, and the oxygen monitor sensor was off of his finger. BF stated the IV pumps and monitors were constantly alarming, and the nurses did not respond to check on the alarms. BF stated one time when the alarm had been going off for a long time and no one came to check on it, Pt 5 could not rest so BF pushed the button on the pump to silence it. BF stated a nurse yelled at him. BF stated there was no one around to help Pt 5 so he (BF) helped Pt 5 get up and walk to the bathroom. BF stated Pt 5 was over six feet tall and weighed over 300 pounds and was not comfortable on a gurney. BF stated in the morning on 2/6/24, there was a significant change in Pt 5. BF stated Pt 5 was confused and was jaundiced. BF stated Pt 5 had tried a few times to urinate but could not. BF stated he helped Pt 5 walk back from the bathroom and get on the gurney, and then the staff brought privacy screens to put next to the gurney, so they could put a catheter in because Pt 5 couldn’t urinate. BF stated as the staff prepared to put the catheter in, something happened with Pt 5 and “all hell broke loose,” and the staff pushed Pt 5 on the gurney from the hallway into a room in another part of the ED to do CPR which BF did not see. BF stated Pt 5 may have had a seizure right before his heart stopped. BF stated he had just talked to Pt 5’s parents ten minutes prior to the code when they were almost at the hospital. Then the code occurred, and BF stated he had to tell Pt 5’s parents what happened. BF stated Pt 5’s parents did not get to see and talk to Pt 5 while he was alert and oriented; when Pt 5’s parents arrived at the hospital Pt 5 was on a ventilator and was not responsive. BF stated he does not understand why Pt 5 was moved from his own room where he was being monitored closely by nurses, to a hallway where there was a lack of help and attention. BF stated Pt 5 was sick, and BF does not think the staff took Pt 5’s condition seriously enough, if they had and monitored him accordingly, he would not have died. During a concurrent interview and record review on 10/1/24 at 12:40 p.m. with the ED manager (NM 6) and the ICU manager (NM 9), Pt 5’s medical record dated 2/4/24 was reviewed. A review of Pt 5’s ED Patient Care Timeline (ED-PCT) dated 2/4/24 at 7:48 p.m. through 2/6/24 at 2 p.m., indicated Pt 5 came to the ED on 2/4/24 at 7:48 p.m. with a chief complaint of Abdominal Pain, Nausea and Vomiting which started that same day (2/4/24) in the morning, pain level 10 (on a scale of 0-10, 0 is no pain, 10 is severe pain). The ED-PCT indicated at 7:54 p.m., Pt 5’s vital signs were Temperature 95.5 degrees Fahrenheit (F- range 97.7-99.5F), heart rate (HR) 97 beats per minute (bpm- range 60-100 bpm), respirations 48 per minute (range 12-20), blood pressure (BP) 90/59 millimeters of mercury (mmHg- range between 90/60 mmHg and 120/80 mmHg). HR and BP were repeated at 7:56 p.m. and indicated HR 125 bpm, and BP 133/97 mmHg. Intravenous (IV) fluids, pain medication, Lab tests, EKG, and due to Pt 5’s disclosed daily alcohol consumption the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol orders were implemented. A CT of the abdomen was completed and indicated acute pancreatitis. 2/4/24 at 11:53 p.m. the ED-PCT indicated admission orders for a CPCU (telemetry unit) bed. During a review of Pt 5’s medical record, the “Head to Toe” flowsheet (a record of the physical assessments performed by nursing) was reviewed. The sections of the flowsheet “Telemetry Strip Analysis” and “Cardiac” indicated from 2/4/24 at 8 p.m. through 2/6/24 at 12:40 p.m. there was no documentation indicating that the telemetry strips from the continuous cardiac monitoring were reviewed. A review of Pt 5’s heart rate during that same time period indicated Pt 5’s heart rate was below 100 bpm just one time, on 2/4/24 at 7:54 p.m. The remainder of the time from 2/4/24 at 7:55 p.m. through 2/6/24 at 8:07 a.m. (the last entry), Pt 5’s heart rate ranged from a low of 108 bpm to a high of 158 bpm. Review of the ED-PCT flowsheet dated 2/4/24 at 7:48 p.m. through 2/6/24 at 2 p.m., indicated the last vital signs taken were at 8:07 a.m.; temperature 98.8 F, HR 111 bpm, RR 20 per minute, BP 105/74 mmHg, oxygen saturation 96%. NM 6 stated the monitor strips are supposed to be reviewed by an RN every four hours and the information entered into the medical record. During a review of Pt 5’s medical record, the “Head to Toe” flowsheet for the Abdominal/Gastrointestinal section of the assessment, the flowsheet indicated on 2/4/24 at 8:31 p.m., Pt 5’s abdomen was rounded and firm, Pt 5 had nausea and was not passing gas. There was no assessment of Pt 5’s bowel sounds or indication of when Pt 5’s last bowel movement was. The next assessment was done on 2/5/24 at 8 a.m. and indicated just that Pt 5 was nauseated. There was no assessment of Pt 5’s abdomen or bowel sounds, or when Pt 5’s last bowel movement was. The next assessment was done on 2/5/24 at 7 p.m. and indicated Pt 5’s abdomen was distended, firm and tender, and that Pt 5 was not passing gas. There was no assessment of Pt 5’s bowel sounds or when his last bowel movement was. The next and last assessment while Pt 5 was in the ED was on 2/6/24 at 8 a.m. and indicated Pt 5’s abdomen was distended, firm and tender. The assessment also indicated Pt 5’s had bruising to his abdomen. There was no assessment of Pt 5’s bowel sounds or when Pt 5’s last bowel movement was. During a review of Pt 5’s medical record, the intake and output flowsheet was reviewed. The flowsheet indicated from 2/4/24 at 8 p.m. through 2/6/24 at 12:40 p.m. there was no intake and output documented for Pt 5. NM 6 stated the intake and output should have been recorded. During a review of Pt 5’s lab results, the lab results indicated Pt 5’s estimated glomerular filtration rate (eGFR-indicates kidney function) was 61 on 2/4/24 (normal is greater than or equal to 90 ml/min/1.73m2), 61 on 2/5/24 and 14 on 2/6/24. Pt 5’s lab results for creatinine (one of the tests to assess kidney function) on 2/4/24 and 2/5/24 was 1.3 mg/dL (range is 0.7- 1.3 mg/dL) and on 2/6/24 it was 4.7 mg/dL. Pt 5’s Lipase level on 2/4/24 was 1920 (high-indicates pancreatitis) and on 2/6/24 at 4:49 a.m. it was 2694, the AST on 2/4/24 was 82 (high), and on 2/6/24 at 4:49 a.m. it was 1432. The ALT was on 2/4/24 was 58 (high), and on 2/6/24 it was 250. During a review of the CIWA monitoring flowsheet dated 2/4/24 at 8 p.m. through 2/6/24 at 2 p.m., the flowsheet indicated on 2/4/24 at 8:54 p.m. the CIWA score was 8. Pt 5’s vital signs were HR 120 bpm, RR 23 per minute, BP 161/119, oxygen saturation 99% on oxygen 2 liters (L) per minute. The flowsheet indicated on 2/5/24 at 12:46 a.m. the CIWA score was 5. At 2:21 a.m. the vital signs were HR 132 bpm, RR 19, and BP 151/109 mmHg. At 2:25 a.m. the HR was 117 bpm, and the RR was 32 per minute. At 3 a.m. the BP was 149/111 mmHg, and at 3:12 a.m. the HR was 143 bpm, and the RR was 25 per minute. At 4:04 a.m. the HR was 136 bpm, and the BP was 142/107 mmHg. Metoprolol (a medication that lowers the heart rate and blood pressure) 5 mg given IV. The CIWA score was 3. Review of the ED-PCT indicated on 2/5/24 at 4:14 a.m., Pt 5 was moved from room 5 in the red zone to a hallway in the yellow zone. Review of the CIWA monitoring flowsheet indicated on 2/5/24 at 4:49 a.m. the CIWA assessment was repeated, and the score was 7. At 5:05 a.m. pt 5’s vital signs were HR 134 bpm, RR 29 per minute, and BP 146/113 mmHg, oxygen saturation 95% on oxygen 2 L/min. The CIWA assessment was done at 5:41 a.m. and the score was 10. Pt anxious and sweating. Lorazepam 2 mg IV given at 5:53 a.m. The flowsheet indicated the next CIWA assessment was not done until 7:15 a.m., around 90 minutes after the last assessment. NM 6 was asked how often the CIWA assessment is supposed to be done and NM 6 stated she would need to look at the orders. Review of the orders indicated for CIWA score 9-15, the assessment is to be done every 30 minutes until it is less than or equal to 8. The CIWA score at 7:15 a.m. was 6, and at 8 a.m. the CIWA score was 9. Pt 5 remained tachycardic and at 10:55 a.m. Pt 5 was given IV metoprolol 5 mg, and a 25 mg extended release tablet for a heart rate of 156 bpm. At 12:30 the CIWA score was 9 and Pt 5 was given Lorazepam 2 mg IV. The flowsheet indicated the CIWA assessment was not done again for ten hours until 2/5/24 at 10:34 p.m. There was no score with that assessment. NM 9 stated a couple of the elements were not assessed so a total score was not reflected. The flowsheet indicated at 10:24 p.m. the Richmond Agitation Sedation Scale (RASS) was assessed and was +2. Pt 5 was given 4 mg of Lorazepam IV. Review of the CIWA protocol orders indicated Lorazepam 4 mg is given if the CIWA score is greater than 15, and then the CIWA score is to be assessed every 15 minutes until it is less than 15. NM 6 stated she does not know why the 4mg dose was given, since there is not a CIWA score associated with it. The flowsheet indicated the next time the CIWA assessment was done was almost five hours later on 2/6/24 at 3:20 a.m., CIWA score 7. The record indicated Pt 5 was given Lorazepam 2 mg IV at 3:23 a.m. followed by Lorazepam 2 mg tablet at 4:33 a.m. Review of the CIWA protocol orders indicated Lorazepam 2mg IV or by mouth is to be given if CIWA score is 9-15. There was no information in the record as to why those two doses of lorazepam were given. Review of the CIWA protocol orders indicated the minimum frequency for the CIWA assessment is every four hours. The flowsheet indicated after the CIWA assessment on 2/6/24 at 3:20 a.m., the next assessment was not done until seven hours later at 10:20 a.m. and the score was 12. Pt 5 was given a Lorazepam 2 mg tablet at 10:40 a.m. The flowsheet indicated the next CIWA assessment was not done until 2/6/24 at 11:40 a.m., an hour and twenty minutes after the last assessment instead of every 30 minutes per the protocol orders. The CIWA score was 11 and Pt 5 was given a Lorazepam 2 mg tablet. The CIWA monitoring flowsheet indicated this was the last CIWA assessment done prior to the code blue at 12:39 p.m. During a review of Pt 5’s medical record, the results review screen in the electronic health record was reviewed. The results review for blood tests done on 2/4/24 at 8:20 p.m. indicated, “Calcium 9.4 mg/dL (range 8.5-10.5 mg/dL),” on 2/5/24 at 3:43 a.m. “Calcium 7.9 mg/dL [low],” on 2/6/24 at 4:49 a.m. “Calcium 5.8 mg/dL [panic],” and on 2/6/24 at 7:36 a.m. “5.9 mg/dL [panic].” The record indicated on 2/6/24 at 06:39 a.m. the lab notified an RN in ED of the critical results for calcium (5.8 mg/dL). There is no documentation in the record of the ED RN’s notification to the physician. The record indicated on 2/6/24 at 9:09 a.m. the lab notified an ED RN of the critical results for calcium (5.9 mg/dL). There is no documentation in the record of the ED RN’s notification to the physician. During an interview on 10/2/24 at 1 p.m. with the laboratory manager (LM), the LM stated critical lab results must be called to the nurse within 10 minutes of the results being posted, and document that notification in the record. The nurse is required to notify the physician of the critical result within 60 minutes and document that notification in the medical record. During a review of the ED-PCT for 2/6/24, the ED-PCT indicated at 12:39 p.m., Pt 5 started seizing and then had a cardiac arrest. The code record indicated the heart rhythm was asystole (electrical and mechanical cardiac activity have stopped). CPR was started and Pt 5 was intubated, medications were given and there was a return of spontaneous circulation (ROSC) after 12 minutes. Pt 5 was transferred to the ICU on 2/6/24 at 2 p.m. The nurses notes and the code record did not have any information about the circumstances leading up to the code. Review of the report for the MRI of head without contrast done on 2/9/24 at 2:29 p.m., indicated, “Diffuse anoxic brain injury with evidence of cerebellar involvement portends to poor prognosis.” The record indicated on 2/10/24 Pt 5 remained unresponsive and Pt 5’s parents made decided to make Pt 5 comfort care and Pt 5 died at 8:40 p.m. The record indicated an autopsy had not been requested. The NM 6 stated they don’t usually speak to the family about this, the physician would do that. NM 6 stated the family could request one, but NM 6 stated she thought they would have to pay for it. NM 6 was asked about the gaps in Pt 5’s care, the failure to follow orders, to monitor I&O, interpret cardiac monitor strips, to monitor alcohol withdrawal symptoms and administer medication according to protocol and physician’s order, the failure to notify the physician of the critical value calcium, the failure to document assessments and patient observations. NM 6 stated, “I can’t disagree with you. But we were in a really bad place at that time (February 2024).” NM 6 was asked if this patient should have been prioritized for a bed in the hospital. NM 6 stated they still provide inpatient care in the hallways. During an interview on 10/1/24 at 4 p.m. with the DED, the issues found during the record review with NM 6 were discussed. The DED was asked what would be done if anything differently for this patient if he were to come in today as opposed to last February. The DED stated Pt 5 was sick and would be prioritized for a bed in the hospital. The DED stated until they were able to get him moved they would keep him in the red zone room with close monitoring. During a review of the reference article from emedicine titled, “Acute Pancreatitis Treatment & Management,” dated 7/14/21, retrieved from https://emedicine.medscape.com/article/181364-treatment, the article indicated, “ ...Medical management of mild acute pancreatitis is relatively straightforward; however, patients with severe acute pancreatitis require intensive care. Both forms of pancreatitis may present in the emergency department (ED) with acute clinical findings. Recognizing patients with severe acute pancreatitis as soon as possible is critical for achieving optimal outcomes. Within hours to days, a number of complications (eg, shock, pulmonary failure, renal failure, gastrointestinal [GI] bleeding, or multiorgan system failure) may develop. The goals of medical management are to provide aggressive supportive care, to decrease inflammation, to limit infection or superinfection, and to identify and treat complications as appropriate. The overall mortality in patients with acute pancreatitis is 10%-15%...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 37529 Based on interview and record review the hospital failed to act on patient care data which showed noncompliance with protocol orders for the assessment and treatment of symptoms of alcohol withdrawal. This failure had the potential to result in negative outcomes to patients experiencing alcohol withdrawal including over sedation and seizures, Findings: During a concurrent observation and interview on 9/17/24 at 3:25 p.m. with the manager (NM) 9 of the intensive care unit (ICU), in the ICU, NM 9 stated he was involved in a project as a result of findings during a previous complaint validation survey. NM 9 stated it was identified that the hospital was not compliant with following the protocol orders for patients who may experience alcohol withdrawal. NM 9 stated the protocol orders are based on the Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR, an assessment tool used by medical professionals to assess and diagnose the severity of alcohol withdrawal). NM 9 stated they reeducated all of the staff, monitored compliance, and then educated some more, but NM 9 stated they still are not compliant. NM 9 stated he thinks one of the barriers to compliance is a confusing order set with monitoring that is too frequent. NM 9 stated they have been working on revising the protocol orders but was unsure of when those would be approved. NM 9 stated until that time the current protocol is being used. The data for the compliance monitoring was requested for the past six months. During a concurrent interview and record review on 10/3/24 at 3:45 p.m. with the Chief Nursing Officer (CNO), the CNO stated the monitoring of compliance with the CIWA protocol was not an official plan of correction in response to a survey deficiency. The CNO stated during a survey it was recognized that the staff were not following the protocol so the clinical nurse specialist (CNS) in ICU educated the staff and was monitoring compliance, but only for the ICU, and the CIWA protocol orders are used other places in the hospital. The CNO stated the reporting of the results of the monitoring of compliance with the protocol is not happening at the moment. It was decided that since it wasn’t a mandatory plan of correction and they were working on order set revisions, they would pause the reporting of the data. The CNO stated the CNS in ICU still did real-time chart reviews, but did not track the data or report compliance as a performance improvement project. The CNO provided a document titled, “ICU CIWA Monitoring Report,” which indicated the “monitoring of a minimum of 10 charts verifying compliance adherence to the Alcohol Withdrawal Order Set to achieve three consecutive months of 100% compliance.” The document indicated in October 2023 they achieved 89% compliance, in November 2023 they did not report data, in December 2023 they achieved 80% compliance, in January 2024 they did not report data, and in February 2024 the achieved 76 % compliance. The document indicated for starting March 2024, “On Hold-Workgroup for order set.””

“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: 37529 Based on observation, interview and record review, the hospital failed to ensure nursing care was provided to all patients in accordance with the hospital’s policies and procedures when: 1. Patient (Pt) 1, a 70 y/o was brought in by ambulance to the Emergency Department (ED) for symptoms of stroke on 8/23/24 and admitted as an inpatient on 8/23/24 on stroke protocol. Pt 1 was not prioritized for a bed in the hospital and remained in the ED on a gurney until 8/27/24, a total of 101 hours. A pressure relief mattress was not provided for two days. Staff did not consider environmental factors related to treatment of the stroke and Pt 1 was subjected to the lights and noise of the ED hallway and staff did not prioritize restorative sleep in Pt 1’s overall care; Pt 1’s family member stated Pt 1 was very uncomfortable and could not sleep. Nursing staff did not administer Pt 1’s asthma medications in a timely manner, and the ordered incentive spirometer (every 1-2 hours) was not initiated during the entire ED stay. Nursing staff did not assess Pt 1’s cardiac monitor strips per policy. Nursing staff were aware of Pt 1’s right sided weakness and did not prioritize or implement interventions to address the use of utensils that could facilitate eating food he could manage. For the four days Pt 1 was in ED, nursing staff did not prioritize nutritional intake and there is documentation of nutritional intake only once. Pt 1’s intake and output were not recorded. The physical therapist’s recommendations for ambulation were not followed, and range of motion to his legs was not provided. Pt 1 was not provided assistance to go to the bathroom in a timely manner the day of admission and as a result was incontinent. He did not receive the speech therapist’s recommended oral hygiene with suctioning twice a day while in the ED. The stroke assessment was not done every twelve hours in accordance with the policy and the physician’s order. The following Policies and procedures were not followed in the care of Pt 1: Cardiac monitoring; Care of the Stroke Patient; Provider Orders; Interdisciplinary Plan of Care; Pressure injury Risk Assessment, Prevention, Staging and Treatment; Admission and Ongoing Assessment- Nursing (Acute Care); Standards of Practice-Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units; Documentation in the Health Record; Standards of Practice, Emergency Department. These failures resulted in Pt 1 not receiving appropriate stroke care for four days causing harm to Pt 4 by depriving him of the specialized care and attention needed during this critical time for recovery in order to minimize the damage caused by the stroke. 2. Pt 2, an 86-year-old male was brought in by ambulance (BIBA) to the ED on 7/2/24 at 6:32 pm for left lower lobe pneumonia (PNA) and was admitted as an inpatient on 7/3/24 at 7:15 a.m. and was not prioritized for an inpatient bed. Pt 2 had an inpatient order and remained in the ED until 7/3/24 at 8 p.m. before transferred to inpatient floor. Pt 2 stayed in the ED hallway on the gurney for approximately 25 hours. Nurses did not develop and implement nursing care plan for pneumonia in accordance with hospital P&P. Nursing staff were not aware of Pt 2’s oxygen saturation decline and was not consistently monitored by nurses. On 7/11/24 nurses did not perform respiratory assessment prior to discharge to a Skilled Nursing Facility (SNF) at approximately. 9:30 a.m. Nurses did not notify the physician of the respiratory status of Pt 2 upon discharge. These failures resulted in an avoidable decline of respiratory status and upon arrival to the SNF, Pt 2 was in acute respiratory distress, with oxygen saturation 86%. Pt 2 was transferred back to the hospital ED and remained in the ED hallway gurney for 33 hours and was found unresponsive and required immediate intubation and admission to the Intensive Care Unit. On 8/8/24 Pt 2 died. 3. Pt 3, an 87 year old with a history of dementia, was BIBA to the ED on 9/15/24 for chest pain and cough, was admitted later the same day on 9/15/24 with possible pneumonia, was not prioritized for a bed in the hospital and remained in the ED until 9/19/24 when he was moved to a bed on the med-surg unit, after spending 104 hours on a gurney in the ED hallway. During his ED stay, Pt 3 who had areas of skin breakdown (on coccyx and head) noted on admission, did not have his care plan interventions implemented for nutrition, did not get a pressure relief mattress pad placed on his gurney until 9/17/24, and did not have his heels elevated off of the gurney mattress until he was moved to the med surg unit on 9/19/24. For Pt 3, nursing did not follow the hospital P&P’s for Interdisciplinary Plan of Care, Pressure Injury Risk Assessment, Prevention, Staging and Treatment, Admission and Ongoing Assessment- Nursing (Acute Care), Standards of Practice-Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, Documentation in the Health Record, Standards of Practice, Emergency Department. These failures led to Pt 3 remaining on a gurney in the hallway, a noisy, bright environment not ideal for a patient with dementia, and resulted in the worsening of the pressure injury to Pt 3’s heel. 4. Pt 4, a 77 year old, came to the ED by ambulance on 9/16/24 from a skilled nursing facility (SNF) after choking on food, and was admitted on 9/16/24 with a diagnosis of pneumonia. Pt 4 was not prioritized for a bed in the hospital and remained in the ED hallway on a gurney for 84 hours before he was moved to the med surg unit. During his ED stay, nursing staff did not perform skin or pain assessments in accordance with policy and procedure, and did not implement measures to relieve pressure on Pt 4’s feet/heels. Nursing staff did not prioritize the importance of adequate nutritional intake and did not record any intake for Pt 4 during his ED stay. For Pt 4, the following Policies and procedures were not followed: Provider Orders, Interdisciplinary Plan of Care, Pressure injury Risk Assessment, Prevention, Staging and Treatment, Admission and Ongoing Assessment- Nursing (Acute Care), Standards of Practice-Acute Adult Medical/Surgical, Telemetry, Stepdown, and Critical Care Units, Documentation in the Health Record, Standards of Practice, Emergency Department. These failures had the potential to result in Pt 4 aspirating food, having unrelieved pain, and developing pressure injuries. Because of the serious actual harm to Pt 1 related to the decline of health in the ED and not appropriately treating the stroke; serious actual harm to Pt 2 related to not adequately assessing and treating respiratory illness; serious actual harm to Pt 3 related to not addressing and treating skin ulcers; and serious potential harm to Pt 4 related to unrelieved pain, aspiration of food and developing pressure injuries; and serious potential harm to each patient for not being prioritized for inpatient bed once determined to need admission an Immediate Jeopardy (IJ) situation was called on 09/26/2024 at 9:25 a.m. under CFR 482.23(b)(6) tag A-0398 Nursing Services with Chief Nursing Officer (CNO) and other hospital leaders. The IJ template was shared with CNO and an explanation was given to submit a Plan of Removal that addressed the IJ situation. Version 1 of the PoR was submitted on 09/26/2024 at 5:08 p.m. and was unacceptable. Version 3 was acceptable on 09/30/2024 at 1:40 p.m. and was acceptable. The PoR addressed the following nursing elements: nursing inservices and education and return demonstration, inpatient placement prioritization process, policy review and monitoring, following hospital policies and procedures in accordance with the needs of patients in the ED and patients admitted to the hospital but remain in the ED. The survey team validated implementation of the actions on the PoR and the IJ was removed on 09/30/2024 at 4:40 p.m. in the presence of the CNO. 5. Three of three patients (Patients 36, 37 and 38) were diagnosed with alcohol withdrawal and nursing staff did not follow the protocol Clinical Institute Withdrawal Assessment for Alcohol (CIWA). These failures resulted in avoidable risk to negative outcomes and clinical decline of alcohol withdrawal, such as, but not limited to, dehydration, electrolyte imbalance, confusion, and seizures. 6. One of one sampled patient (Pt 25) had physician orders for Intake and Output (I&O-a medical measurement of the fluids and food that enter and exit the body) monitoring and the output was not documented in Pt 25’s electronic health record (EHR) by the licensed nurses according to the facility’s policy and procedure “Standards of Practice- ..., Telemetry, Step-Down and Critical Care Units”. This failure resulted in Pt 25’s urine output not being monitored for over 13 hours and had the potential to result in the physician not being accurately notified of Pt 25’s urine output and potentially impact Pt 25’s care, delayed or inaccurate diagnosis and inadequate fluid management. 7. Nurses did not assess and re-assess pain and follow physicians order for pain medication administration for five of seven patients (Pt 15, Pt 19, Pt 29, Pt 32, Pt 40) in accordance with the hospital policy and procedure “Pain assessment and Management- Patients 14 and Older ...” This failure resulted in (Pt 15, Pt 19, Pt 29, Pt 32, Pt 40) not being monitored and had the potential to result in the physician not being accurately notified of (Pt 15, Pt 19, Pt 29, Pt 32, Pt 40) pain and potentially bring about delayed care. 8. The nurse did not follow physician’s order for Telemetry Cardiac Monitoring (TCM-a portable device used to continuously monitor patient’s heat activity) for reading and documenting four of four patients, Pt 15, Pt 27, Pt 28, and Pt 41’s telemetry cardiac strip (a recording of patient’s heart electrical activity) every four hours. This failure had the potential for Pt 15, Pt 27, Pt 28, and Pt 41 to experienced abnormal heart rhythms without the nurse knowing and decreased the chances of early detection and treatments. 9. Nursing staff failed to start Patient (Pt) 23’s diltiazem (a medication that relaxes the blood vessels in the body and lowers the heart rate) drip (continuous intravenous infusion) at the appropriate rate on 8/28/24 as ordered by the physician and failed to document Pt 23’s heart rate (HR) and blood pressure (BP) when titrating (increasing or decreasing the dose of) the drip according to the facility’s policy and procedure. This failure resulted in potential harm to Pt 23. Findings: 1. During a concurrent observation and interview on 9/17/24 at 11:05 a.m. with the Emergency Department (ED) manager (NM 6), in the ED, there were twenty-five patients on gurneys in the hallway outside of the ED rooms in the green and yellow “zones” of the ED.. NM 6 stated the patients in the hallways and many of the patients in the ED rooms (also on gurneys) had admission orders to the med-surg unit or the cardiac progressive care unit (CPCU) but there were no available hospital beds on the inpatient units to move them to. NM 6 stated she does not know whether this means there are no physical beds available or no available nurses to staff the beds. The patients on gurneys in the hallway did not have bedside tables, water pitchers/cups, access to a television or phone. The patients on gurneys in the hallway had minimal privacy with portable privacy screens next to and/or between some of the gurneys, and were surrounded by the lights, noise, and activity of the ED. NM 6 stated the admit hold times had improved and they were averaging about 36 hours holding after admission orders were placed by the admitting physician. NM 6 stated Bed Control (a centralized office which supports the three hospitals and coordinates bed assignments) notifies them when there is a bed assigned for an admitted patient, and NM 6 did not know what the time frame was for moving the admitted patients or where each patient was on the list. NM 6 stated not all of the admitted patients would be moved from the ED to the med surg unit or CPCU. NM 6 stated some of the patients would spend their entire inpatient hospital stay in the ED. NM 6 stated currently there were 62 admitted patients being cared for in the ED. NM 6 stated the hospital had hired and trained nurses to work in the ED specifically to provide inpatient care to the admitted patients, and not to work as ED nurses caring for ED patients. During a review of the complaint submitted by Pt 1’s family member (FM 2) dated 8/27/24, the complaint indicated Pt 1 was a 70 y/o man who came to the ED on 8/23/24 and was diagnosed with a stroke. The complaint indicated Patient 1 remained on the gurney for four days in the ED, two of them in the hallway, before being moved to the telemetry unit (for patients who require continuous cardiac monitoring) on 8/27/24. The complaint indicated during the time Pt 1 was in the ED, the nurses did not get him up to a chair or make sure he walked during the day, or perform range of motion exercises on his legs, took too long to put a waffle pad on top of the gurney, and as a result he was in pain and his legs and back were stiff. The complaint indicated that the weakness in his right arm and hand from the stroke made it difficult for him to hold the utensils needed to eat the food that was provided to him. The complaint indicated Pt 1 had asthma that was made worse by stress and lack of sleep due to the bright lights and noise and was wheezing and uncomfortable, with mucus building up in his throat and that he had to wait for hours to get his asthma treatment and inhaler. The complaint indicated it took too long to get help when requested and Pt 1 did not have a call light or bell during the time he was in the hallway. The complaint indicated Pt 1 needed specialized care due to his diagnosis of stroke and did not get that in the ED. Attempts to reach FM 2 by phone and email were not successful. During a concurrent interview and record review on 9/18/24 at 2:45 p.m. with NM 6, Pt 1’s medical record was reviewed. Review of the ED Patient Care Timeline, dated 8/23/24 through 8/27/24, indicated Pt 1 arrived in the ED by ambulance on 8/23/24 at 3 p.m. with symptoms of a stroke. Pt 1 had a history of high blood pressure, and asthma. Pt 1’s arrival blood pressure was 196/102, heart rate 98 beats per minute, respirations 22 per minute, and oxygen saturation 100% on 6 liters (L)/minute of oxygen. Pt 1 had slurred speech, right sided facial droop, and right sided weakness. Stroke protocol orders were initiated and at 4:04 p.m. Pt 1 was moved to room 4 in the red zone (area of ED where the most acute patients are assigned). An MRI of the brain indicated an “acute central pontine infarct (occurs when blood flow is blocked to a part of the brainstem called the pons, which controls important functions including breathing, swallowing, and heart rhythm), but was not a candidate for an intervention to restore the blood flow because too much time had passed since his symptoms began.. The decision to admit Pt 1 was made at 6:30 p.m. and the admitting physician accepted the patient at 8:02 p.m. Review of the physician’s orders dated 8/23/24 at 9:01 p.m.. indicated, “ ...Admit to inpatient ...Document National Institute of Health Stroke Scale [NIHSS- a systematic, quantitative assessment tool to measure stroke-related neurological deficit] within 12 hours of arrival to the emergency department, then every 12 hours and at discharge, Intake and output every shift, incentive spirometer (a medical device that helps exercise the lungs)10 times every 1-2 hours while awake, neuro checks every 4 hours, cardiac monitoring ...” Review of the admit nurse’s note indicated on 8/23/24 at 9:08 p.m., Pt 1 was to be admitted to the cardiac progressive care unit (CPCU), anticipated diagnosis cerebral vascular accident (CVA [also known as a stroke]- a medical condition that occurs when blood flow to part of the brain is interrupted causing damage to the brain cells), however the record indicated that Pt 1 remained in the ED from the time of arrival on 8/23/24 until 8/27/24 at 8:40 p.m. when he was transferred to CPCU, after having spent 101 hours in the ED on a gurney. Review of the ED Patient Care Timeline dated 8/23/24 through 8/27/24 indicated the NIHSS was assessed at least every 12 hours on 8/23/24 and 8/24/24. On 8/25/24, the NIHSS assessment was done at 8 a.m. and the next time it was assessed was 8/26/24 at 11:49 a.m., almost 28 hours later. NM 6 stated she was not sure how often an assessment of the NIHSS was supposed to be done, and would need to check the orders or policy. Review of the “Head to Toe” flowsheet dated 8/23/24 through 8/27/24, indicated on 8/23/24 “telemetry strip analysis” was documented at 11:04 p.m. and was next assessed 8 hours later on 8/24/24 at 7:49 a.m. After the telemetry strip analysis on 8/24/24 at 11:16 a.m., the next assessment was 6 hours later at 5:18 p.m. After the telemetry strip analysis on 8/24/24 at 11 p.m., the next assessment was 8 hours later on 8/25/24 at 7 a.m. After the telemetry strip analysis on 8/25/24 at 3 p.m., the next assessment was 12 hours later on 8/26/24 at 3 a.m. NM 6 stated the telemetry strips are supposed to be reviewed by the RN every four hours. The monitor tech (MT) prints out the strips and the RN has to review it and enter the specific information into the medical record. Review of the Physical Therapist’s (PT) note dated 8/24/24 at 10:24 a.m., indicated Pt 1 was a high fall risk and required assistance when out of bed. The PT note indicated Pt 1 was assisted by the PT to walk 50 ft, and the PT note indicated recommendations to nursing to ambulate two to three times a day. NM 6 stated they don’t ambulate the patients very often in the ED. Review of the activity flowsheet indicated on 8/23/24, 8/24/24, and 8/25/24 Pt 1 remained “Lying in bed (gurney)” with no documentation that Pt 1 was ambulated, up in a chair, or repositioned. Review of the Speech Therapist’s (ST) Note dated 8/25/24 at 8:17 a.m. indicated, “ ...Plan/Recommendations: 1. Regular texture/thin liquids. 2. Standard aspiration precautions. 3. Aggressive oral care with toothbrush, toothpaste, and concurrent suctioning needed at least twice daily ...” NM 6 was unable to find evidence the speech therapist’s plan for oral care was implemented. Review of the diet orders dated 8/23/24 through 8/27/24 at 10:01 a.m., indicated orders for a diabetic diet on 8/23/24 until 8/26/24 at 5:50 p.m. when there was an NPO (nothing to eat or drink) order. On 8/27/24 at 10:01 a.m. a “heart healthy” diet was ordered. Review of the flowsheet “Daily Cares-Nutrition” dated 8/23/24 through 8/26/24, indicated there was no documentation regarding Pt 1’s nutritional intake, appetite, ability to hold utensils or feed himself on 8/23/24, 8/24/24, and 8/25/24. On 8/26/24 the flowsheet indicated Pt 1 consumed 75% of his lunch, his ability to hold utensils or feed himself was not documented. FM 2’s concerns regarding Pt 1 having asthma and wheezing and having mucus building up in his throat, and having to wait too long for his asthma inhaler and treatment were shared with NM 6. Review of the physician orders indicated on 8/25/24 at 10:21 p.m. the albuterol inhaler was ordered, and on 8/26/24 at 3:20 p.m. the Advair inhaler was ordered. Review of the medication administration record indicated the albuterol inhaler was first given on 8/26/24 at 5:53 p.m., almost twenty hours after being ordered, and the Advair inhaler was given on 8/26/24 at 11:17 p.m., eight hours after it was ordered. There are no nurses notes regarding Pt 1’s request for the asthma medications or regarding there being a delay in getting the medications. Review of the “Daily cares” flowsheet dated 8/23/24 through 8/27/24, indicated no use of the incentive spirometer on 8/23/24, 8/24/24, 8/25/24, 8/26/24, and 8/27/24 until 8 p.m. after he was admitted to the cardiac progressive care unit (CPCU). A chest x-ray done on 8/27/24 indicated, “Bibasilar atelectasis (a collapse in the bottom part of both lungs).” FM 2’s concerns regarding Pt 1 experiencing pain due to being on a gurney for days and not having his pain assessed by the nursing staff were shared with NM 3. Review of the “Skin Integrity Report” dated 8/23/24 through 8/27/24, indicated a pressure relief pad was not put on Pt 1’s gurney until 8/26/24. Review of the “Pain Monitoring” summary dated 8/23/24 through 8/27/24, indicated on 8/23/24 Pt 1’s pain was assessed at 9:54 p.m., and was next assessed 13 hours later on 8/24/24 at 11 a.m., and then 9 hours later at 8 p.m. The next pain assessment was 12 hours later on 8/25/24 at 8 a.m., and then almost 15 hours after that on 8/25/24 at 10:44 p.m. After a pain assessment on 8/25/24 at 11:45 p.m., the next assessment was over 8 hours later on 8/26/24 at 8:16 a.m. After a pain assessment on 8/26/24 at 12:22 p.m., the next pain assessment was almost 8 hours later on 8/26/24 at 8 p.m. After a pain assessment on 8/26/24 at midnight, the next pain assessment was 9 hours later on 8/27/24 at 9 a.m. During an interview on 9/19/24 at 2 p.m. with the Chief Nursing Officer (CNO), and the Chief Operating Officer (COO), and the Vice President of Regulatory and Risk Management (VPRRM), the hospital’s practice of keeping admitted patients in the ED hallways on gurneys was discussed. The CNO stated in the past six months they have been concentrating on orienting and educating the nursing staff on the care of the admitted patients with the goal being that their care in the ED as an inpatient is comparable to the care that patient would receive if they were in a bed on the unit in the hospital. They have hired nurses specifically for the purpose of taking care of the inpatients as well as supervisors and a manager to oversee the staff and the care of these patients. The CNO stated this “unit” (ED-IN, ED Inpatient) is something that is going to be maintained, it is not a short term plan. The ED-IN is not a specific geographical area of the ED, but refers to inpatients in the ED, whatever room, or hallway they are in. The COO stated they have been working on making sure care in the hospital is efficient as possible to ensure patients can be discharged in a timely manner, so patients can get into hospital beds. The CNO stated some patients will be admitted and discharged from the ED without getting to a hospital bed. During an interview on 9/24/24 at 10:55 a.m. with the Director of ED (DED), the gaps in Pt 1’s nursing care were reviewed. The DED stated she was aware of the specific details of the complaint by Pt 1’s family and had spent time speaking with the family member who complained (FM 2). The DED stated when she received the complaint she reviewed the chart and spoke with staff. The DED stated the documentation of the care provided to Pt 1 during the four days he was an inpatient in the ED did not reflect her expectations of the care that should have been provided to Pt 1. The DED stated this was disappointing and she apologized to FM 2. The DED stated the expectation is that the patients in the ED who have been admitted but remain in the ED, receive the same care they would receive if they were in a bed in the intended unit in the hospital. The DED stated this means inpatient nursing policies and procedures and orders are to be followed. During an interview on 9/24/24 at 11:10 a.m. with the DED, the DED acknowledged that inpatients who remain in the ED instead of being admitted to a bed in the hospital will be on a gurney rather than a hospital bed. The DED stated this is not ideal and patients should not have to ask for a pressure relieving pad to be put on the gurney. The DED stated the staff are being told to put the pressure relieving pad on the gurney when the patient gets there, regardless of whether or not the patient has admission orders. The DED stated this week they replaced gurneys with hospital beds in the ED rooms where inpatients stay, but the ED inpatients in hallway “beds” will remain on gurneys due to space constraints. The DED stated she was made aware that Pt 1 was not prioritized for a bed in the hospital even though he had a new diagnosis of stroke because the plan after discharge was for him to go to rehab. The DED stated she was unaware this was the practice and that it has now been stopped. The DED stated they are working on a process to help guide decision-making for prioritizing the assignment of hospital beds to the inpatients in the ED. The DED stated when the speech therapist and physical therapist put recommendations in their note, the staff don’t know to look there. The DED stated a nursing order would need to be entered for whatever the recommendation is. The DED stated they are working on that. During an interview on 9/24/24 at 12:20 p.m. with the DED, the Manager of the ED/ED-IN Manager (MEEM), and the manager of med-surg oncology (NM 7), NM 7 stated she was the one who had oversight of the hiring and orienting of the new staff for the ED-IN unit. She said the majority of them are new grads. NM 7 stated now that a manager has been hired for the ED-IN (MEEM), he will assume oversight of the nursing staff and their training, and will coordinate with the med surg managers as far as training. NM 7 stated the nursing staff hired for this purpose were oriented for 6-8 weeks with an RN from the med-surg/oncology unit. The orientation occurred in the ED. The NM 7 stated the new staff had med-surg training, and were not trained for CPCU (telemetry) yet. NM 7 stated the new staff have six months to get their advanced cardiovascular life support (ACLS) certification, NIHSS training and certification, and basic arrhythmia certification. NM 7 stated the supervisors or experienced nurses in ED will do the telemetry strip assessments if the nurse has not had the training yet. NM 7 stated going forward the orientation and training of any new staff hired for the ED-IN will be 16 weeks long instead of 6-8 weeks long. The NEEM stated they are working on a workflow for the prioritization of moving inpatients in the ED into hospital beds which should be finished next week, and they are working closely with the bed control department. During an interview on 9/26/24 at 10:20 a.m. with the Stroke Supervisor (SS) 1, and two Stroke Coordinators (SC 1 and SC 2), SS 1 stated she was the project lead for the hospital’s primary stroke center (PSC) certification process. SS 1 stated the hospital received Primary Stroke Center certification by Joint Commission in January 2024. SS 1 stated a requirement of the certification is to have designated beds where stroke patients will be admitted, and CPCU is the unit with the designated beds. The education the staff receive as ED nurses focuses on the recognition of a stroke and the initial care. The education and training of the nurses on the unit in the hospital also focus on the ongoing care of the patient. The program’s focus is defined in the order set and standard of care. During a review of the hospital’s policy and procedure (P&P) titled, “Care of the Stroke Patient,” dated 12/19/23, the P&P indicated, “ ...Stable stroke and TIA patients are to be admitted to designated stroke beds, if available. If stroke patients are admitted to a non-stroke bed, oversight will be provided by a clinical supervisor whose has certification in the National Institute of Health Stroke Scale (NIHSS). Stroke trained providers, licensed nurses and code stroke responders are to successfully complete an approved NIHSS Certification and maintain per the institution guidelines. (NIH Stroke Scale Certification) IV. PROCEDURE: On admission, provide a calm, quiet atmosphere. Perform the NIHSS once per shift, upon discharge and whenever a change in neurological status is identified for acute ischemic stroke and TIA patients. If a stroke patient is on a non-neuroscience specific unit, a NIHSS certified RN will perform the NIHSS evaluation ...” During a review of the hospital’s P&P titled, “RN NIH Stroke Scale Certification,” dated 11/14/22, the P&P indicated, “ ...Purpose: To ensure all Registered Nurses (RNs), including contracted staff, obtain National Institute of Health (NIH) Stroke Scale certification prior to assuming care of stroke patients. Policy: NIH stroke scale training: Initial validation and annual re-validation completed online for nurses who identify and manage acute stroke patients ...” During a review of the hospital’s P&P titled, “Cardiac and Remote Monitoring - Inpatients 14 and Older,” dated 6/14/24, the P&P indicated, “ ...Patients are to receive the care appropriate for their diagnoses or procedure including cardiac monitoring as ordered by a provider. Orders for Cardiac monitoring are based on these guidelines ...Tier I: Cardiac monitoring is indicated in most, if not all, patients in this group. This category includes all patients who are at significant risk of an immediate life-threatening arrhythmia ...Cardiac arrest ...new onset heart failure ...acute stroke ...All telemetry/cardiac monitored patients are to receive continuous cardiac monitoring unless otherwise ordered by a provider ...Staff assigned to units providing continuous cardiac monitoring will demonstrate competencies as described in procedure ...All monitored patients will have rhythm strips printed for admission, transfer, temporary removal, any rhythm abnormalities, and every 4 hours for the duration of the cardiac monitor order. All cardiac rhythm strips will be placed in the patient’s thin chart to be scanned into the EHR after discharge. The assigned RN/designee is responsible for validating and documenting the patient’s rhythm and any changes and interventions that occur. The RN will date and sign the cardiac monitoring strip printed by the Monitor Tech (MT) every 4 hours ...” During a review of the hospital’s policy and procedure (P&P) titled, “Standards of Practice - Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units,” dated 2/22/23, the P&P indicated, “These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in the Critical Care, Step-Down/Progressive Care, Telemetry, and Medical/Surgical units, within [Name of Hospital System] ... Licensed professionals are accountable for assigned patient care until end of shift, physical transfer, hand-off to another licensed staff member, or patient discharge. Unlicensed staff members are to provide care as assigned and/or delegated to them until end of shift, physical transfer, or patient discharge ... If there is a difference between the physician order and the standards below [in this policy], the one that is stricter will be followed ...” During a review of the P&P attachment titled, “Standards of Practice-Documentation Grid,” dated 2/22/23, the P&P attachment indicated, “ ...Pulse, Respirations, and Blood Pressure & Pain Assessment- General Medical /Surgical- Every 8 hours and as needed, unless otherwise ordered. Telemetry, Progressive Care/Stepdown: Every 4 hours and as needed, unless otherwise ordered. Intake and Urine Output- General Medical /Surgical-Every 8 hours as needed, unless otherwise ordered; Telemetry, Progressive Care/Stepdown- Every 4 hours unless otherwise ordered ... Cardiac Monitoring: PR, QRS, QT, Rate, Rhythm, and Ectopy- General Medical /Surgical- Not Applicable (Exception: Centrally monitored patients: continuous monitoring and document every 4 hours.); Telemetry, Progressive Care/Stepdown: Continuous monitoring and document every 4 hours ...” During a review of the hospital’s P&P titled, “Provider Orders,” dated 08/25/23, the P&P indicated, “ ... I. PURPOSE A. to provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan. II. DEFINITIONS C. Orders Categories 2. Urgent/ As Soon As Possible (ASAP) .... The process of obtaining the requested tests, studies or procedures are initiated and completed within 4 hours of the request ....3. STAT- The process of obtaining the requested tests, studies or procedures are initiated and finalized within 1 hour of the request ... III. M....The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ... R. The RN and LVN are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area ...” During a review of the hospital’s P&P titled, “Standard of Practice for Emergency Department,” dated 9/23/24, the P&P indicated, “ ...These Standards of Practice are necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive by the Emergency Departments (ED) ... The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: Adhere to all established policies/procedures, Intervene appropriately to correct unsafe situations, Follow the Infection Control policies found in the Infection Control Manual. The patient will have a systematic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will: Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician order. The data is to include a health history and physical assessment to determine patient’s capabilities, limitations, nutritional, physiological, psychosocial, cultural, and environmental needs/problems. Vital signs with pain assessment a minimum of every 4 hours unless otherwise ordered or warranted. Total intake/output monitored based on order or warranted by condition. Follow established policies/procedures when implementing nursing care. Implement physician orders. Follow the recommendations for wound management as described in the Corporate Patient Care Policy Manual. Maintain and/or improve skin integrity during hospitalization through appropriate nursing interventions. Promote patient comfort, cleanliness, and sense of well-being by assisting with activities of daily living (ADL’s). Reposition patient every 2 hour or more frequently, as needed. Document the condition of the skin as warranted, frequency of re-positioning, use of comfort measures and pressure relieving device. Follow the standard as adopted by [Name of hospital] for pain management using the [Name of Hospital] assessment tool. Document the nursing interventions/patient responses in the medical record ...” During a review of the hospital’s policy and procedure (P&P) titled, “Interdisciplinary Plan of Care,” dated 10/12/23, the P&P indicated, “ ...The Plan of Care is to be used for all patients admitted to [Name of Hospital] with time measurable goals evaluated daily and at discharge. The appropriate disciplines (e.g., physical therapy, speech/language pathology, registered dietitians) are to document on the Plan of Care within their scope of practice upon assessment and when changes to the established treatment plan occur. A Plan of Care is to be initiated as soon as possible and completed within 24 hours of admission or prior to any procedure. Patient’s care needs and planning are based on an assessment of their needs (physical, psychosocial, spiritual and cultural), the severity of their disease, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patient’s plan for care ...” During a review of the article titled “Acute Stroke,” dated 8/17/23. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK535369/, the article indicated, “Stroke survivors should be directly admitted from the ED to specialized stroke inpatient units to enhance outcomes. This practice reduces mortality rates and promotes increased patient independence during the inpatient stay ...Due to its proven benefits, initiating rehabilitation as early as possible following a stroke is recommended. Inpatient teams commonly comprise stroke clinicians, nurses, speech and language therapists, physiotherapists, occupational therapists, and assistants. Early rehabilitation enhances health outcomes, promotes patient confidence, and improves self-care abilities ...” During a review of the article from the NINDS-National Institute of Neurological Disorders and Stroke found at https://www.ninds.nih.gov/health-information/stroke/recovery, the article indicated, “ ...National Institutes of Health (NIH) Stroke Scale (NIHSS) helps health care providers assess the severity of a stroke. Health care providers use it to measure neurological function and deficits by asking the person to answer questions and perform several physical and mental tests. This checklist of questions and tasks scores a person’s level of alertness and ability to communicate and perform simple movements ...Rehabilitation is vital to stroke recovery.. Rehabilitation therapy usually first takes place in the hospital within 48 hours of a stroke. It often starts with exercises to help overcome any paralysis or weakness. Recovering the ability to do basic activities of daily living is the first stage in the return to independence after having a stroke ...” During a review of the National Library of Medicine, Stat Pearls article titled, “Incentive Spirometer and Inspiratory Muscle Training,” dated 4/27/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK572114/, the article indicated, “An incentive spirometer is a device that measures the volume of the air inhaled into the lungs during inspiration. The incentive spirometry device is widely used in physical, speech, and respiratory therapy as it encourages the patient to perform a slow and deep inspiration through visual feedback ...Stroke induces important alterations in the respiratory system due to respiratory muscle and/or postural impairments related to central nervous system lesions. Alterations of phasic and tonic patterns of respiratory muscles commonly lead to respiratory muscle weakness, altered breathing patterns, and diminished lung volumes. Postural modifications resulting from motor impairments also decrease functional efficiency of diaphragm contraction, causing an impaired inspiration leading to numerous respiratory complications ... Breathing exercises may positively affect the quality of life, hyperventilation symptoms, and lung function in adults with mild to moderate asthma ...” During a review of the Mayo Clinic article titled, “Atelectasis,” dated 11/8/23, retrieved from https://www.mayoclinic.org/diseases-conditions/atelectasis/symptoms-causes/syc-20369684, the article indicated, “ ...Atelectasis is the collapse of a lung or part of a lung, also known as a lobe. It happens when tiny air sacs within the lung, called alveoli, lose air. Risk factors include: Any condition that makes it hard to swallow. Needing to stay in bed a long time and not having enough changes of position. Lung disease, such as asthma ...” 2. During a review of Pt 2’s demographic face sheet (FS) dated 9/18/24, FS indicated Pt 2 was an 86-year-old male, admitted on 7/2/24 at 6:44 p.m. with the diagnosis of multifocal pneumonia (PNA-infection in the lungs). During a concurrent interview and record review on 9/18/24, at 2:30 p.m., with the Manager of Medical Surgical Unit (NM) 8 and the Director of Inpatient Services (DIS), Pt 2’s Electronic health records (EHR) for his admission starting 7/2/24 was reviewed. NM 8 stated, “No care plan for pneumonia” was created for Pt 2, “yeah it would have been a good one to put in a diagnosis specific care plan”. NM 8 stated there was no order to monitor Pt 2’s oxygen levels and after reviewing Pt 2’s vital sign flow sheet dated 7/2/24-7/11/24, Pt 2’s oxygen levels were not monitored consistently, on 7/9/24 no oxygen saturations were documented. NM 8 stated routine vital signs should have been done for Pt 2, which means VS should be done every 8 hours but an order is required to monitor the oxygen saturations with the VS. During an interview on 9/24/24, at 9:17 a.m., Nurse Supervisor (NM) 4 for Medical-Surgical, NS 4 stated she was the clinical supervisor on 7/11/24. NS 4 stated “we need to individualize the care plans” since Pt 2 was diagnosed with PNA a care plan for this diagnosis would have been appropriate. During a concurrent interview and record review on 9/24/24, at 11:04 a.m., with Registered Nurse (RN) 7, Pt 2’s EHR for his admission starting 7/2/24 was reviewed. RN 7 stated she took care of Pt 2 on 7/10/24 and 7/11/24. RN 7 stated Pt 2 was being treated for PNA and was discharged on 2 liters nasal cannula (NC) oxygen on 7/11/24. RN 7 stated a care plan for PNA should have been created for Pt 2, “nurses are responsible creating the care plan”. RN 7 stated care plans are important to help tell nurses what is going on with a patients care and to monitor them to see if the patient is improving and ready for discharge. RN 7 stated she was not aware that a specific order was required for oxygen saturations. RN 7 stated she was aware that Pt 2’s oxygen sats on discharge was 91 % on 2 l NC but did not notice Pt’s 2 oxygenation trend that showed Pt 2 oxygen levels were going down and he was requiring more oxygen. During an interview on 10/2/24, at 3:20 p.m., with the Chief Nursing Officer (CNO), the CNO stated the expectation is nursing would have created a care plan for Pt 2’s PNA diagnosis. During a review of the facility’s policy titled, “Interdisciplinary Plan of Care” dated 10/12/23, indicated, “PURPOSE A. To promote the provision of consistent, cost-effective and safe patient care. B. To promote a role-based interdisciplinary approach to patient care. C. To promote interdisciplinary collaboration in order to develop a Plan of Care that is individualized, age and developmentally appropriate, and takes into consideration the physical, psychosocial, spiritual, and cultural needs of the patient and their family. D. To meet regulatory requirements. E. To instruct staff on the appropriate use of evidence based Plan of Care. II. DEFINITIONS A. Care Plan/Plan of Care: A comprehensive, interdisciplinary approach to patient care from entry into the system until discharge. Phases of care are designed to address individual patient problems, expected outcomes and an interdisciplinary treatment plan. The intent of the care plan is to meet the patient’s individualized needs and create a collaborative and communicative environment for all the members of the health care team. The care plan contributes to the role-based decision-making process by considering the stability of the patient and incorporating data collection, patient assessment, plan of care, implementation, evaluation, patient/family teaching, and care coordination ... III. POLICY A. The Plan of Care is to be used for all patients admitted to [name of facility] with time measurable goals evaluated daily and at discharge. B. The appropriate disciplines (e.g., physical therapy, speech/language pathology, registered dietitians) are to document on the Plan of Care within their scope of practice upon assessment and when changes to the established treatment plan occur. C. A Plan of Care is to be initiated as soon as possible and completed within 24 hours of admission or prior to any procedure. (Refer to Admissions/Assessment/Nursing policy). Elements of the plan of care are found throughout the patient’s EHR. D. The development, implementation, and maintenance of a patient’s plan of care is an interdisciplinary process. All disciplines involved in the care of a patient collaborate to develop the patient’s plan of care. Each health care team member provides input into the plan of care. The patient/family/significant other is included in the development, implementation, maintenance, planning and evaluation of the care provided. E. Patient’s care needs and planning are based on an assessment of their needs (physical, psychosocial, spiritual and cultural), the severity of their disease, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patient’s plan for care ...” 3. During a concurrent interview and record review on 9/23/24 at 12 p.m. with NM 6, Pt 3’s medical record was reviewed. Review of the ED Patient Care Timeline dated 9/15/24 at 1:56 p.m., indicated Pt 3 was brought to the hospital by ambulance with complaints of chest pain and a cough for four days. Pt 3 was 87 years old, had a history of dementia, and was a full code. After a chest x-ray indicated possible pneumonia, admit orders for med-surg were initiated on 9/15/24 at 7:30 p.m.. The admit assessment indicated Pt 3 had wounds to the skin on his head and coccyx. Review of the Interdisciplinary Care Plan (ICP) dated 9/15/24 through 9/19/24 indicated on 9/15/24 a plan was initiated for the problem “Risk of Impaired Skin Integrity,” with the goal/intervention “Promote oral nutritional intake including dietary supplements as ordered, promote physical activity, proper surface selection.” On 9/16/24 a plan was initiated for the problem “High Risk for Skin Integrity Impairment,” with the interventions “Heels off bed surface with pillows/ air-filled boots, apply pressure relief surface as appropriate, assist to chair/chair position for meals and at least twice a day, consult dietary, nutritional supplementation, oral intake promotion.” On 9/19/24 the dietician initiated a plan for the problem “Nutrition-Altered.” Review of the ICP did not indicate a plan for pneumonia. Review of the nutrition flowsheet dated 9/15/24 at 2:06 p.m. through 9/19/24 at 9:55 p.m., indicated there was no documentation of nutritional intake on 9/15/24. The flowsheet indicated on 9/16/24, Pt 3 ate 75% of breakfast with a fair appetite, and no other nutritional intake or supplements for the rest of the day. The flowsheet indicated no nutritional intake (meals or supplements) for 9/17/24 and 9/18/24, and on 9/19/24, the flowsheet indicated Pt 3 ate 75% of breakfast. NM 6 stated his meal intake should have been recorded. There was no indication of supplements given or oral intake encouraged and no dietary consult until 9/19/24, despite the planned interventions indicated on the ICP initiated on 9/15/24 and 9/16/24. Review of the Wound Care/Skin Integrity flow sheet dated 9/15/24 through 9/19/24, indicated on 9/15/24 at 2:30 p.m., the nurse identified a reddened area on Pt 3’s coccyx and a foam dressing was applied. There was also a wound on Pt 3’s head. On 9/15/24 at 10 p.m. the nurse indicated the dressing on the coccyx was dry and intact, and indicated there was a wound on Pt 3’s neck. On 9/16/24 at 1:35 a.m. the Braden Scale score was 14 (Braden Scale-assessment tool to identify risk of pressure injury; scores range from 6-23, a lower score means higher risk). On 9/16/24 at 8 a.m. the skin assessment indicated the presence of the coccyx area dressing and the wound on Pt 3’s head, and the Braden score was 9. On 9/16/24 at 9:52 p.m., the skin assessment identified the coccyx and the head, and the Braden score was 10. The flow sheet indicated on 9/17/24 at 1:27 a.m. a pressure relief mattress pad was put on the gurney. On 9/18/24 at 11:40 p.m., the skin assessment indicated the presence of the coccyx area dressing, a wound on Pt 3’s head and neck, and the Braden score was 12. On 9/19/24 at 8 p.m., the Braden score was 13, and the skin assessment indicated the presence of the coccyx dressing, and a wound on Pt 3’s head and neck. The flowsheet indicated from 9/15/24 at 2 p.m. until 9/19/24 at 9:55 p.m. when Pt 3 was moved to a bed on the med surg unit, Pt 3 was not up in a chair for any meals, and did not have his heels positioned off of the gurney mattress. On 9/19/24 at 10 p.m., the flow sheet indicated there were dressings on Pt 3’s coccyx and heel. Review of the ICP dated 9/20/24 after Pt 3 had been moved from the ED hallway to a bed on the med surg unit, indicated a plan was initiated for “Pressure Injury Care and Treatment,” with interventions for cleansing of wounds, assessment, wound nurse consult, low air loss mattress and heel elevation. Review of the Wound Care/Skin Integrity flow sheet dated 9/20/24 at 12:55 a.m., indicated Pt 3 had a low air loss mattress, his heels were elevated off of the bed, and on the afternoon of 9/20/24, the wound nurse saw Pt 3.. Review of the “Pain Monitoring” summary dated 9/15/24 through 9/19/24, indicated on 9/16/24 Pt 3’s pain was assessed at 8 a.m. and the next time a pain assessment was done was almost fourteen hours later at 9:52 p.m. The summary indicated after Pt 3’s pain was assessed on 9/16/24 at 10:30 p.m., the next time a pain assessment was done was ten hours later on 9/17/24 at 8:29 a.m. The summary indicated after Pt 3’s pain was assessed on 9/17/24 at 11:38 a.m., the next time a pain assessment was done was eleven hours later at 10:41 p.m.. The summary indicated on 9/18/24 there were seventeen hours in between pain assessments, and on 9/19/24 there were twelve hours in between pain assessments. During an interview on 9/25/24 at 4:45 p.m., with the Chief Nursing Officer (CNO), the gaps in care of Pt 3 were discussed. The CNO stated her expectation is for admitted patients who remain in the ED to receive the same level of care they would receive if they were in a bed in the hospital. The CNO stated the ED leadership is developing criteria for prioritization of bed assignment and will be meeting twice a day with bed control to discuss which patients need to be prioritized to move out of the ED into a hospital unit. The CNO stated elderly patients with skin breakdown would need to be prioritized. The CNO stated they are reeducating the staff regarding the need to document meal intake, follow the physical therapist’s and speech therapist’s recommendations, implementing the physician’s orders and developing a care plan. The CNO stated they stopped the practice of “skipping over” patients who may go to a SNF when prioritizing bed assignments. The CNO stated that was probably a factor in the case of Pt 3. During a review of the International Wound Journal article titled, “Preventing pressure injuries in the emergency department: Current evidence and practice considerations,” dated 1/21/19, the article indicated, “ ...The prevention of hospital-acquired PIs (HAPIs) remains a significant clinical challenge internationally. These largely preventable injuries can lead to decreased quality of life, pain, suffering and increased morbidity, and in some cases mortality. In addition, HAPIs can increase patient length of stay and health care costs and may expose the hospital to litigation. As 40% of hospitalized patients are admitted through the ED, it is critical that prevention begin at this point of entry to the acute health system. Generally, the greater acuity and complexity of the patient’s condition combined with longer length of stay in the ED results in a significant and continuously growing risk of developing a HAPI. Patient position on an ED stretcher is also a risk factor whether it is from prolonged lying in the supine position or having the head of the stretcher elevated at 30 degrees to maintain respiratory integrity. Elevation of the head of the stretcher increases the pressure and shear forces exerted on the sacrum and significantly increases the risk of a sacral PI. The successful implementation of contemporary PI prevention strategies in the ED may require not only education of all ED staff on the ED incidence rates and pathogenesis of PI but also the evidence of which patients are at greatest risk, recommended preventative interventions, and the need for ongoing monitoring. Similarly, the ED staff bears the responsibility of understanding the positive or negative impact their care has on an admitted patients’ skin integrity ...” 4. During a concurrent interview and record review on 9/23/24 at 12:15 p.m. with NM 6, Pt 4’s medical record was reviewed. Review of the ED Patient Care Timeline dated 9/16/24, indicated Pt 4 was brought to the hospital by ambulance from a skilled nursing facility (SNF) at 1:23 p.m. after Pt 4 choked on a piece of food, which paramedics removed with a laryngoscope. The record indicated Pt 4 initially had a Glasgow coma scale (GCS-A clinical scale used to measure a person’s level of consciousness, based on their ability to perform eye movements, speak, and move their body. A score of 15 means a person is fully awake, responsive and has no problems with thinking ability or memory) score of 5 when the paramedics responded to the SNF, which improved to a GCS of 13 (Pt 4’s baseline) by the time Pt 4 arrived at the hospital. Pt 4’s medical and surgical history included diabetes on insulin, peripheral neuropathy (occurs when nerves that are located outside of the brain and spinal cord [peripheral nerves] are damaged. This causes weakness, numbness and pain, usually in the hands and feet.), peripheral vascular disease (a circulation disorder that causes narrowing, blockage, or spasms of blood vessels to parts of the body other than the brain and heart), dementia, chronic back pain, back and neck surgery, high blood pressure, pacemaker insertion, chronic obstructive pulmonary disease (COPD) and kidney disease. Pt 4 was admitted on 9/16/24 with a diagnosis of aspiration pneumonia and Pt 4 remained in the ED hallway on a gurney until 9/19/24 at 11:57 p.m. when he was transferred to the med-surg unit. Review of the Interdisciplinary Care Plan (ICP) dated 9/16/24 through 9/19/24 indicated on 9/16/24 a plan was initiated for the problem “Risk of Impaired Skin Integrity,” with the goal/intervention “Promote oral nutritional intake including dietary supplements as ordered, promote physical activity, alleviate pressure, apply protective dressing when appropriate, proper surface selection.” Review of the ICP dated 9/20/24 after Pt 4 had been moved from the ED hallway to a bed on the med surg unit, indicated a plan was initiated for “Pressure Injury Care and Treatment,” with interventions for cleansing of wounds, assessment, wound nurse consult, and a dietary consult. Review of the Speech Language Pathologist (SLP) consult note dated 9/17/24 at 10:01 a.m. indicated, “3 ounce water test: Fail- Coughed during or immediately after ...SLP provided patient education regarding diet recommendations and aspiration precautions [taking small sips with liquids and chew food well] and Plan of Care, however, unclear extent of patient understanding or retention of information due to history of dementia.” Review of Pt 4’s nutrition flowsheet dated 9/16/24 at 8 p.m. through 9/19/24 at 11:57 p.m., indicated there was no documentation of intake of meals or nutritional supplements from 9/16/24 through 9/19/24. There was no indication of supplements ordered or oral intake encouraged despite the planned interventions indicated on the ICP initiated on 9/16/24. Review of the Wound Care/Skin Integrity flow sheet dated 9/16/24 through 9/19/24, indicated on 9/16/24 at 8:18 p.m., the skin assessment indicated a skin tear on Pt 4’s coccyx, foot, and leg, and the Braden Scale assessment score was 13. On 9/17/24 at 8:05 a.m. the skin assessment indicated a skin tear and redness on Pt 4’s coccyx, foot, and leg. The skin assessment on 9/17/24 at 7:30 p.m. indicated the presence of a skin tear and redness on Pt 4’s coccyx and the Braden score was 13. On 9/18/24 at 9 a.m. the skin assessment indicated the skin integrity was “intact” and the skin integrity location was “generalized,” with no skin tears or reddened areas, and the Braden score was 16. NM 6 stated she does not know what the nurse meant by “generalized” or how there would be no reddened areas or skins tears present during this assessment and an improved Braden score. The skin assessment on 9/18/24 at 9 p.m. indicated there was redness to Pt 4’s buttocks, and the Braden score was 13. The skin assessment on 9/19/24 at 8 a.m. indicated redness on Pt 4’s coccyx, and the Braden score was 12. Pt 4 was moved from the ED hallway to the med surg unit on 9/19/24 at 11:57 p.m. and the skin assessment done after arrival to the med surg unit on 9/20/24 at 12:04 a.m. indicated the presence of a redness and skin tear on arm and coccyx, a foam dressing was applied to the coccyx, and the foot of the bed was elevated to relieve pressure on Pt 4’s heels. The flowsheet indicated from 9/16/24 at 8 p.m. until 9/19/24 at 11:57 p.m. when Pt 4 was moved to a bed on the med surg unit, Pt 4 did not have a protective foam dressing applied to his coccyx despite having redness identified on admission. Pt 4 did not have his heels positioned off of the mattress until Pt 4 was moved to med-surg on 9/19/24 at 11:57 p.m., despite Pt 4’s history of peripheral neuropathy, and peripheral vascular disease, and having a reddened area and skin tear identified on his leg and foot on 9/16/24. Review of the “Pain Monitoring” summary dated 9/16/24 through 9/19/24, indicated on 9/16/24 Pt 4’s pain was assessed on arrival to the hospital, and the next pain assessment was done ten hours later at 11:30 p.m. The summary indicated Pt 4’s pain was assessed on 9/17/24 at 4:23 a.m. and the next pain assessment was done fifteen hours later at 7:30 p.m. On 9/18/24 Pt 4’s pain was assessed at 5:24 a.m., and the next pain assessment was done over seven hours later at 12:48 p.m., and after that the next pain assessment was done over eight hours later at 9 p.m. on 9/18/24. The summary indicated Pt 4’s pain was assessed on 9/19/24 at 8 a.m. and the next pain assessment was done nine hours later at 5 p.m. During an interview on 9/25/24 at 4:45 p.m., with the Chief Nursing Officer (CNO), the gaps in care of Pt 4 were discussed. The CNO stated her expectation is for admitted patients who remain in the ED to receive the same level of care they would receive if they were in a bed in the hospital, and that the nursing staff follow all hospital policies and procedures. The CNO was asked about the decision to keep Pt 4 in the hallway on a gurney for days rather than prioritizing him for a bed in the hospital, knowing the elderly are at increased risk for pressure injury. The CNO stated previously there was not a consistent process to guide the decision-making in terms of which patients need to go to a bed next, and there is a prioritization workflow being developed now involving bed control and the ED supervisor.. The CNO stated Pt 4 may be one of the patients who was “skipped over” instead of being moved to a bed on med-surg because he came from a SNF and would be returning there. The CNO stated this practice was stopped as of 9/20/24. During a review of the International Wound Journal article titled, “Preventing pressure injuries in the emergency department: Current evidence and practice considerations,” dated 1/21/19, the article indicated, “ ... Patients are generally becoming older and have more comorbid conditions and consequently require more complex care and assessment on admission to the ED. Concurrently, we have seen the demand for ED care increase within an environment of limited increases in available bed stock in hospitals. A consequence of these and other factors is that a greater number of older and sicker patients are unable to be transferred to a ward in a timely manner, often resulting in a longer length of stay in the ED ...Pneumonia, which is also common in ED patients, particularly the elderly, may impair tissue oxygenation levels even further if present and add greater biochemical stress as cells are pushed into an anaerobic metabolic state that lowers tissue pH. In addition, the overall mass of soft tissues surrounding the sacrum may be diminished in older individuals, and the anchoring between the skin layers is typically compromised. These factors, taken together, make the sacral region of the elderly highly vulnerable to PIs ...” During a review of the AHRQ Patient Safety Resource titled, “Preventing Pressure Ulcers in Hospitals,” retrieved from https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html, the resource indicated, “ ...Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented. Several specific factors should be considered as part of the risk assessment process: ... Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels ...Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers ...” . 5. During a review of Pt 36 demographic (face sheet- with name, date of birth, date of visit, reason for visit and more) sheet dated 10/2/24, indicated Pt 36 was a 28-year-old (yo) male admitted on 9/26/24 at 11:11 p.m. with diagnosis of Alcohol withdrawal (set of symptoms that occur when someone who is physically dependent upon alcohol suddenly stops drinking can include headaches, nausea, tremors, anxiety, hallucinations, and seizures) During a concurrent interview and record review on 10/2/24 at 2:33 p.m. with Manager of Emergency Services (NM) 6, Pt 36’s Electronic Health Records (EHR) for Admission dated 9/26/24 was reviewed. NM 6 confirmed Pt 36 was admitted for Alcohol withdrawal and was placed on the CIWA protocol on 9/26/24 at 11:28 p.m. Order set was for Phenobarbital (medication used to prevent seizures and withdrawal symptoms from alcohol) for Alcohol Withdrawal indicated, “ ... Assess once upon admission and then as indicated below according to score: Mild Severity (Score 0-8): Monitor every hour until CIWA- Ar (score) is less than or equal to 8 x 4 hours consecutively, then every 4 hrs; Moderate Severity (Score 9-15): Monitor every 30 minutes PRN per CIWA - Ar (score) until CIWA - Ar (score) is less than 8; Severe Severity (Score greater than 15): Monitor every 15 minutes PRN per CIWA - Ar (score) until CIWA - Ar is less than 15; Discontinue CIWA - Ar assessment when CIWA - Ar is less than or equal to 8 for 72 hours. (CIWA Protocol)” Review of Pt 36’s CIWA flowsheet dated 9/26/24-9/28/24 indicated first CIWA Score as 24 at 11:57 p.m., second CIWA Score as 20 at 12:25 a.m. next CIWA Score done at 2 a.m. was a 21; next CIWA Score was done at 8:38 a.m. was a 6; next CIWA Score was done at 7:30 p.m. was a 2. NM 6 stated the CIWA protocol was not followed for Pt 36, CIWA score should have been checked 15 minutes after giving medication for score of 24 and after score of 20 and there was a gap, and next score was done at 2 a.m. when it should have been done 15 minutes later. NM 6 stated “something bad could happen to the patient” if not being monitored appropriately. The NM 6 stated after the 2 a.m. CIWA score of 21 Pt 36 should have been monitored 15 minutes later with another CIWA score given instead the CIWA flowsheet shows the next CIWA score was done at 8:38 a.m. and was a 6 and then the next CIWA was done at 7:30 p.m. During an interview on 10/2/24 at 3:30 p.m., with the Chief Nursing Officer (CNO) stated the expectation is that staff follow the CIWA protocol and follow the orders given by the physicians. During a review of the facility’s policy titled, “Provider Orders” dated 8/25/23, indicated, “I. PURPOSE A. To provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician’s orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician’s orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ...” During a review of Pt 37’s demographic sheet dated 10/2/24, indicated Pt 37 was a 33 yo female admitted on 9/29/24 at 4:40 a.m. with diagnosis of Alcohol Withdrawal. During a concurrent interview and record review on 10/2/24 at 4:47 p.m. with Clinical Nurse Supervisor (NS) 7 in Intensive Care Unit (ICU) and NS 8, Pt 37’s EHR were reviewed for her admission starting 9/29/24. NS 7 and NS 8 confirmed Pt 37 was admitted with the diagnosis of Alcohol Withdrawal and was placed on a CIWA protocol starting 9/29/24 at 8:24 a.m. During a review Pt 37’s order titled “Clinical institute Withdrawal Assessment for Alcohol ... Lorazepam for Alcohol Withdrawal Orders ...” follow the CIWA Protocol. During a review of Pt 37’s flowsheet for CIWA indicated on 9/30/24 at 4:09 p.m. CIWA score 10, next score at 4:47 p.m. was a 4, next score at 6 p.m. is a 4, next score at 8:30 p.m. was a 3, next score was done on 9/31/24 at 3 a.m. and was a 2, next score at 8 a.m. was a 6, next score done at 11 a.m. was a 5, next score done at 7 p.m. was a 3. CNS 2 stated after medication given for score of 10 at 4:09 p.m. for Pt 37, Pt 37 should have been monitored every 30 minutes and if score between 0-8 then monitor every hour times 4 hours and if below an 8 can then monitor every 4 hours and this was not done. NS 8 stated if the CIWA protocol was not followed patient could have had symptoms of withdrawal that were not managed to include seizures. During an interview on 10/2/24 at 3:30 p.m., with the CNO stated the expectation is that staff follow the CIWA protocol and follow the orders given by the physicians. During a review of Pt 38’s demographic sheet dated 10/2/24, indicated Pt 38 was a 72 yo male admitted on 9/23/24 at 12:04 p.m. with diagnosis of Acute Metabolic Encephalopathy (a condition that occurs when the body lacks oxygen, glucose, or vitamins; can be caused by alcohol). During a concurrent interview and record review on 10/2/24 at 2:55 p.m. with Nurse Manager (NM) 9 of the Intensive Care Unit (ICU), Pt 38 EHR were reviewed for his admission starting 9/23/24. Corey confirmed Pt 38 was admitted with Acute Metabolic Encephalopathy and severe alcohol withdrawal and was placed on a CIWA protocol order date 9/23/24 at 5:07 p.m. During a review of Pt 38’s order titled “Clinical Institute Withdrawal Assessment for Alcohol” dated 9/23/24 at 5:08 p.m. indicated, “ ... Phenobarbital for Alcohol Withdrawal ...” follow the CIWA Protocol. During a review of Pt 38’s flowsheet for CIWA indicated on 9/23/24-9/24/24 at 5:30 p.m. first CIWA score was a 14, next score at 6:17 p.m. was a 15, next score at 6:34 p.m. was a 6, next score at 8 p.m. was a 13, next score at 9:01 p.m. was a 10, next score at 10:10 p.m. was a 9, next score at 11 p.m. was a 11, next score at midnight was a 10, next score on 9/24/24 at 1 a.m. was a 10. NM 9 stated the CIWA protocol for Pt 38 was not followed. During an interview on 10/2/24 at 3:30 p.m., with the Chief Nursing Officer (CNO) stated the expectation is that staff follow the CIWA protocol and follow the orders given by the physicians. 6. During a review of Pt 25’s “Patient Demographics (PD)” dated 9/24/24, the indicated a 82-year-old female was admitted to the hospital on 9/23/24 at 6:22 p.m., with an admission diagnosis of atrial fibrillation with rapid ventricular response (a type of irregular heartbeat that occurs when the heart’s electrical signals are disorganized). Pt 25 was discharged home on 9/24/24 at 12:03 a.m. During a review of Pt 25’s “Emergency Department Patient Care Timeline (EDPCT)” dated 10/1/24 and “History and Physical (H&P)” dated 9/24/24 at 8:19 p.m., the EDPCT indicated “Pt 25 arrived in the ED on 9/24/24 at 7:46 p.m. (returned to the ED 19 hours and 49 minutes later after being discharged on 9/24/24)”, the H&P indicated “Pt 25 came to the hospital with a chief complaint of generalized weakness heart rate of 161 (normal resting heart rate for adults is between 60 and 100 beats per minute), temperature of 100.4 (fever), a white blood cell count of 20 (normal number of WBCs in the blood is 4.5 to 11) and urinary tract infection (a bacterial infection that affects the bladder, urethra, and kidneys)”. During a review of Pt 25’s “Intake and Output (I&O- a measurement of the fluids that enter and exit the body) Order” dated 9/25/24 at 3:06 a.m., the (I&O) Order indicated, “ ... Order Details- Frequency: PER ROUTINE ... Duration: until specified ...” During a review of Pt 25’s “I&O Flowsheet” dated 9/26/24, the I&O flowsheet indicated there was no documentation of urine output on 9/26/24 from 6:57 a.m. to 8:49 p.m. (13 hours and 8 minutes). During a concurrent interview and record review on 10/2/24 at 11 a.m. with Nurse Supervisor (NS) 5, Pt 25’s I&O flowsheet dated 9/26/24 was reviewed. NS 5 stated the last documentation of urine output was documented on 9/26/24 at 6:56 a.m. and it was 600 milliliters (mls-unit of measurement). NS 5 validated the next documentation of urine output was documented on 9/26/24 at 8:50 p.m. and it was 500 mls. NS 5 stated staff should have documented urine output because Pt 25 had a UTI and had physician orders for intake and output monitoring. During an interview with Registered Nurse (RN) 10 on 10/2/24 at 2:27 p.m., RN 10 stated urine output was documented every four hours. RN 10 stated her practice was to document urine output every four hours. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders,” dated 08/25/23, the P&P indicated, “I. PURPOSE A. to provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan. II. DEFINITIONS C. Orders Categories 1. Routine - .... procedures are initiated and completed within 24 hours ... M....The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ... During a review of the facility’s P&P titled, “Standards of Practice- Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” dated 9/25/2024, the P&P indicated, “...I. PURPOSE These standards of practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in the critical care, step down/ progressive care, telemetry, and medical/ surgical units within [hospital] II. DEFINITIONS B. Documentation: Assessment findings recorded in the patient’s electronic health record (EHR). III. POLICY B. If there is a difference between the physician order and the standards below the one that is stricter will be followed (e.g. physician orders intakes and output measured every 12 hours but the unit standard every eight hours; the unit standard will be followed). IV. STANDARDS. See standards of practice documentation grid ...Document: Intake and Urine Output: ...Telemetry/ Progressive Care / Stepdown: Every 4 hours unless otherwise ordered ... V. DOCUMENTATION: ... will be completed in the EHR per standards of practice documentation.” 7. During a review of Pt 15’s “Patient Demographics (PD) “ (a document providing demographic information about the patient including name, date of birth, admission date, emergency contact) dated 9/24/24, the PD indicated a 68-year-old male was admitted to the hospital on 9/16/24 at 6:47 p.m., with an admission diagnosis of urinary tract infection (UTI-a bacterial infection that affects the bladder, urethra, and kidneys). During a concurrent interview and record review on 9/23/24 at 1:48 p. m. with the Director of the Emergency Department (DED), Pt 15’s “Pain Monitoring Summary (PMS)”, dated 9/17/24 was reviewed. The PMS indicated Pt 15 was administered Morphine (narcotic, strong pain medication) 15 milligrams (mg-unit of measurement) by mouth at 8:32 p.m. for a pain score of 3 out of 10 (a pain screening tool used to assess pain severity 0 no pain, one-three mild pain, four-six moderate pain, seven-nine severe pain, 10 worst pain), no reassessment was completed. The DED validated there was no documentation of onset, duration and type of pain. The DED stated the expectation for the licensed nurses was reassessment should be completed within 60 minutes after pain medication was administered. The DED stated if a Patient’s pain was not reassessed the patient could experience respiratory depression (when the lungs do not exchange gases properly, causing a low breathing rate), hypotension (when blood flows through your blood vessels at lower than normal pressures), allergic reaction (when your immune system overreacts to substances), or could be found unresponsive. During a review of Pt 19’s PD dated 9/24/24, the PD indicated a 55-year-old female was admitted to the hospital on 9/16/24 at 2:13 a.m., with an admission diagnosis of ureteral colic (a condition that causes severe pain in the urinary system and abdomen). During a concurrent interview and record review on 9/23/24 at 11:40 a.m. with the Nurse Supervisor (NS) 2, Nurse Manager (NM) 3 and Nurse Manager (NM) 4. Pt’s 19’s PMS and hospital’s P&P “Pain assessment and Management- Patients 14 and Older ...” was reviewed. Pt 19 had physician orders for Ketorolac (medication used to treat moderate-to-severe acute-onset pain) 15 mg Intravenous (IV- administered into a vein) and Hydrocodone-acetaminophen 5-325mg (potent drug for moderate-to-severe pain control in postoperative patients). Pt 19 was evaluated for pain on 9/16/24 at 8:32 a.m., with a score of 6 out of 10, was administered Ketorolac 15mg at the same time, the pain assessment did not include location, onset, duration and type of pain. Pt’s pain was reassessed at 11 a.m. At 11:35 a.m., Pt 19 had a pain score of 4 out of 10 and Hydrocodone-acetaminophen 5-325mg 1 tablet was administered. NS2 validated that there was no reassessment for Hydrocodone-acetaminophen and the Ketorolac was reassessment after over 2 hours. NS 2 stated PO (medication taken by mouth) medication should be reassessed within an hour and IV medication should be reassessed within 30 minutes. NM 3 stated the policy was not followed, no documentation could be seen. NM 3 stated pt 19 had the potential to have an increase in pain, a change in respiration status (how well a person is exchanging air), or sedation (A state of calmness, relaxation, or sleepiness caused by certain drugs). During a review of Pt 29’s PD dated 9/24/24, the PD indicated a 56-year-old female was admitted to the hospital on 9/2/24 at 1:03 p.m., with an admission diagnosis of Colonic Mass (growths that form on the inside lining of the colon caused by colon cancer).” During a concurrent interview and record review on 9/20/24 at 2:00 p. m. with the Nurse Manager (NM) 2 and Director of Stepdown & Surgical Telemetry/Intensive Care Unit (DSSI), Pt 29’s “Surgical operative Report dated 9/4/24, Operative Report dated 9/12/24 and Medication Administration Record (MAR) were reviewed. Pt 29 had an endoscopy (a medical procedure that allows a doctor to examine the inside of the body using a flexible tube with a camera and light) 9/3/24 had surgery on 9/4/24 for a bowel obstruction (when the small or large intestine is blocked, preventing food, liquid, gas, and stool from passing through normally), had a left percutaneous nephrostomy tube placement (a procedure where a small, flexible tube through your skin into your kidney to drain your urine) on 9/6/24, Image guided drainage catheter placement (a minimally invasive procedure that uses imaging guidance to insert a catheter into a fluid collection or abscess in the body) on 9/19/24. Pt 29’s MAR indicated: - Hydromorphone (potent opioid medication for managing moderate-to-severe acute and severe chronic pain) IV 1 mg was administered for pain 10 out of 10 on 9/10/24 at 11:35 a.m., and pain was reassessed at 12:35 p.m., Pt 29 had a pain score of 6 out of 10, no further action was taken. - Hydromorphone IV 1 mg was administered for pain 8 out of 10 on 9/15/24 at 8:37 a.m., and reassessed at 9:37 a.m. - Hydromorphone IV 1 mg was administered for pain 8 out of 10 on 9/15/24 at 3:50 p.m., and reassessed at 4:50 p.m. - Hydromorphone IV 1 mg was administered for pain 7 out of 10 on 9/16/24 at 9:27 p.m., and reassessed at 10:27 p.m. - Hydromorphone IV 1 mg was administered for pain 7 out of 10 on 9/17/24 at 5:23 a.m., and reassessed at 6:23 a.m.. NM 2 stated the nurses did not follow the hospitals policy on pain assessment and reassessment. NM 2 stated the expectation for nursing staff was the Patient’s pain should be reassessed and documented within 30 minutes. NM 3 stated if pain was not reassessed the Pt could have uncontrolled pain and could have changed hemodynamically (relating to or involving blood circulation). During a review of Pt 32’s “History and Physical (H&P)” dated 9/28/24, the H&P indicated a 36-year-old female was history of anxiety (an emotion that can feel like fear, dread, or uneasiness) and chronic pain presented to the emergency department (ED) with intermittent episodes of rapid heart rate (a heart rate that’s faster than 100 beats per minute (bpm) while resting), chest pain (a feeling of discomfort or pain in the chest that can feel like a dull ache, sharp stab, burning, or crushing sensation), and shortness of breath since 11 p.m. The ED Patient care timeline indicated that Pt 32 arrived at the ED on 9/28/24 at 3:55 a.m. During an interview on 9/27/24, at 8:37 a. m., with Registered Nurse (RN), RN 3 stated if Patients were on IV medication reassessment should be completed within 30 minutes and if oral pain medications were administered pain should be reassessed within 60 minutes. RN 3 stated a pain assessment was part of the patients of vital signs (VS-measurements of the body’s basic functions, such as breathing, heart rate, and temperature) .... RN 3 stated if pain was not assessed a patient may not get the adequate medication, and nurses may not relieve the pain and without reassessment there was a possibility of overdosing. During an observation of the ED on 9/28/24 at 3:10 p.m., Pt 32 was heard screaming in the ED. Licensed Vocational Nurse (LVN) 1 attended to Pt 32 at 3:13 p.m., Pt 32’s pain score was 10 out of 10. During a concurrent interview and record review with LVN 1 on 9/28/24, at 3:45 p.m., Pt 32’s “PMS” was reviewed. LVN 1 stated Hydrocodone - acetaminophen 15 mg PO was administered to Pt 32 for pain 7 out of 10 on 9/28/14 at 11:12 a.m. LVN 1 stated Pt 32’s pain was reassessed at 12:05 p.m. and Pt 32’s pain score was 5 out of 10. LVN 1 validated no other interventions were completed to address Pt 32’s pain. During a review of Pt 40’s PD dated 9/24/24, the PD indicated a 60-year-old female was admitted to the hospital on 9/12/24 at 6:39 p.m., with admission diagnosis of “Pulmonary Embolism (a life-threatening medical emergency that occurs when a blood clot or other substance blocks an artery in the lungs)”. During a concurrent interview and record review on 9/20/24, at 12:45 p. m., with the NM 2 and the DSSI, Pt 40’s MAR dated 9/12/24 was reviewed. NM 2 validated Pt 40’s was administered hydromorphone IV 1 mg for pain score 10 out of 10, reassessment was not performed 30 minutes after the pain medication administration but was performed at 11:11 p.m. and Pt 40 was still in severe pain 7 out of 10, duration was continuous. NM 2 stated there was no documentation of acceptable level of pain. NM 2 stated reassessment of patients for IV medication is within 30 mins. The DSSI stated patients should be reassessed up to 30 mins after IV medication administration. The DSSI stated the previous policy was not the standard. During a concurrent interview and record review with the DED on 9/20/24 at 1:14 p. m. Pt 40’s MAR dated 9/12/24 was reviewed. The DED validated Hydromorphone IV 1 mg was administered at 8:42 p.m., The DED stated the expectation was for the licensed nurse to find the physician and get to the bottom of why the pt was having severe pain .... get more comfort measure, some intervention to get the pain alleviated. The DED stated, severe pain indicates something potentially is emergent. The DED stated the licensed nurse should have determined why Pt 40 was in still in pain. The DED stated it was paramount that pain control was achieved. The DED stated severe pain in patients is unacceptable. During a review of the facility’s Policy and Procedure (P&P) titled, “Pain Assessment & Management- Patients 14 and Older”, dated 9/13/24, the P&P indicated, “PURPOSE: A. To demonstrate [Hospital Name] commitment to a patient’s right to effective pain management. B. To establish standards of nursing care and practice that defines the role and responsibilities of the Nurse to provide pain management and monitor for potential adverse effects ... III. POLICY: A. It is the policy ... to provide safe and effective pain treatment for all patients ... B. Pain screen is used to determine if pain is present ... D. Pain management tool is a reliable and validated tool used to measure clinical pain intensity and approved for use ... E. A sedation scale will be utilized for assessment on all patients receiving opioid medications. IV. PROCEDURE: ... 5. Assess and reassess pain using one of the following scales as appropriate. a. 0-10 pain intensity scale ... The appropriate pain rating scale is used to determine an appropriate pain management modality ... 6. Pain management scales utilizing the 0-10 descriptors, will be assessed as a pain rating of 0=no pain, 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain. Patients’ denial of pain will be interpreted as 0....11. For patients receiving opioid medications, assess and reassess sedation level using one of the following skills as appropriate a. Pasero opioid induced sedation scale (POSS) [a tool used to rank sedation and agitation] ... b. Richmond agitation and sedation scale (RASS) [a tool used to rank sedation and agitation] ...D. Implementation ... 1. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider ... E. Evaluation/Reassessment of Pain Management ...2. Reassessment: Pain intensity, level of sedation, respiratory rate and pattern, if receiving opioids, and presence of all adverse effects will be reassessed after each unscheduled pharmacological pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect. a. Generally, IV medication is effective within 30 minutes and PO/ IM medication is effective within 60 minutes. This re-assessment will be documented in the EHR using the appropriate pain and sedation scale. 4. Compare post intervention pain level to acceptable level of pain women intervention effectiveness ...5. If upon reassessment at the appropriate interval for the patient condition ...., the patient’s pain remains above the acceptable level notify the provider ... 6. Evaluate and reassess for side effects of treatment and risk factors for adverse events caused by treatment ... F. ...2. Monitor patients receiving opioids for opioid induced respiratory depression and sedation by using either the RASS or POSS assessment tools along with respiratory rates and pattern assessment during routine and post pharmacological reassessment time frames. V. DOCUMENTATION: ... 2. Subsequent reassessments should include the following: intensity, location, response to treatment modalities (the way in which something happens or is experienced) and type of pain assessment scaled used ...3. Inclusion of sedation, respiratory rate and pattern and any adverse effects with routine pain assessments and reassessments with active opioid medications ordered ....VI. PATIENT EDUCATION: ... 2. The patient’s pain and the effective treatment is an important part of the treatment plan ...4. The need to communicate all relieved pain so that they may receive prompt evaluation and effective treatment”. The “Lippincott Manual of Nursing Practice 10th Edition,” dated 2014, page 16-17 indicated, “ Standards of practice General Principles... 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable ...b. These standards provide patients with a means of measuring the quality of care they receive ...5. A deviation from the protocol should be documented in the patient’s chart with clear, concise statements of the nurse’s decisions, actions, and reasons for the care provided, including any apparent deviation ... Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record ... Failure to formulate or follow the nursing care plan ...” Review of National Institutes of Health.gov Professional Reference titled, “Access to Pain Management as a Human Right”, dated January 2019, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301399/#:~:text=The%20right%20of%20all%20people%20to%20have%20acknowledgment%20of%20their,by%20adequately%20trained%20health%20professionals.%E2%80%9D ) indicated, “ ...The right of all people to have acknowledgment of their pain and to be informed about how it can be assessed and managed. “Article 3. The right of all people in pain to have access to appropriate assessment and treatment of the pain by adequately trained health professionals ...”. 8. During a review of Pt 15’s Patient Demographics (PD) (document providing demographic information about the patient including name, date of birth, admission date, emergency contact and more), dated 9/24/24, the PD indicated Pt 15 was a 68-year-old male admitted to the hospital on 9/16/24 at 6:47 p.m., with an Admission Diagnosis of Urinary tract infection (UTI- a bacterial infection that affects the bladder, urethra, and kidneys). During a concurrent interview and record review on 9/23/24 at 1:48 p.m. with Director of Emergency Department (DED), Pt 15’s “Cardiac Monitoring Order (CMO)”, dated 9/17/24, Cardiac /Telemetry Flowsheet (CTF) was reviewed. The CMO indicated Pt 15 had an order for TCM on 9/17/24 at 8.22 a. m... Frequency: Continuous, Level: Tier II: Indication for Monitoring: New and/or potential for cardiac arrhythmia ...” The DED stated the nurse did not document Pt 15’s telemetry cardiac strip reading on the CFT. The DED stated in the ED, the telemetry cardiac strip reading was done hourly or every four hours depending on the case of the patient. The DED stated the reason for the TCM was to assess cardiac rhythm and identify irregular heartbeats. The DED stated the expectation was for the nurse to place the TCM once ordered by the doctor and to read and document the telemetry cardiac strips. During a concurrent interview and record review on 9/25/24 at 11:36 a.m. with Medical Director 2- Hospitalist (MD) 2, Pt 15’s CMO dated 9/17/24 was reviewed. MD 2 stated, Pt 15 had orders for TCM because his Hemoglobin (Hb- carries oxygen in the blood from the lungs to body tissues) dropped from baseline and had hyponatremia (low salt in the blood), which placed Pt 15 at risk for hypotension (low blood pressure) and cardiac arrhythmia (electrical impulse in the heart now working properly). MD 2 stated Pt 15 was categorized under Tier II- Indicated for Monitoring: New and/or potential for cardiac arrhythmia. MD 2 stated, for Tier I, the expectation was for the licensed nurses to place the TCM on the patient immediately, and for Tier II, the expectation was for the licensed nurses to place the TCM on the patient within 30 minutes. MD 2 stated irregular heartbeats could be missed if patient was not placed in TCM which could lead to delay of care. During a review of Pt 27’s PD dated 9/25/24, the PD indicated Pt 27 was a 69-year-old female admitted to the hospital on 9/24/24 at 6:53 p.m., with an Admission Diagnosis of Weakness Generalized. During a concurrent interview and record review on 9/25/24 at 5:27 p.m. with Nurse Manager (NM) 6, Pt 27’s CMO dated 9/24/24 and CTF dated 9/25/25 and were reviewed. NM 6 stated Pt 27 had orders for TCM. NM 6 stated the nurse did not document Pt 27’s telemetry cardiac strip reading on the CFT. NM 6 stated the hospital nurses are not documenting telemetry cardiac strip reading on the CFT and should have. During a concurrent interview and record review on 10/01/24 at 3:37 p.m. with MD 3, Pt 27’s CMO dated 9/24/24 and CTF 9/25/25 were reviewed. MD 3 stated Pt 27’s CMO indicated STAT (urgent) physician order for continuous on 9/24/24 at 11:07 p.m. MD 3 stated the nurse did not document Pt 27’s telemetry cardiac strip reading on the CFT. MD 3 stated the nurse should have documented Pt 27’s telemetry cardiac strip reading on the CFT. During a review of Pt 28’s PD, the PD indicated Pt 28 was a 59-year-old female admitted to the hospital on 9/19/24 at 1:58 p.m., with an Admission Diagnosis of Bacteremia (the presence of viable bacteria in the circulating blood) and was transferred on 9/20/24 at 4:50 p.m. to another acute care hospital. During a concurrent interview and record review on 9/24/24, at 5:43 p.m. with MD 1, Pt 28’s CMO and CTF dated 9/19/24 and 9/20/24 were reviewed. The CMO indicated PT 28’s TCM was ordered on 9/19/24 at 6:55 p.m., and the CFT indicated the nurse initial documentation of the telemetry cardiac strip reading was on 9/20/24 at 3:00 a.m. MD 1 stated there was an eight-hour delay in reading and documenting Pt 28’s telemetry cardiac strip. MD 1 stated the potential outcome when the nurse did not read, and document Pt 28 telemetry cardiac strip was for Pt 28 could have suffered a cardiac arrest without the nurse knowing which could lead to death. During a review of Pt 41’s PD dated 9/25/24, the PD indicated Pt 41 was a 77-year-old female admitted to the hospital on 9/20/24 at 1:20 p.m., with an Admission Diagnosis of Symptomatic sinus bradycardia (a heart rhythm where your heart beats slower than expected) and was discharged on 9/27/24. During a concurrent interview and record review on 9/25/24 at 5:27 p.m. with NM 6, Pt 41’s CMO and CTF dated 9/20/24 and 9/21/24 were reviewed. NM 6 stated Pt 41 had a physician order on 9/20/24 at 1:53 p.m. for STAT continuous TCM Tier I indicated for patients who are significant risk of an immediate life-threatening arrhythmia. NM 6 stated the nurse did not read and document Pt 41 telemetry cardiac strip every four hours and only documented on 9/20/24 at 2 p.m., 8 p.m. and on 9/21/24 at 3:30 a.m. NM 6 stated the potential outcome when the nurse did not read, and document Pt 41’s telemetry cardiac strip as ordered by the physician, the nurse could have a missed the opportunity to catch an abnormal heart rhythm when it happens which could lead in delayed treatment. A. Cardiac Monitoring: continuous cardiac monitoring, which is the visualization of the electrical activity in the heart, through a portable or hardwired monitoring system with the use of retaliatory transmitter. III. POLICY. ...1. Tier I ... cardiac monitoring is indicated in most... This category includes all patients who are at significant risk of an immediate life-threatening arrhythmia... 2. Tier II: cardiac monitoring may be of benefit in some patient but is not as essential for all. a. sepsis c. significant risk of cardiac or respiratory arrest f. New and /or potential for cardiac arrhythmia ... C. A provider’s order is required to initiate cardiac monitoring and that order is time limited D. All telemetry/ cardiac monitor patients are to receive continuous cardiac monitoring unless otherwise ordered by a provider. VI. DOCUMENTATION A. ...The assigned RN/designee is responsible for validating and documenting the patient’s rhythm ... B. The RN will date and sign the cardiac monitoring strip ... every 4 hours ...Routine Cardiac monitoring documentation includes the patient’s rate, rhythm ...This documentation will be a minimum of every 8 hours or by unit standard (4 hours in Emergency Department) in the Electronic Health Record ...” During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders,” dated 08/25/23, the P&P indicated, I. PURPOSE A. to provide guidelines for initiating and n/or updating the physician’s therapeutic treatment plan. II. DEFINITIONS C. Orders Categories 2. Urgent/ As Soon As Possible (ASAP) .... Procedures are initiated and completed within 4 hours of the request ....3. STAT- The process of obtaining the requested test ..., procedures are initiated and finalized within 1 hour of the request ... III. M....The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ... During a review of the facility’s policy and procedure (P&P) titled, “Standards of Practice- Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” dated 02/22/2022, the P&P indicated, “ ...II. DEFINITIONS B. Documentation: Assessment findings recorded in the patient’s electronic health record (EHR). Untitled document attached indicates ...Cardiac Monitoring ... Continuously monitoring and document every 4hours.” 9. During a review Pt 23’s “History and Physical (H&P)”, dated 8/24/24, was reviewed. The “H&P” indicated Pt 23 had a history of poorly controlled diabetes (a chronic disease that occurs when the body cannot produce or use insulin properly, resulting in high blood sugar levels), , chronic kidney disease (a progressive condition that occurs when the kidneys are damaged and cannot filter blood properly), persistent atrial fibrillation (a type of irregular heartbeat that lasts more than a week that can lead to a stroke), had a removal of a damaged spinal disc on 8/20/24 , and came by ambulance to the facility after a ground level fall. During a review of Pt 23’s “Diltiazem Order (DO)”, dated 8/24/24, the “DO” indicated, “ ... diltiazem ... 125 mg [milligram, a unit of measure] in D5W [5% dextrose {sugar} water] in 125 mL [milliliters, a unit of measure] IV [intravenous] infusion ... 2-15 mg/hr [per hour] ... Admin Instructions: Start at 10 mg/hour. Titrate [increase or decrease] by 5 mg/hour every 30 minutes to a goal effect of heart rate: 60-120 BPM [beats per minute]. When infusion is increased, rebolus [give extra dose] (see separate order) over 1 minute ... Patients are to be continuously monitored with vital signs documented every hour (for ICU [Intensive Care Unit]) or every 2-4 hours (for CPCU/SDU [Cardiac Progressive Care Unit/Step Down Unit] and with each titration ... Contact prescriber if heart rate less than 60 or greater than 120 BPM; and/or systolic [larger number] blood pressure less than 60 or greater than 200 mmHg [millimeters of Mercury, a unit of measure] ...”. During a review of Pt 23’s “Diltiazem Rebolus Order (DRO)”, dated 8/24/24, the “DRO” indicated, “ ... diltiazem 5 mg IV every 30 minutes PRN [as needed] ...”. During a concurrent interview and record review on 9/20/24 at 2:10 p.m. with Nurse Manager (NM) 1 and Nurse Supervisor (NS) 1, Pt 23’s “Diltiazem Drip and Vital Signs (DD)”, dated 8/26/24 to 9/19/24, was reviewed. The “DD” indicated Pt 23 was located on the CPCU from 8/28/24 to 9/19/24. The NS stated the diltiazem drip was turned off on 8/28/24 at 6:43 a.m., and restarted at 8:20 p.m. at a 5 mg/hr., and the drip increased to 10 mg/hr. at 9:13 p.m. The “DD” indicated no HR was documented from 7:15 p.m. to 9:56 p.m. The NS stated on 9/3/24 at 7:37 p.m. the drip was increased form 5mg/hr. to 10 mg/hr. and increased again to 15 mg/hr. at 8:18 p.m. The “DD” indicated HR and BP were documented at 7:37 p.m., 8:07 p.m., and 10:13 p.m. The NS stated on 9/18/24 at 1:07 a.m., the diltiazem drip was decreased from 15 mg/hr. to 10 mg/hr. The “DD” indicated no HR was documented from 12:19 a.m. to 1:37 a.m. The NS stated on 9/19/24 at 12:50 a.m. the diltiazem drip was decreased from 10 mg/hr. to 5 mg/hr. The “DD” indicated no HR was documented from 9/18/24 at 11:54 p.m. to 9/19/24 at 1:11 a.m. During an interview on 9/24/24 at 9:10 a.m. with NM 1, NM 1 stated when a patient is on a diltiazem drip, it was reasonable for the HR or vital signs to be documented within 30 minutes before a rate change. During a review of the facility’s policy and procedure titled, “Vasoactive [something that affects blood vessels by causing them to constrict or dilate] Infusion Guidelines for Progressive Care units (VI)”, dated 4/8/21, the “VI” indicated, “ ... Purpose ... To ensure appropriate level of care for patients requiring administration of vasoactive medications by continuous infusion ... Procedure ... Vital signs (blood pressure, heart rate, respirations, and oxygen saturation) will be taken at initiation of infusion. Blood pressure and heart rate will be taken, at a minimum, immediately before initiation of the infusion, within 5 minutes after initiation of the infusion, then every 15 minutes until the target heart rate or blood pressure (physician prescribed parameter) is reached or stabilized ... Documentation ... Any dose adjustments ... All vital signs and patient responses to medication ...”.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 37529 Based on observation, interview, and record review the hospital failed to follow a nitroglycerin drip (nitro gtt- medication given for high blood pressure intravenously (IV)- through a vein) order for one of three sampled patients (Patient (Pt) 13) when increases to the amount given were double the prescribed dose. This placed Pt 13 at risk of rebound (a sudden increase in blood pressure that occurs when a person stops taking or reduces the dose of certain medications, especially those that treat high blood pressure. It can be dangerous and may lead to a hypertensive emergency) blood pressure which can be dangerous to the patient. Findings: During an observation on 9/17/24, at 11:30 a.m. in the stepdown unit, Pt 13 was seen sitting up in her bed with family at bedside. Pt 13 was Spanish speaking, denied having any issues and currently had IV fluids up and running. During a concurrent interview and record review on 9/23/24, at 1:56 p.m., with Manager of Step Down, Surgery, and Chest Pain Cardiac Unit (CPCU) (NM) 2, Pt 13’s Electronic Health Records were reviewed for her admission starting 9/10/24. Pt 13’s ED Provider Note dated 9/10/24 at 12:37 p.m. indicated, “ ...Chief complaint Patient presents with Reparatory Short of Breath (SOB) Pt brought in by ambulance from urgent care with reports of SOB x 7 days ... SPO2 (oxygen levels) at 75 % (percent normal 95-100%) RA (room air), with EMS (emergency medical services) ... Pt on 6 LNC (liters nasal canula- plastic tubing used to transport oxygen into ones nose) at 100%, pt hypertension (high blood pressure), + cough ... 71 y.o. (year old) female ... No fever. She does have chills. She reports a productive cough with yellow sputum. No Chest pain ... ED (emergency department) Course as of 9/10/24 1842 [6:42 p.m.] ... 1838 [6:38 p.m.] Patient presents to ED for cough, dyspnea for past week. No fever. Flu and influenza negative. Chest x-ray (imaging creates pictures of the inside of your body) shows pulmonary edema and BNP (B-type natriuretic peptide (BNP) is a hormone that helps the body compensate for heart failure) is elevated. No pneumonia (lung infection). Pt treated with diuretics (a drug that increases the amount of urine your body produces, which helps get rid of extra salt and fluid). Patient also noted to have persistent hypertension/hypertensive emergency. Treated with nitro drip ...” During a review of Pt 13’s “nitroglycerin 50 mg [milligrams-unit of measurement]/250 ml [milliter- unit of measurement] (0.2 mg/ml) IV infusion” order start date 9/10/24 at 6:11 p.m. indicated “Ordered Dose: 2-200 mcg [micrograms- unit of measurement]/min [minute] Route: Intravenous Frequency: CONTINOUS at 0.6-60 mL/hr [hour] ... Admin Instructions: Start at 5 mcg/min. If less than or equal to 20 mcg/min, titrate (up or down) by 5 mcg/min every 5 minutes OR if greater than 20 mcg/min, titrate (up or down) by 10 mcg/min every 5 minutes to a goal effect of systolic blood pressure (SBP): 140-160 mmHG [Millimeters of mercury- unit of pressure] Patients are to be continuously monitored with vital signs ...” During a review of Pt 13’s document titled, “All Administrations of nitroglycerin” dated 9/10/24-9/11/24, it indicated the following dose changes: “ ... Rate Changed: 40 mcg/min: 12 mL/hr: Intravenous 9/10/24 at 1850 (6:50 p.m.) by [name of RN 12] Rate Changed: 60 mcg/min: 18 mL/hr: Intravenous 9/10/24 at 1855 (6:55 p.m.) by [name of RN 12] Rate Changed: 80 mcg/min: 24 mL/hr: Intravenous 9/10/24 at 2300 (11 p.m.) by [name of RN 11] Rate Changed: 100 mcg/min: 30 mL/hr: Intravenous 9/11/24 at 0259 (2:59 a.m.) by [name of RN 11] Rate Changed: 120 mcg/min: 36 mL/hr: Intravenous 9/11/24 at 0411 (4:11 a.m.) by [name of RN 11] Rate Changed: 140 mcg/min: 42 mL/hr: Intravenous 9/11/24 at 0501 (5:01 a.m.) by [name of RN 11] ...” During a concurrent interview and record review on 9/26/24, at 4 p.m., with ED Registered Nurse (RN) 12 and ED Manager (MEEM), Pt 13’s document titled “All Administrations of nitroglycerin” dated 9/10/24-9/11/24 was reviewed. RN 12 stated he remembered taking care of Pt 13 on 9/10/24, he described Pt 13 as Spanish speaking with family at bedside who spoke English and helped to translate, Pt 13 had hypertension. RN 12 stated he does not administer nitro drips often and it had been a while since he had administered the one, he gave Pt 13’s. RN 12 stated if he had any questions about the nitro gtt he could always ask the pharmacist or his charge nurse that shift. RN 12 stated normally he would adjust the nitro gtt by 10 and that he follows the order, he remembers having multiple drips that day. RN 12 stated it is important to follow the orders for patient safety, if the patient received too much nitro “it could tank (drop) the bp (blood pressure)”. MEEM stated “No” RN 12 and RN 11 did not follow the order for the nitro gtt. MEEM stated too much Nitro can cause a rebound effect, or hypotension, this is why we titrate slow up and down. During a review of the hospital’s policy titled, “Vasoactive Infusion Guidelines for Progressive Care Units” dated 4/8/21, indicated “I. PURPOSE A. to clearly delineate guidelines for the administration of vasoactive medication by continuous infusion in Progressive Care Units (PCU). B. To ensure appropriate level of care for patients requiring administration of vasoactive medication by continuous infusion ... IV. PROCEDURE A. New IV Vaso active infusions: 1. Vital signs (blood pressure, heart rate, respirations, and oxygen saturations) will be taken at initiation of infusion. Blood pressure and heart rate will be taken at a minimum immediately before initiation of the infusion, within 5 minutes after initiation of the infusion, then every 15 minutes until the target heart rate or blood pressure (physician prescribed parameter) is reached or stabilized ... B. Dose adjustment: Vasoactive medications may be adjusted in accordance with written orders that include all appropriate dosing and monitoring parameters ...” During a review of the facility’s policy titled, “Provider Orders” dated 8/25/23, indicated, “I. PURPOSE A. To provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician’s orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician’s orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 42321 Based on observation, interview, and record review the hospital failed to follow a nitroglycerin drip (nitro gtt- medication given for high blood pressure intravenously (IV)- through a vein) order for one of three sampled patients (Patient (Pt) 13) when increases to the amount given were double the prescribed dose. This placed Pt 13 at risk of rebound (a sudden increase in blood pressure that occurs when a person stops taking or reduces the dose of certain medications, especially those that treat high blood pressure. It can be dangerous and may lead to a hypertensive emergency) blood pressure which can be dangerous to the patient. Findings: During an observation on 9/17/24, at 11:30 a.m. in the stepdown unit, Pt 13 was seen sitting up in her bed with family at bedside. Pt 13 was Spanish speaking, denied having any issues and currently had IV fluids up and running. During a concurrent interview and record review on 9/23/24, at 1:56 p.m., with Manager of Step Down, Surgery, and Chest Pain Cardiac Unit (CPCU) (NM) 2, Pt 13’s Electronic Health Records were reviewed for her admission starting 9/10/24. Pt 13’s ED Provider Note dated 9/10/24 at 12:37 p.m. indicated, “ ...Chief complaint Patient presents with Reparatory Short of Breath (SOB) Pt brought in by ambulance from urgent care with reports of SOB x 7 days ... SPO2 (oxygen levels) at 75 % (percent normal 95-100%) RA (room air), with EMS (emergency medical services) ... Pt on 6 LNC (liters nasal canula- plastic tubing used to transport oxygen into ones nose) at 100%, pt hypertension (high blood pressure), + cough ... 71 y.o. (year old) female ... No fever. She does have chills. She reports a productive cough with yellow sputum. No Chest pain ... ED (emergency department) Course as of 9/10/24 1842 [6:42 p.m.] ... 1838 [6:38 p.m.] Patient presents to ED for cough, dyspnea for past week. No fever. Flu and influenza negative. Chest x-ray (imaging creates pictures of the inside of your body) shows pulmonary edema and BNP (B-type natriuretic peptide (BNP) is a hormone that helps the body compensate for heart failure) is elevated. No pneumonia (lung infection). Pt treated with diuretics (a drug that increases the amount of urine your body produces, which helps get rid of extra salt and fluid). Patient also noted to have persistent hypertension/hypertensive emergency. Treated with nitro drip ...” During a review of Pt 13’s “nitroglycerin 50 mg [milligrams-unit of measurement]/250 ml [milliter- unit of measurement] (0.2 mg/ml) IV infusion” order start date 9/10/24 at 6:11 p.m. indicated “Ordered Dose: 2-200 mcg [micrograms- unit of measurement]/min [minute] Route: Intravenous Frequency: CONTINOUS at 0.6-60 mL/hr [hour] ... Admin Instructions: Start at 5 mcg/min. If less than or equal to 20 mcg/min, titrate (up or down) by 5 mcg/min every 5 minutes OR if greater than 20 mcg/min, titrate (up or down) by 10 mcg/min every 5 minutes to a goal effect of systolic blood pressure (SBP): 140-160 mmHG [Millimeters of mercury- unit of pressure] Patients are to be continuously monitored with vital signs ...” During a review of Pt 13’s document titled, “All Administrations of nitroglycerin” dated 9/10/24-9/11/24, it indicated the following dose changes: “ ... Rate Changed: 40 mcg/min: 12 mL/hr: Intravenous 9/10/24 at 1850 (6:50 p.m.) by [name of RN 12] Rate Changed: 60 mcg/min: 18 mL/hr: Intravenous 9/10/24 at 1855 (6:55 p.m.) by [name of RN 12] Rate Changed: 80 mcg/min: 24 mL/hr: Intravenous 9/10/24 at 2300 (11 p.m.) by [name of RN 11] Rate Changed: 100 mcg/min: 30 mL/hr: Intravenous 9/11/24 at 0259 (2:59 a.m.) by [name of RN 11] Rate Changed: 120 mcg/min: 36 mL/hr: Intravenous 9/11/24 at 0411 (4:11 a.m.) by [name of RN 11] Rate Changed: 140 mcg/min: 42 mL/hr: Intravenous 9/11/24 at 0501 (5:01 a.m.) by [name of RN 11] ...” During a concurrent interview and record review on 9/26/24, at 4 p.m., with ED Registered Nurse (RN) 12 and ED Manager (MEEM), Pt 13’s document titled “All Administrations of nitroglycerin” dated 9/10/24-9/11/24 was reviewed. RN 12 stated he remembered taking care of Pt 13 on 9/10/24, he described Pt 13 as Spanish speaking with family at bedside who spoke English and helped to translate, Pt 13 had hypertension. RN 12 stated he does not administer nitro drips often and it had been a while since he had administered the one, he gave Pt 13’s. RN 12 stated if he had any questions about the nitro gtt he could always ask the pharmacist or his charge nurse that shift. RN 12 stated normally he would adjust the nitro gtt by 10 and that he follows the order, he remembers having multiple drips that day. RN 12 stated it is important to follow the orders for patient safety, if the patient received too much nitro “it could tank (drop) the bp (blood pressure)”. MEEM stated “No” RN 12 and RN 11 did not follow the order for the nitro gtt. MEEM stated too much Nitro can cause a rebound effect, or hypotension, this is why we titrate slow up and down. During a review of the hospital’s policy titled, “Vasoactive Infusion Guidelines for Progressive Care Units” dated 4/8/21, indicated “I. PURPOSE A. to clearly delineate guidelines for the administration of vasoactive medication by continuous infusion in Progressive Care Units (PCU). B. To ensure appropriate level of care for patients requiring administration of vasoactive medication by continuous infusion ... IV. PROCEDURE A. New IV Vaso active infusions: 1. Vital signs (blood pressure, heart rate, respirations, and oxygen saturations) will be taken at initiation of infusion. Blood pressure and heart rate will be taken at a minimum immediately before initiation of the infusion, within 5 minutes after initiation of the infusion, then every 15 minutes until the target heart rate or blood pressure (physician prescribed parameter) is reached or stabilized ... B. Dose adjustment: Vasoactive medications may be adjusted in accordance with written orders that include all appropriate dosing and monitoring parameters ...” During a review of the facility’s policy titled, “Provider Orders” dated 8/25/23, indicated, “I. PURPOSE A. To provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician’s orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician’s orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ...””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 37529 Based on observation, interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patients (Patient 44) when Pt 44 was administered blood products and the intravenous (IV) (into the blood stream via vein) tubing was not primed (the process of removing air from tubing) before giving blood, Saline (a mixture of water and salt concentration of 0.9%) was not started when blood product was received, and RN (Registered Nurse) 5 did not use aspetic technique when spiking (impale on or pierce with a sharp point) blood product bag. These failures resulted in placing the patient at risk of experiencing an air embolus (air or gas bubbles which can block a blood vessel in the circulatory system). An air emolus is serious and can lead to a heart attack, stroke, respiratory failure, and death. Findings: During a record review of Pt 44’s “History and Physical (H&P-the complete assessment of the patient and the problem),” dated 9/14/24, the H&P indicated, “ ... 69 y.o. [year old] male, with PMH [past medical history] significant for recently diagnosed colon cancer in Arizona pending chemotherapy, presents to the Emergency Department with generalized weakness, difficulty swallowing, decreased oral intake and unintentional weight loss of approximately 40 lb [pounds, a unit of measure] over the last 6 months. ... recently re-evaluated for ongoing weight loss in August 2024 and was found to have colon cancer ...”. During a record review of Pt 44’s “Transfusion Orders,” dated 9/24/24 at 11:06 a.m., the orders indicated, “Transfuse Fresh Frozen Plasma (Adult ) ... Placing Order ... 09/19/24 1807 [6:07 p.m.] ... Released on ... 9/20/24 08:51 [a.m.] ...Transfusion duration per unit 4 (hrs [hours]) ...” During a concurrent observation and interview on 9/20/2024 at 9:45 a.m., with RN 5, in Pt 44’s room, RN 5 prepared and administered the blood to Pt 44. RN 5 was observed preparing the IV tubing for the FFP transfusion. RN 5 did not use a technique to manually prepare the tubing to remove all possible are bubbles. RN 5 did not prime the blood transfusion filter Y-tubing (special tubing used for administering blood products that flushes the blood product to the patient) prior to obtaining the blood product from the Blood Bank (a place where blood is collected and stored before it is used for transfusions). RN 5 primed the blood transfusion filter and tubing with normal saline and then spiked the blood product bag against his body. RN 5 stated he was nervous and forgot to spike bag according to the policy. RN 5 then connected the IV line to the patient. During a concurrent interview and record review on 9/26/24 at 1:05 p.m., with RN 5, the hospital’s policy and procedure (P&P) “Blood Products Transfusion”, dated 5/6/24 was reviewed. RN 5 stated, he was familiar with the policy. RN 5 stated he did not prime the IV tubing prior to obtaining the blood. RN 5 stated he did not start the infusion when receiving the blood product from the blood bank. RN 5 stated he spiked the bag against his body instead of laying blood product bag on a clean surface or hanging from a IV pole. RN 5 stated this is important to not cause a delay in giving the blood as there is a four-hour window to give the blood to the patient. During a concurrent interview and record review on 9/24/24 at 11:00 a.m., with NM 7, the hospital’s P&P “Blood Products Transfusion”, dated 5/6/24 was reviewed. NM 2 stated, RN 7 should follow the policy as the blood needs to be administered as efficiently as possible so that there is no delay. NM 7 stated, without exception, must completely follow the policy. NM 7 stated RN 5 did not follow the policy. During an interview on 10/2/24 at 3:30 p.m., with the Chief Nursing Officer (CNO), the CNO stated, her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important to ensure that blood or blood products is done efficiently and administered appropriately. During a review of the hospital’s P&P titled, “Blood Products Transfusion”, dated 5/6/24, the P&P stated, “ ... E. Preparation for Blood Transfusion ... 3. Prime the blood transfusion filter and tubing with normal saline ... G. Steps to be taken once blood product arrives at the nurse’s station ... 4. Start normal saline drip at 10ml/hr [milliliters, unit of measurement] unless already started. ... I. Routine Handling of Blood at Point of Service ... 1. Transfusion of blood products must be completed within four hours after the time of issue from Blood Bank. ... 2. Begin the transfusion as soon as possible after the blood is issued from Blood Bank. a. There is not a requirement that transfusion must be initiated within 30 minutes of blood issue, but it should be started as soon as possible to avoid wastage .... J. Registered Nurse instruction for blood infusion, patient monitoring and follow up ... 2. With the blood product lying flat or hanging from an IV pole, spike the bag aseptically with primed blood tubing using a twisting motion ...””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 49769 Based on observation, interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patients (Patient 44) when Pt 44 was administered blood products and the intravenous (IV) (into the blood stream via vein) tubing was not primed (the process of removing air from tubing) before giving blood, Saline (a mixture of water and salt concentration of 0.9%) was not started when blood product was received, and RN (Registered Nurse) 5 did not use aspetic technique when spiking (impale on or pierce with a sharp point) blood product bag. These failures resulted in placing the patient at risk of experiencing an air embolus (air or gas bubbles which can block a blood vessel in the circulatory system). An air emolus is serious and can lead to a heart attack, stroke, respiratory failure, and death. Findings: During a record review of Pt 44’s “History and Physical (H&P-the complete assessment of the patient and the problem),” dated 9/14/24, the H&P indicated, “ ... 69 y.o. [year old] male, with PMH [past medical history] significant for recently diagnosed colon cancer in Arizona pending chemotherapy, presents to the Emergency Department with generalized weakness, difficulty swallowing, decreased oral intake and unintentional weight loss of approximately 40 lb [pounds, a unit of measure] over the last 6 months. ... recently re-evaluated for ongoing weight loss in August 2024 and was found to have colon cancer ...”. During a record review of Pt 44’s “Transfusion Orders,” dated 9/24/24 at 11:06 a.m., the orders indicated, “Transfuse Fresh Frozen Plasma (Adult ) ... Placing Order ... 09/19/24 1807 [6:07 p.m.] ... Released on ... 9/20/24 08:51 [a.m.] ...Transfusion duration per unit 4 (hrs [hours]) ...” During a concurrent observation and interview on 9/20/2024 at 9:45 a.m., with RN 5, in Pt 44’s room, RN 5 prepared and administered the blood to Pt 44. RN 5 was observed preparing the IV tubing for the FFP transfusion. RN 5 did not use a technique to manually prepare the tubing to remove all possible are bubbles. RN 5 did not prime the blood transfusion filter Y-tubing (special tubing used for administering blood products that flushes the blood product to the patient) prior to obtaining the blood product from the Blood Bank (a place where blood is collected and stored before it is used for transfusions). RN 5 primed the blood transfusion filter and tubing with normal saline and then spiked the blood product bag against his body. RN 5 stated he was nervous and forgot to spike bag according to the policy. RN 5 then connected the IV line to the patient. During a concurrent interview and record review on 9/26/24 at 1:05 p.m., with RN 5, the hospital’s policy and procedure (P&P) “Blood Products Transfusion”, dated 5/6/24 was reviewed. RN 5 stated, he was familiar with the policy. RN 5 stated he did not prime the IV tubing prior to obtaining the blood. RN 5 stated he did not start the infusion when receiving the blood product from the blood bank. RN 5 stated he spiked the bag against his body instead of laying blood product bag on a clean surface or hanging from a IV pole. RN 5 stated this is important to not cause a delay in giving the blood as there is a four-hour window to give the blood to the patient. During a concurrent interview and record review on 9/24/24 at 11:00 a.m., with NM 7, the hospital’s P&P “Blood Products Transfusion”, dated 5/6/24 was reviewed. NM 2 stated, RN 7 should follow the policy as the blood needs to be administered as efficiently as possible so that there is no delay. NM 7 stated, without exception, must completely follow the policy. NM 7 stated RN 5 did not follow the policy. During an interview on 10/2/24 at 3:30 p.m., with the Chief Nursing Officer (CNO), the CNO stated, her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important to ensure that blood or blood products is done efficiently and administered appropriately. During a review of the hospital’s P&P titled, “Blood Products Transfusion”, dated 5/6/24, the P&P stated, “ ... E. Preparation for Blood Transfusion ... 3. Prime the blood transfusion filter and tubing with normal saline ... G. Steps to be taken once blood product arrives at the nurse’s station ... 4. Start normal saline drip at 10ml/hr [milliliters, unit of measurement] unless already started. ... I. Routine Handling of Blood at Point of Service ... 1. Transfusion of blood products must be completed within four hours after the time of issue from Blood Bank. ... 2. Begin the transfusion as soon as possible after the blood is issued from Blood Bank. a. There is not a requirement that transfusion must be initiated within 30 minutes of blood issue, but it should be started as soon as possible to avoid wastage .... J. Registered Nurse instruction for blood infusion, patient monitoring and follow up ... 2. With the blood product lying flat or hanging from an IV pole, spike the bag aseptically with primed blood tubing using a twisting motion ...””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 41166 Based on interview and record review the hospital failed to develop and implement systems to ensure the safe use of medications when 6 of 7 patients (Patients 4, 5, 6, 8, 9, 10) were not accurately monitored for sedation (sleepiness) adverse effects after being administered IV (intravenous- into the vein) opioids. This deficiency had the potential to cause respiratory depression and or patient death if one of these opioid medications had been administered to a patient without appropriate sedation assessment being implemented and in place. Findings: California Department of Public Health conducted a complaint validation survey dated 5/17/24, when Patient 1 received multiple doses of intravenous opioids (a class of medication identified as high-risk/high-alert medications), exceeding the manufacturer’s recommended dose for the patient’s medical conditions, and suffered respiratory and cardiac arrest (stopping of the heart and breathing) leading to anoxic brain injury (death of brain cells due to oxygen deprivation to the brain) and subsequently expired 10 days later. Findings indicated the hospital failed to develop and implement systems to ensure the safe use of IV opioids medications for Patient 1. A review of the hospital’s nursing staff education module titled, “Pain & Sedation Monitoring- Safe Opioid Administration”, dated August 2024, indicated, “Policy Change: For patients with active opioid medication orders there is an additional sedation assessment required including the patient’s level of sedation, respiratory rate, and pattern for the following assessments: Routine pain assessment- Patients will be assessed using the appropriate pain assessment tools during routine assessment times and as needed and will include: ... level of sedation ..., respiratory rate, respiratory pattern Reassessment of pain, and sedation, respiratory rate and pattern will be done after each unscheduled pharmacological pain intervention [using medication to treat pain] when sufficient time has lapsed for the medication to reach peak effectiveness [operating at maximum]. [Assessment for] IV medication within 30 minutes ... PO [by mouth]/IM [into the muscle] within 60 minutes” A review of the hospital’s P&P titled, “Pain Assessment & Management- Patients 14 and Older”, dated 9/13/24, indicated, “Monitor patients receiving opioids for opioid-induced respiratory depression (breath too slowly) and sedation by using either the RASS [Richmond Agitation and Sedation Scale- used for targeted sedation] or POSS [Pasero Opioid-induced Sedation Scale- used for monitoring adverse effects of sedation] assessment tools along with respiratory rate and pattern assessment during routine and post pharmacological reassessment timeframes. All patients receiving opioid based pharmacologic intervention are at risk for opioid-induced respiratory depression (OIRD) and opioid-induced sedation (OIS) and require additional assessment for adverse outcomes ... Monitor patients receiving opioids for opioid-induced respiratory depression and sedation by using either the RASS or POSS assessment tools along with respiratory rate and pattern assessment during routine and post pharmacological reassessment timeframes”. During a concurrent interview and record review on 9/17/24 at 3:34 p.m. with Medication Safety Pharmacist (MSRPH), Patient 4’s “Admission Summary” was reviewed. Patient 4’s clinical record indicated Patient 4 was a 57-year-old, admitted on 8/30/24. Patient 4’s physician order indicated hydromorphone (potent opioid used for pain) 1 mg (milligram-unit of measure) IV was ordered on 8/30/24 at 12:18 p.m., 3:36 p.m., 6:26 p.m., 8:28 p.m., and administered by nursing staff on 8/30/24 at 1:17 p.m., 4:01 p.m., 6:40 p.m., and 8:38 p.m. MSRPH was unable to provide documentation of Patient 4’s adverse effect monitoring for RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 4’s 1:17 p.m., 4:01 p.m., and 6:40 p.m. IV hydromorphone doses; no RASS/POSS score and respiratory rate 30 minutes after administration of 8:38 p.m. dose, and acknowledged Patient 4 was not adequately reassessed for sedation or respiratory depression after each administration of IV hydromorphone. During a concurrent interview and record review on 9/18/24 at 11:00 a.m. with MSRPH, Patient 5’s clinical record was reviewed. Patient 5’s “Admission Summary” indicated Patient 5 was a 46-year-old with kidney failure and on dialysis (treatment that removes excess water, salt, and waste from the blood when kidneys are no longer able to do so) admitted on 8/25/24. Patient 5’s physician order indicated morphine (potent opioid use for pain) 2 mg IV for every 4 hours as needed for moderate pain was ordered on 8/26/24 at 10:23 a.m., and administered by nursing staff on 8/26/24 at 10:44 a.m., 4:35 p.m., and 9:13 p.m. MSRPH was unable to provide documentation of Patient 5’s adverse effect monitoring for RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 5’s 10:44 a.m., 4:35 p.m., and 9:13 p.m. IV morphine doses, and acknowledged Patient 5 was not adequately monitored for adverse effects of sedation or respiratory depression after each administration of IV morphine. During an interview on 9/18/24 at 2:27 p.m., with Director of Emergency Department (DED), DED stated the expectation was for nursing staff to assess patients for sedation within 30 minutes following IV opioid administration for respiratory pattern, respiratory effort, and pain. DED stated adverse effects of opioids included respiratory depression, hypotension (low blood pressure), and over sedation. DED acknowledged Patients 4 and 5 were not appropriately monitored for sedation adverse effects after administration of IV opioids. During a concurrent interview and record review on 9/18/24 at 3:04 p.m. with 4 North Oncology Clinical Supervisor (4NOCS), Patient 6’s “Admission Summary” was reviewed. Patient 6’s clinical record indicated Patient 6 was a 44-year-old, admitted on 9/1/24. Patient 6’s physician order indicated fentanyl patient-controlled analgesia (PCA- patient controls amount of pain medication they receive) 250 mcg (microgram- unit of measure)/25 ml syringe intermittent with patient PCA 5 mcg dose, 5 minutes lockout interval (time patient cannot get dose), and 300 mcg 4-hour dose limit was ordered on 9/2/24 at 9:51 a.m. and was initiated at 5:02 p.m. 4NOCS was unable to provide documentation of Patient 6’s assessment of RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 6’s at 5:02 p.m. 4NOCS stated nursing staff was expected to do an initial 30-minutes within 30 minutes after PCA opioid administration, followed by an assessment every two hours. 4NOCS stated sedation assessments were important for patient safety, to make sure patient could tolerate medication as ordered, and to recognize over sedation. During a review of the hospital’s P&P titled, Patient Controlled Analgesia- Patients 14 and Older”, the P&P indicated, “monitor and record the vital signs [measurement of how body is functioning], pain intensity, and RASS every 30 minutes times two, then assess and record the level of sedation (RASS), respiratory rate, respiratory effort [energy it takes to breath], oxygen saturation [how much oxygen is getting to the body’s tissues], EtC02 [level of carbon dioxide release at end of exhaled breath] if available, and pain intensity every two hours while the patient in on PCA therapy.” During a concurrent interview and record review on 9/18/24 at 3:42 p.m. with Director of Pharmacy (DOP), Patient 8’s clinical record was reviewed. Patient 8’s “Admission Summary” indicated Patient 8 was a 76-year-old with chronic kidney disease [long term illness where kidney have become damaged over time], admitted on 9/12/24. Patient 8’s physician order indicated hydromorphone 0.5 mg IV every 3 hours as needed for breakthrough pain was ordered on 9/17/24 at 4:32 p.m., and administered by nursing staff on 9/18/24 at 3:11 p.m. DOP was unable to provide documentation of Patient 8’s assessment of RASS/POSS score, respiratory pattern and rate within 30 minutes after administration of Patient 8’s 3:11 p.m. dose. DOP acknowledged Patient 8 was not adequately reassessed for sedation or respiration depression after administration of IV hydromorphone. During a concurrent interview and record review on 9/18/24 at 3:51 p.m. with DOP, Patient 9’s clinical record was reviewed. Patient 9’s “Admission Summary” indicated Patient 9 was a 57-year-old, admitted on 9/15/24. Patient 9’s physician order indicated hydromorphone 0.5 mg IV every 4 hours as needed for severe pain was ordered on 9/16/24 at 8:24 p.m. and administered on 9/18/24 at 5:15 a.m. DOP acknowledged documentation of Patient 9’s assessment of POSS score, respiratory pattern and rate an hour after administration at 6:15 a.m. DOP acknowledged nursing assessment was 30 minutes late, and Patient 9 should have been monitored for sedation adverse effects within 30 minutes of hydromorphone IV administration. During an interview on 9/19/24 at 10:27 a.m. with DED, when asked about nursing staff auditing to ensure compliance with sedation assessment, DED was unable to provide documentation. DED stated documentation for sedation assessment was not a required element for nursing, so nursing staff was not being monitored or audited. During an interview on 9/19/24 at 10:34 a.m. with Pharmacy Manager (PM), when asked about the importance of sedation assessment, PM stated it was important to monitor adverse reaction that could be happening so pharmacy is able is to make recommendations regarding the use of the opioid. During an interview on 9/19/24 at 2:33 p.m. with DOP, Patient 10’s clinical record was reviewed. Patient 10’s “Admission Summary” indicated Patient 10 was a 59-year-old dialysis patient who presented to the Emergency Department on 9/13/24. Patient 10’s physician ordered fentanyl 50 mcg IV for one dose on 9/13/24 at 6:32 p.m. and was administered on 9/13/24 at 9:07 p.m. MSRPH acknowledged Patient 10 was not monitored for sedation adverse effects within 30 minutes of fentanyl IV administration, with only respiration rate being assessed more than 1 hour later. During an interview on 9/19/24 at 3:40 p.m. with DOP, when asked about sedation adverse effect monitoring for IV opioids ordered routinely, DOP stated it was allowable for prescribers to order IV opioids not only as one time or as needed, but also routinely [given consistently at a scheduled time], and monitoring was based on the routine assessment policy and procedures. DOP stated timing of the routine assessment would be dependent on the type of care unit on the standard of practice grid. During a review of the hospital’s P&P titled, “Pain Assessment & Management- Patients 14 and Older”, dated 9/13/24, the P&P indicated, Routine Pain Assessment: Patients will be assessed during the appropriate pain assessment tools during routine assessment times and as needed. Routine pain assessment includes pain intensity (as reported by patient or assessed during behavioral scales for patient unable to report): for patients receiving opioid based pharmacologic pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect.” A review of the hospital’s “Standard of Practice Grid”, the “Standard of Practice Grid”, indicated “Document: pulse, respirations and blood pressure and pain assessment ..... [for general medical/surgical units] every 8 hours and as needed, unless otherwise ordered. “ During an interview on 9/19/24 at 3:57 p.m. with DED and Medical Surgical CPCU and CPND Manager (CPCUCPNDNM), DED stated side effects for opioids included respiratory depression, oversedation and hypotension. DED stated that at the end of August 2024, there was not a clear sedation assessment policy, and the expectation was that nursing would be doing sedation assessment when reassessing pain as a standard of practice or standard of care. DED stated that if nursing staff did not monitor patients appropriately for sedation adverse effects, nursing staff can walk in and patient is not going to be alive or be respiratory compromised. DED stated the expectation was for nursing staff to monitor for sedation adverse effects and document sedation assessment for patients receiving opioids as a one time or as needed doses. CPCUCPNDNM stated sedation assessment was about patient safety, trying to avoid adverse event from administration of opioids. CPCUCPNDNM stated nursing was expected to do sedation assessments in a timely manner and document all required areas. During an interview on 9/19/24 at 4:24 p.m. with DOP, DOP stated IV opioids have a faster onset of action than other routes of administration, and come with risk of sedation and respiratory depression; so for safety of patients it is important to confirm patient is not having an adverse event following opioid administration. DOP stated the expectation is following administration of IV opioid, the nurse assesses pain score to determine efficacy and also sedation level, respiratory rate, and pattern for monitoring of adverse event within 30 minutes. DOP acknowledged monitoring sedation adverse effects is important for pharmacy tracking as part of the hospital’s medication error reduction plan. During an interview on 9/19/24 at 5:22 p.m., with DED, DED stated nursing staff were not being audited for sedation assessment. DED stated it was important to make sure the staff was doing what they were taught to do. During an interview on 9/20/24 at 9:36 a.m., with Chief Nursing Officer (CNO) and DOP, CNO stated part of the nursing process was to was to assess patients and response to interventions; specifically with opioids, nursing should be assessing for adverse events and with opioids respiratory efforts and sedation level to make sure patients are safe after they receive medication. CNO stated monitoring for sedation assessment was not being done but was being added moving forward. CNO stated nursing staff should not follow the standard of practice grid when assessing sedation for opioids ordered routinely, and would need to clarify the policy and procedure. CNO also stated monitoring for sedation adverse effects was a collaboration between pharmacy, nursing, and physician to provide safe use of opioids. DOP acknowledged she was in charge of pharmaceutical services which included tracking nursing staff monitoring for sedation adverse effects as part of the hospital’s medication error reduction plan. During a review of the hospital’s P&P titled, “Opioid Safety- Patients 14 and Older”, dated 9/18/24, the P&P indicated, “Pain assessment and monitoring Refer to the pain assessment and management- Patients 14 and Older policy for detailed procedures on conducting pain screening on admission and throughout hospitalization, performing comprehensive pain assessments, and monitoring patients for opioid -induced respiratory depression (OID) and opioid -induce sedation (OIS). Notify the provider and pharmacist if an adverse drug reaction occurs, and complete an incident reporting intranet system (IRIS) notification (refer to Medication Event Reporting policy). During a review of the hospital’s Plan of Correction (POC) Revision 4, the POC indicated, “Beginning 8/2/24, Director of Pharmacy developed new policy: “Opioid Safety - Patients 14 and Older.” The purpose of the policy is to define practices and procedures to reduce medication-related errors and reduce the risk of patient harm associated with opioids. The policy includes: Prescribing Prescription order communication Product labeling Packing and nomenclature Compounding Dispensing Administration Monitoring Education Use ... Monitoring and tracking procedures that will be implemented to ensure that the POC is effective, and that the specific deficiency(ies) cited remain corrected and in compliance with the regulatory requirements ... “ During a review of ISMP (Institute for Safe Medication Practices- a recognized nonprofit organization devoted to the prevention of medication errors) publication titled, “ISMP List of High-Alert Medications in Acute Care [inpatient care] Settings,” dated 1/10/24, the publication indicated, “High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 37529 Based on interview and record review the hospital failed to reassess two of three patient’s (Patient (Pt) 2 and Pt 25) discharge plans when: 1.Nursing staff did not reassess Pt 2’s oxygen saturation and need for oxygen and discharged Pt 2 to a Skilled Nursing Facility (SNF) without first notifying the physician. These failures resulted in Pt 2 arriving at the SNF in respiratory distress, below normal oxygen levels, high respiratory rate and an avoidable transport back to the hospital for readmission. Pt 2 remained in the ED for over 33 hours when he was found unresponsive and needed to be intubated and sent to the intensive care unit (ICU). 2.Pt 2 Emergency Department (ED) visit on 9/23/24 addressed her low blood pressure and high heart rate but failed to address a Urine Analysis (UA- a medical test that examines a urine sample to evaluate its physical properties, chemical composition, and microscopic appearance) test was performed which revealed abnormal results showing presence of leukocytes (colorless, round, and extremely small cells that are part of the body’s immune system and help fight infection and disease) and nitrites in Urine (may be a sign of a bacterial infection that affects the bladder, urethra, and kidneys). These failures resulted in inadequate evaluation, lack of monitoring, insufficient patient and family education and the outcome was delayed diagnosis, worsening condition and the potential outcome for unnecessary harm, anxiety or distress to the patient and family members. This oversight compromised the patient’s health and safety. Findings: 1.During a review of Pt 2’s demographic face sheet dated 9/18/24, it indicated Pt 2 was an 86-year-old male, admitted on 7/2/24 at 6:44 p.m. with the diagnosis of multifocal pneumonia (PNA-infection in the lungs; multifocal meaning pneumonia in several parts of the lungs). During a concurrent interview and record review on 9/18/24, at 2:30 p.m., with the Manager of Medical Surgical Unit (NM) 8, Pt 2’s Electronic health records (EHR) for his admission starting 7/2/24 were reviewed. NM 8 stated there was no order to monitor Pt 2’s oxygen levels and after reviewing Pt 2’s vital sign (VS) flow sheet dated 7/2/24-7/11/24, Pt 2’s oxygen levels were not monitored consistently, and on 7/9/24 no oxygen saturations were documented. NM 8 stated routine vital signs should have been done for Pt 2, which means VS should be done every 8 hours but an order is required to monitor the oxygen saturations with the VS. NM 8 stated she was not aware of Pt 2’s oxygen saturation(O2 sats- the amount of one’s blood cells that are carrying oxygen- normal is 96-100%) trend indicating he needed more oxygen based on his oxygen demand and did not feel this was a reason to call the physician and or keep the patient longer before discharging the patient to a skilled nursing facility over an hour away. During a concurrent interview and record review on 9/24/24, at 9:17 a.m., with Clinical Nurse Supervisor (NS) 4 for the medical surgical unit, Pt 2’s EHR for his admissions starting 7/2/24 and 7/11/24 were reviewed. NS 4 stated she was the clinical supervisor that was on when Pt 2 was discharged to the skilled nursing facility (SNF). NS 4 stated on 7/11/24 she spoke with RN 7 and was informed that Pt 2 would be discharged to a SNF and getting picked up between 9:30-10 a.m. NS 4 stated she was not aware that Pt 2 had been taken off his oxygen, nor was she aware that on 7/9/24 no oxygen saturations were documented for Pt 2. NS 4 stated VS on med/surg are done routinely every 8 hours and saturations should be checked at last once every shift. NS 4 reviewed Pt 2’s VS flowsheet and did not feel RN 7 needed to call the physician about Pt 2’s O2 sats at 91 % on 2 L (liters- unit of measurement) NC (nasal canula- plastic tubing used to transport oxygen through the nose). NS 4 stated the current policy for standards of practice for VS on med/surg does not include checking oxygen levels, an order is required for this but that she is on a group that is looking at changing this policy and requiring every shift have VS that includes saturations. NS 4 stated she received a call from a nurse at the SNF on 7/11/24 informing her that Pt 2 was being sent back to the hospital because his oxygen saturations went low and the patient on arrival to the SNF was in respiratory distress. During a concurrent interview and record review on 9/24/24, at 11:04 a.m., with Registered Nurse (RN) 7, Pt 2’s EHR for his admission starting 7/2/24 was reviewed. RN 7 stated she took care of Pt 2 on 7/10/24 and 7/11/24. RN 7 stated Pt 2 was being treated for PNA and was discharged on 2 L nasal cannula (NC- plastic device placed in one’s nose to deliver oxygen) oxygen on 7/11/24. RN 7 stated she was not aware that a specific order was required for oxygen saturations to be monitored. RN 7 stated she was aware that Pt 2’s oxygen sats on discharge was 91 % on 2 l NC but did not notice Pt’s 2 oxygenation trend that showed Pt 2 oxygen levels were going down and he was requiring more oxygen. RN 7 stated she did not think Pt 2 was short of breath and did not feel it was necessary to call the physician to hold up the discharge of patient 2. RN 7 stated Pt 2 was anxious to get to his new facility. During an interview on 9/24/24, at 2 p.m., with Medical Doctor (MD) 6 and the Chief Medical Officer (CMO). MD 6 stated he has been a physician for one year and wrote the discharge orders for Pt 2. MD 6 stated Pt 2 came into the ED where labs, imaging, and he was suspected of having left lower lobe PNA, he was started on antibiotics times 5 days, and he managed his care while he was at the hospital. MD 6 stated he wrote Pt 2’s discharge orders on 7/10/24 and he would need to be discharged with oxygen. MD 6 stated Pt 2 recovered quickly when he took off his oxygen and it was placed back on him, if Pt 2 had not recovered so quick and had issues then he would have worried, but Pt 2 had been stable since 7/8/24and had finished his course of antibiotics, so he felt it was a safe discharge. During an interview on 10/2/24, at 11:12 a.m., with the Director of Risk Management, Regulatory and Patient Safety (DRM), the DRM stated the risk department became aware of the issue with Pt 2’s discharge on 7/11/24 on 9/18/24. DRM stated once there was an issue her department started to investigate “looking for any gaps or follow up” that needed to be reviewed and noted that Pt 2’s spouse had filed a complaint prior to 9/18/24 about Pt 2’s discharge on 7/11/24. DRM stated, “we noted there were some potential gaps with care at discharge, O 2 (oxygen saturations) had been trending down on the day of discharge and the spouse had reported concerns to the nurse about the patient [Pt 2] not being ready for discharge, this was not escalated at that time and the patient was discharged to a SNF (skilled nursing facility) and came back within 6 hours and needed to be readmitted”. DRM stated MD 6 was sent to peer review (The process of Medical Staff office assigning peer to peer, meaning MD to MD, review of the situation.) on 9/19/24 by risk management because there were concerns that Pt 2 may not have been ready for discharge on 7/11/24. During a concurrent interview and record review on 10/2/24, at 3:20 p.m., with the Chief Nursing Officer (CNO), Pt 2’s EHR for his admission beginning on 7/2/24 were reviewed. The CNO stated looking at Pt 2’s vital signs flow sheets dated 7/6/24-7/11/24 that “it does appear his [referring to Pt 2] rate [referring to Pt 2’s oxygen saturation rate] is trending down, yes, it is a reason to call the provider if he is getting ready” to be discharged. The CNO stated the expectation is that the policies for this facility are followed. During an interview on 9/18/24, at 3:32 p.m. with the Director of Nursing (DON) at the skilled nursing facility Pt 2 was discharged to. The DON stated Pt 2 arrived on 7/11/24, he was not on oxygen and his mentation was altered, he was lethargic and not able to answer questions. The DON stated they put the patient on oxygen and his saturations were in the 80’s (normal oxygen saturations are 96-100%) once on 4 L NC sats came up to 96%. The DON stated Pt 2 arrived to them hypoxic and in severe respiratory distress, he had pedal edema (swelling in his feet) and swelling to his abdomen. The DON stated Pt 2’s spouse was at bedside and informed them that she had been begging the hospital to keep him until he was more stable. The DON stated she called the hospital back to let them know that Pt 2 would be coming back to them by ambulance and provided the clinical status he was currently in. The DON stated it took a little longer for Pt 2 to leave back to the hospital because he needed a higher level of transport due to his respiratory distress. During a review of Pt 2’s “Patient Care Report” (PCR- a document that supports the medical necessity for ambulance transport and serves as a factual assessment of the patient’s condition.) dated 7/11/24, at 12:08 p.m. was reviewed. The PCR indicated under Narrative “Called out to SNF for pt w/ CC: Respiratory Distress. Pt was discharged from [name of hospital] this morning, and family would like him transported back to [same hospital] as he is not ‘thriving.’ Pt was in hospital for approximately 9 hays with pneumonia and was discharged to SNF for rehab ... 83 yo (year old) M (male) lying supine on bed in facility. BLS (basic life support) ambulance on scene reports SPO2 86% on 6 lpm (liters per minute). GCS 14 (Baseline 15) ... O2 switched over to high flow at 15 lpm via NRB (nonrebreather mask) SPO2 improved to 100%... Pt transferred to [name of hospital] ED w/o (without) further incident ...” During a concurrent interview and record review on 9/26/24, at 8:30 a.m., with MD 7, Pt 2’s ED Provider Note dated 7/11/24 at 3:39 p.m. was reviewed. MD 7 stated Pt 2 came in for shortness of breath “Chief Complaint Patient presents with Difficulty Breathing Pt brought in by ambulance with baseline Glasgow coma scale of 15. With EMS pt GCS is 14 with initial O2 sats of 86. NRM elevated O2 to 100. Visible labored respirations ... BP (blood pressure): 166/80 Heart Rate: 80 ... Temp. 36.9 C (98.5 F) Resp (respirations): 32 SpO2: 96 %” on 4 liters per minute “ ... appears dehydrated ... lips dry ... Pulmonary: ... Breath Sounds: Decreased air movement (bilaterally) present ... Clinical Impression 1. Acute respiratory failure with hypoxia 2. Dyspnea ... 3. Elevated troponin (labs looks at cardiac damage) ...” MD 7 stated he ordered labs, chest x-ray (a type of electromagnetic radiation that can pass through most objects, including the body, to generate images of its internal structures and tissues), EKG (electrocardiogram -measures the electrical activity of the heart), and a CT (computed tomography scan, is a medical imaging technique that uses X-rays and a computer to create detailed pictures of the inside of the body) of Pt 2’s chest to diagnose and stabilize. MD 7 stated his job in the ED is to stabilize the patients coming in and he does not know if Pt 2 was discharged too soon. During a review of the facility’s policy titled, “Discharge of Inpatient” dated 6/14/24, indicated, “I. PURPOSE A. To provide guidelines for discharging patients from the inpatient facility. B. To facilitate continuity of care ... V. PROCEDURE ... C. Assess patient as per Patent Assessment policy or unit specific policies. D. Communicate if there are any changes in the patient’s condition to the provider ...” During a review of the facility’s policy titled, “Standard of Practice- Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” dated 2/22/23, indicated, “I. PURPOSE These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in” each of these units. “ ... IV. STANDARDS See Standards of Practice Documentation Grid .... General Medical/Surgical ... On-going/Reassessment ... with changes in patient condition and as needed ... Document: Pulse, Respirations, and Blood pressure & Pain assessment Every 8 hours and as needed, unless otherwise ordered ... Temperature every 8 hours ... Pulse Oximetry applied as ordered ... Telemetry every 4 hours ...” During a review of the facility’s policy titled, “Provider Orders” dated 8/25/23, indicated, “I. PURPOSE A. To provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician’s orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician’s orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ...” 2. During a review of Pt 25’s “Patient Demographics” (PD-a document providing demographic information about the patient including name, date of birth, admission date, emergency contact), dated 9/24/24, the PD indicated Pt 25 was a 82-year-old Spanish speaking female, admitted to the hospital on 9/23/24 at 6:22 p.m., Pt 25 was discharged home on 9/24/24 at 12:03 a.m., and returned to the ED on 9/24/24 at 7:46 p.m.(returned to the ED 19 hours and 49 minutes later after being discharged on 9/24/24). During an interview on 10/01/24 at 4:26 p.m., with Pt 25’s Family member (FM), FM stated Pt 25’s was brought to the hospital on 9/23/24 because Pt 25’s heart rate was high and blood pressure was low. FM stated a Urine Analysis was done and the doctor said Pt 25 had been stable because heart medication was given through the vein. FM stated the doctor told her Pt 25 was medically stable to be discharge home and the urine culture result was pending and would call her once the result comes back. FM stated she was never informed about the result of the Urine Analysis. FM stated she never receive a call from the doctor of the urine culture result. During a review of Pt 25’s “History &Physical (H&P)” dated 9/23/24 at 6:27 p.m., the H&P indicated Pt 25 had “history of atrial fibrillation with rapid ventricular response (RVR) (a type of irregular heart rhythm that occurs when the heart’s upper chambers contract in an uncoordinated way, causing the lower chambers to beat too fast), Chronic obstructive pulmonary disease (COPD- a common lung disease that makes it difficult to breathe), hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood), Alzheimer’s (a brain disorder that gradually destroys memory and thinking skills). Pt 25 came to the hospital with chief complaint of Cardiac Tachycardia (a condition where the heart rate is faster than normal, usually more than 100 beats per minute (bpm) at rest). Vital signs (VS-measurements of the body’s basic functions, such as breathing, heart rate, and temperature)- Blood Pressure (BP): 111/76, Heart Rate (HR): 149(normal resting heart rate for adults is between 60 and 100 beats per minute), Temperature: 97 Fahrenheit (F- a scale that measures the temperature) , Respiration: 18, Cardiovascular Rate and Rhythm: Tachycardia ... Rhythm Irregularly Irregular ... Discussion: ... patient presents to the ED with complaints of RVR that started 9/23/24 .... Patient’s heart rate improved in the Emergency Department (ED)... Patient discharged with instructions for primary care physician (PCP) follow up within the next 48 hours ... Clinical impression: Atrial fibrillation with RVR, Hyponatremia (a condition where the level of sodium in your blood is lower than normal) ... Disposition: Discharged to home. Results, diagnosis, and follow-up instructions were explained to patients. Patients comfortable going home and was advised to return immediately if symptoms worsen or if any concerns develop. Based on the patient’s clinical picture and the result of a medical screening exam, there is no emergent medical condition present at this time. The patient is stable for discharge from the ED with the agreed upon follow up plan and return precautions”. During a review of Pt 25’s “History &Physical (H&P)” dated on 9/24/24 at 8:19 p.m., the H&P indicated Pt 25 came to the hospital on 9/24/24 at 7:46 p.m. with chief complaint- “Generalized Weakness, VS- Blood Pressure (BP): 113/78, Heart Rate (HR): 161, Temperature: 38 C (100.4 F)(indicating fever), Respiration: 22, Cardiovascular Rate and Rhythm: Tachycardia ... Rhythm Irregularly Irregular, white blood cell count (WBC) of 20 (normal number of WBCs in the blood is 4.5 to 11), Nitrites: Positive ... Clinical Impression: Shortness of breath (SOB), Generalized weakness, Urinary tract infection (UTI- a bacterial infection that affects the bladder, urethra, and kidneys) without hematuria (the presence of red blood cells in the urine), Super ventricular tachycardia (SVT- a condition that causes a rapid heart rate due to an issue with the heart’s electrical system)”. During a review of Pt 25’s Result Review Flowsheet (RRF), the RRF indicated, “ ... on 9/23/24 at 9:57 p.m. .... Leukocyte esterase (enzymes that break down esters into acids and alcohols through a chemical reaction with water) 1+, nitrites: Positive, Red Blood Cells [RBC-carries oxygen and nutrients from the lungs throughout the body]-: 4 ... on 9/24/24 at 10 26 p.m. ... Leukocyte esterase 4+, nitrites: Positive, Protein: 20, WBC: 20 ...” Pt 25 had infection: Extended-spectrum beta-lactamases (ESBL- are enzymes that make some bacteria resistant to antibiotics, making infections harder to treat). During a review of Pt 25’s document titled “Culture Urine (CU)” with specimen collected date on 9/23/24 at 11:49 p.m. and last resulted date on 9/27/24 at 8:46 a.m., the CU indicated the urine culture was > (more than)100,000 cfu/ml (colony-forming units per millimeter- unit of measurement) ESBL Escherichia Coli (bacteria). During a concurrent interview and record review on 10/1/24 at 3.37 p.m., with the Emergency Department Chair (MD) 3 Pt 25’s “Emergency Department Patient Care Timeline (PCT)” and History and Physical (H&P) were reviewed, the PCT with arrival date 9/23/24 indicated Pt 25 was discharged after UA result came back positive. The PCT with arrival date 9/24/24 indicated Pt 25 arrived in the ED on 9/24/24 at 7:46 p.m. The H&P indicated Pt 25 came to the hospital with a chief complaint of generalized weakness, heart rate: 161, temperature of 100.4 (fever), a WBC: 20, Nitrite: Positive. MD 3 stated withholding treatment is appropriate due to the high prevalence of chronic bacteria in the elderly. MD 3 stated “I would not have ordered a UA in the first place”. MD 3 stated there is a very high rate of colonization (the presence and multiplication of a microorganism in or on a host or an inanimate object or surface) in mobility impaired elderly women in particular, the rate for Pt 25 is 80% colonization; it becomes difficult with people like this. MD 3 stated asymptomatic (producing or showing no symptoms) bacteria is a chronically debated area within medicine. MD 3 stated “I would not have checked the UA because it makes the not treating decision simpler”. MD 3 stated the doctor discussed with FM before discharge. MD 3 stated “I would have told the FM that there were some bacteria in the urine, this is something Pt 25 has had for a long time, there was no fever, labs looked good, HR was controlled with medication given, culture has been sent and you would be informed if there is any abnormality”. MD 3 stated it was possible Pt 25 returned to the hospital because the UA result was not addressed, but blood cultures were negative. MD 3 stated if Pt 25 had been admitted during the 9/23/24 visit, Pt 25 may still be in the hospital. MD 3 stated either Pt 25 stayed in the hospital to get Meropenem (used to treat infections caused by bacteria) or be discharged with a peripherally inserted central catheter (PICC) line (a long, thin, flexible tube that’s inserted into a vein in the upper arm and threaded into a larger vein above the heart). MD 3 stated “not treating with anything is appropriate because of the high rate of chronic bacteremia in the elderly, it almost makes less sense to discharge with oral antibiotics because of the likelihood of resistance”. MD 3 stated the difference in the two cases is the presence of fever. MD 3 stated it is appropriate when you don’t treat on the first encounter, for ESBL than to treat. MD 3 stated most of the time, when patients are not treated, they don’t come back to the hospital. MD 3 stated the standard practice is we see all the results and still send the patient home. During a review of the California Advocates for Nursing Home Reform (CANHR) Reference titled, “ Challenging Hospital Discharge Decisions” dated January 12, 2024, (https://canhr.org/challenging-hospital-discharge-decisions/). Discharge Planning Services. Medicare certified hospitals must: “ ...Have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support persons as active partners in the discharge planning for post-discharge care; ...Discuss the evaluation results with the patient or representative; ...Reevaluate and modify discharge plans as needed ...””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 42321 Based on interview and record review the hospital failed to reassess two of three patient’s (Patient (Pt) 2 and Pt 25) discharge plans when: 1.Nursing staff did not reassess Pt 2’s oxygen saturation and need for oxygen and discharged Pt 2 to a Skilled Nursing Facility (SNF) without first notifying the physician. These failures resulted in Pt 2 arriving at the SNF in respiratory distress, below normal oxygen levels, high respiratory rate and an avoidable transport back to the hospital for readmission. Pt 2 remained in the ED for over 33 hours when he was found unresponsive and needed to be intubated and sent to the intensive care unit (ICU). 2.Pt 2 Emergency Department (ED) visit on 9/23/24 addressed her low blood pressure and high heart rate but failed to address a Urine Analysis (UA- a medical test that examines a urine sample to evaluate its physical properties, chemical composition, and microscopic appearance) test was performed which revealed abnormal results showing presence of leukocytes (colorless, round, and extremely small cells that are part of the body’s immune system and help fight infection and disease) and nitrites in Urine (may be a sign of a bacterial infection that affects the bladder, urethra, and kidneys). These failures resulted in inadequate evaluation, lack of monitoring, insufficient patient and family education and the outcome was delayed diagnosis, worsening condition and the potential outcome for unnecessary harm, anxiety or distress to the patient and family members. This oversight compromised the patient’s health and safety. Findings: 1.During a review of Pt 2’s demographic face sheet dated 9/18/24, it indicated Pt 2 was an 86-year-old male, admitted on 7/2/24 at 6:44 p.m. with the diagnosis of multifocal pneumonia (PNA-infection in the lungs; multifocal meaning pneumonia in several parts of the lungs). During a concurrent interview and record review on 9/18/24, at 2:30 p.m., with the Manager of Medical Surgical Unit (NM) 8, Pt 2’s Electronic health records (EHR) for his admission starting 7/2/24 were reviewed. NM 8 stated there was no order to monitor Pt 2’s oxygen levels and after reviewing Pt 2’s vital sign (VS) flow sheet dated 7/2/24-7/11/24, Pt 2’s oxygen levels were not monitored consistently, and on 7/9/24 no oxygen saturations were documented. NM 8 stated routine vital signs should have been done for Pt 2, which means VS should be done every 8 hours but an order is required to monitor the oxygen saturations with the VS. NM 8 stated she was not aware of Pt 2’s oxygen saturation(O2 sats- the amount of one’s blood cells that are carrying oxygen- normal is 96-100%) trend indicating he needed more oxygen based on his oxygen demand and did not feel this was a reason to call the physician and or keep the patient longer before discharging the patient to a skilled nursing facility over an hour away. During a concurrent interview and record review on 9/24/24, at 9:17 a.m., with Clinical Nurse Supervisor (NS) 4 for the medical surgical unit, Pt 2’s EHR for his admissions starting 7/2/24 and 7/11/24 were reviewed. NS 4 stated she was the clinical supervisor that was on when Pt 2 was discharged to the skilled nursing facility (SNF). NS 4 stated on 7/11/24 she spoke with RN 7 and was informed that Pt 2 would be discharged to a SNF and getting picked up between 9:30-10 a.m. NS 4 stated she was not aware that Pt 2 had been taken off his oxygen, nor was she aware that on 7/9/24 no oxygen saturations were documented for Pt 2. NS 4 stated VS on med/surg are done routinely every 8 hours and saturations should be checked at last once every shift. NS 4 reviewed Pt 2’s VS flowsheet and did not feel RN 7 needed to call the physician about Pt 2’s O2 sats at 91 % on 2 L (liters- unit of measurement) NC (nasal canula- plastic tubing used to transport oxygen through the nose). NS 4 stated the current policy for standards of practice for VS on med/surg does not include checking oxygen levels, an order is required for this but that she is on a group that is looking at changing this policy and requiring every shift have VS that includes saturations. NS 4 stated she received a call from a nurse at the SNF on 7/11/24 informing her that Pt 2 was being sent back to the hospital because his oxygen saturations went low and the patient on arrival to the SNF was in respiratory distress. During a concurrent interview and record review on 9/24/24, at 11:04 a.m., with Registered Nurse (RN) 7, Pt 2’s EHR for his admission starting 7/2/24 was reviewed. RN 7 stated she took care of Pt 2 on 7/10/24 and 7/11/24. RN 7 stated Pt 2 was being treated for PNA and was discharged on 2 L nasal cannula (NC- plastic device placed in one’s nose to deliver oxygen) oxygen on 7/11/24. RN 7 stated she was not aware that a specific order was required for oxygen saturations to be monitored. RN 7 stated she was aware that Pt 2’s oxygen sats on discharge was 91 % on 2 l NC but did not notice Pt’s 2 oxygenation trend that showed Pt 2 oxygen levels were going down and he was requiring more oxygen. RN 7 stated she did not think Pt 2 was short of breath and did not feel it was necessary to call the physician to hold up the discharge of patient 2. RN 7 stated Pt 2 was anxious to get to his new facility. During an interview on 9/24/24, at 2 p.m., with Medical Doctor (MD) 6 and the Chief Medical Officer (CMO). MD 6 stated he has been a physician for one year and wrote the discharge orders for Pt 2. MD 6 stated Pt 2 came into the ED where labs, imaging, and he was suspected of having left lower lobe PNA, he was started on antibiotics times 5 days, and he managed his care while he was at the hospital. MD 6 stated he wrote Pt 2’s discharge orders on 7/10/24 and he would need to be discharged with oxygen. MD 6 stated Pt 2 recovered quickly when he took off his oxygen and it was placed back on him, if Pt 2 had not recovered so quick and had issues then he would have worried, but Pt 2 had been stable since 7/8/24and had finished his course of antibiotics, so he felt it was a safe discharge. During an interview on 10/2/24, at 11:12 a.m., with the Director of Risk Management, Regulatory and Patient Safety (DRM), the DRM stated the risk department became aware of the issue with Pt 2’s discharge on 7/11/24 on 9/18/24. DRM stated once there was an issue her department started to investigate “looking for any gaps or follow up” that needed to be reviewed and noted that Pt 2’s spouse had filed a complaint prior to 9/18/24 about Pt 2’s discharge on 7/11/24. DRM stated, “we noted there were some potential gaps with care at discharge, O 2 (oxygen saturations) had been trending down on the day of discharge and the spouse had reported concerns to the nurse about the patient [Pt 2] not being ready for discharge, this was not escalated at that time and the patient was discharged to a SNF (skilled nursing facility) and came back within 6 hours and needed to be readmitted”. DRM stated MD 6 was sent to peer review (The process of Medical Staff office assigning peer to peer, meaning MD to MD, review of the situation.) on 9/19/24 by risk management because there were concerns that Pt 2 may not have been ready for discharge on 7/11/24. During a concurrent interview and record review on 10/2/24, at 3:20 p.m., with the Chief Nursing Officer (CNO), Pt 2’s EHR for his admission beginning on 7/2/24 were reviewed. The CNO stated looking at Pt 2’s vital signs flow sheets dated 7/6/24-7/11/24 that “it does appear his [referring to Pt 2] rate [referring to Pt 2’s oxygen saturation rate] is trending down, yes, it is a reason to call the provider if he is getting ready” to be discharged. The CNO stated the expectation is that the policies for this facility are followed. During an interview on 9/18/24, at 3:32 p.m. with the Director of Nursing (DON) at the skilled nursing facility Pt 2 was discharged to. The DON stated Pt 2 arrived on 7/11/24, he was not on oxygen and his mentation was altered, he was lethargic and not able to answer questions. The DON stated they put the patient on oxygen and his saturations were in the 80’s (normal oxygen saturations are 96-100%) once on 4 L NC sats came up to 96%. The DON stated Pt 2 arrived to them hypoxic and in severe respiratory distress, he had pedal edema (swelling in his feet) and swelling to his abdomen. The DON stated Pt 2’s spouse was at bedside and informed them that she had been begging the hospital to keep him until he was more stable. The DON stated she called the hospital back to let them know that Pt 2 would be coming back to them by ambulance and provided the clinical status he was currently in. The DON stated it took a little longer for Pt 2 to leave back to the hospital because he needed a higher level of transport due to his respiratory distress. During a review of Pt 2’s “Patient Care Report” (PCR- a document that supports the medical necessity for ambulance transport and serves as a factual assessment of the patient’s condition.) dated 7/11/24, at 12:08 p.m. was reviewed. The PCR indicated under Narrative “Called out to SNF for pt w/ CC: Respiratory Distress. Pt was discharged from [name of hospital] this morning, and family would like him transported back to [same hospital] as he is not ‘thriving.’ Pt was in hospital for approximately 9 hays with pneumonia and was discharged to SNF for rehab ... 83 yo (year old) M (male) lying supine on bed in facility. BLS (basic life support) ambulance on scene reports SPO2 86% on 6 lpm (liters per minute). GCS 14 (Baseline 15) ... O2 switched over to high flow at 15 lpm via NRB (nonrebreather mask) SPO2 improved to 100%... Pt transferred to [name of hospital] ED w/o (without) further incident ...” During a concurrent interview and record review on 9/26/24, at 8:30 a.m., with MD 7, Pt 2’s ED Provider Note dated 7/11/24 at 3:39 p.m. was reviewed. MD 7 stated Pt 2 came in for shortness of breath “Chief Complaint Patient presents with Difficulty Breathing Pt brought in by ambulance with baseline Glasgow coma scale of 15. With EMS pt GCS is 14 with initial O2 sats of 86. NRM elevated O2 to 100. Visible labored respirations ... BP (blood pressure): 166/80 Heart Rate: 80 ... Temp. 36.9 C (98.5 F) Resp (respirations): 32 SpO2: 96 %” on 4 liters per minute “ ... appears dehydrated ... lips dry ... Pulmonary: ... Breath Sounds: Decreased air movement (bilaterally) present ... Clinical Impression 1. Acute respiratory failure with hypoxia 2. Dyspnea ... 3. Elevated troponin (labs looks at cardiac damage) ...” MD 7 stated he ordered labs, chest x-ray (a type of electromagnetic radiation that can pass through most objects, including the body, to generate images of its internal structures and tissues), EKG (electrocardiogram -measures the electrical activity of the heart), and a CT (computed tomography scan, is a medical imaging technique that uses X-rays and a computer to create detailed pictures of the inside of the body) of Pt 2’s chest to diagnose and stabilize. MD 7 stated his job in the ED is to stabilize the patients coming in and he does not know if Pt 2 was discharged too soon. During a review of the facility’s policy titled, “Discharge of Inpatient” dated 6/14/24, indicated, “I. PURPOSE A. To provide guidelines for discharging patients from the inpatient facility. B. To facilitate continuity of care ... V. PROCEDURE ... C. Assess patient as per Patent Assessment policy or unit specific policies. D. Communicate if there are any changes in the patient’s condition to the provider ...” During a review of the facility’s policy titled, “Standard of Practice- Acute Adult Medical/Surgical, Telemetry, Step-Down and Critical Care Units” dated 2/22/23, indicated, “I. PURPOSE These Standards of Practice establish necessary and realistic levels of the nursing process, which assure that quality care is given to each patient. The purpose of these standards is to outline the basic care each patient can expect to receive in” each of these units. “ ... IV. STANDARDS See Standards of Practice Documentation Grid .... General Medical/Surgical ... On-going/Reassessment ... with changes in patient condition and as needed ... Document: Pulse, Respirations, and Blood pressure & Pain assessment Every 8 hours and as needed, unless otherwise ordered ... Temperature every 8 hours ... Pulse Oximetry applied as ordered ... Telemetry every 4 hours ...” During a review of the facility’s policy titled, “Provider Orders” dated 8/25/23, indicated, “I. PURPOSE A. To provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan ... R. Questions and concerns regarding carrying out physician’s orders ... 3. The RN, LVN and LPT are health practitioners and must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible, or potentially inappropriate physician’s orders. This includes, but is not limited to, medication dosages and administration ... 5. All physician orders are to be reviewed and acknowledged to assure proper completion ...” 2. During a review of Pt 25’s “Patient Demographics” (PD-a document providing demographic information about the patient including name, date of birth, admission date, emergency contact), dated 9/24/24, the PD indicated Pt 25 was a 82-year-old Spanish speaking female, admitted to the hospital on 9/23/24 at 6:22 p.m., Pt 25 was discharged home on 9/24/24 at 12:03 a.m., and returned to the ED on 9/24/24 at 7:46 p.m.(returned to the ED 19 hours and 49 minutes later after being discharged on 9/24/24). During an interview on 10/01/24 at 4:26 p.m., with Pt 25’s Family member (FM), FM stated Pt 25’s was brought to the hospital on 9/23/24 because Pt 25’s heart rate was high and blood pressure was low. FM stated a Urine Analysis was done and the doctor said Pt 25 had been stable because heart medication was given through the vein. FM stated the doctor told her Pt 25 was medically stable to be discharge home and the urine culture result was pending and would call her once the result comes back. FM stated she was never informed about the result of the Urine Analysis. FM stated she never receive a call from the doctor of the urine culture result. During a review of Pt 25’s “History &Physical (H&P)” dated 9/23/24 at 6:27 p.m., the H&P indicated Pt 25 had “history of atrial fibrillation with rapid ventricular response (RVR) (a type of irregular heart rhythm that occurs when the heart’s upper chambers contract in an uncoordinated way, causing the lower chambers to beat too fast), Chronic obstructive pulmonary disease (COPD- a common lung disease that makes it difficult to breathe), hyperlipidemia (a condition where there are abnormally high levels of lipids or fats in the blood), Alzheimer’s (a brain disorder that gradually destroys memory and thinking skills). Pt 25 came to the hospital with chief complaint of Cardiac Tachycardia (a condition where the heart rate is faster than normal, usually more than 100 beats per minute (bpm) at rest). Vital signs (VS-measurements of the body’s basic functions, such as breathing, heart rate, and temperature)- Blood Pressure (BP): 111/76, Heart Rate (HR): 149(normal resting heart rate for adults is between 60 and 100 beats per minute), Temperature: 97 Fahrenheit (F- a scale that measures the temperature) , Respiration: 18, Cardiovascular Rate and Rhythm: Tachycardia ... Rhythm Irregularly Irregular ... Discussion: ... patient presents to the ED with complaints of RVR that started 9/23/24 .... Patient’s heart rate improved in the Emergency Department (ED)... Patient discharged with instructions for primary care physician (PCP) follow up within the next 48 hours ... Clinical impression: Atrial fibrillation with RVR, Hyponatremia (a condition where the level of sodium in your blood is lower than normal) ... Disposition: Discharged to home. Results, diagnosis, and follow-up instructions were explained to patients. Patients comfortable going home and was advised to return immediately if symptoms worsen or if any concerns develop. Based on the patient’s clinical picture and the result of a medical screening exam, there is no emergent medical condition present at this time. The patient is stable for discharge from the ED with the agreed upon follow up plan and return precautions”. During a review of Pt 25’s “History &Physical (H&P)” dated on 9/24/24 at 8:19 p.m., the H&P indicated Pt 25 came to the hospital on 9/24/24 at 7:46 p.m. with chief complaint- “Generalized Weakness, VS- Blood Pressure (BP): 113/78, Heart Rate (HR): 161, Temperature: 38 C (100.4 F)(indicating fever), Respiration: 22, Cardiovascular Rate and Rhythm: Tachycardia ... Rhythm Irregularly Irregular, white blood cell count (WBC) of 20 (normal number of WBCs in the blood is 4.5 to 11), Nitrites: Positive ... Clinical Impression: Shortness of breath (SOB), Generalized weakness, Urinary tract infection (UTI- a bacterial infection that affects the bladder, urethra, and kidneys) without hematuria (the presence of red blood cells in the urine), Super ventricular tachycardia (SVT- a condition that causes a rapid heart rate due to an issue with the heart’s electrical system)”. During a review of Pt 25’s Result Review Flowsheet (RRF), the RRF indicated, “ ... on 9/23/24 at 9:57 p.m. .... Leukocyte esterase (enzymes that break down esters into acids and alcohols through a chemical reaction with water) 1+, nitrites: Positive, Red Blood Cells [RBC-carries oxygen and nutrients from the lungs throughout the body]-: 4 ... on 9/24/24 at 10 26 p.m. ... Leukocyte esterase 4+, nitrites: Positive, Protein: 20, WBC: 20 ...” Pt 25 had infection: Extended-spectrum beta-lactamases (ESBL- are enzymes that make some bacteria resistant to antibiotics, making infections harder to treat). During a review of Pt 25’s document titled “Culture Urine (CU)” with specimen collected date on 9/23/24 at 11:49 p.m. and last resulted date on 9/27/24 at 8:46 a.m., the CU indicated the urine culture was > (more than)100,000 cfu/ml (colony-forming units per millimeter- unit of measurement) ESBL Escherichia Coli (bacteria). During a concurrent interview and record review on 10/1/24 at 3.37 p.m., with the Emergency Department Chair (MD) 3 Pt 25’s “Emergency Department Patient Care Timeline (PCT)” and History and Physical (H&P) were reviewed, the PCT with arrival date 9/23/24 indicated Pt 25 was discharged after UA result came back positive. The PCT with arrival date 9/24/24 indicated Pt 25 arrived in the ED on 9/24/24 at 7:46 p.m. The H&P indicated Pt 25 came to the hospital with a chief complaint of generalized weakness, heart rate: 161, temperature of 100.4 (fever), a WBC: 20, Nitrite: Positive. MD 3 stated withholding treatment is appropriate due to the high prevalence of chronic bacteria in the elderly. MD 3 stated “I would not have ordered a UA in the first place”. MD 3 stated there is a very high rate of colonization (the presence and multiplication of a microorganism in or on a host or an inanimate object or surface) in mobility impaired elderly women in particular, the rate for Pt 25 is 80% colonization; it becomes difficult with people like this. MD 3 stated asymptomatic (producing or showing no symptoms) bacteria is a chronically debated area within medicine. MD 3 stated “I would not have checked the UA because it makes the not treating decision simpler”. MD 3 stated the doctor discussed with FM before discharge. MD 3 stated “I would have told the FM that there were some bacteria in the urine, this is something Pt 25 has had for a long time, there was no fever, labs looked good, HR was controlled with medication given, culture has been sent and you would be informed if there is any abnormality”. MD 3 stated it was possible Pt 25 returned to the hospital because the UA result was not addressed, but blood cultures were negative. MD 3 stated if Pt 25 had been admitted during the 9/23/24 visit, Pt 25 may still be in the hospital. MD 3 stated either Pt 25 stayed in the hospital to get Meropenem (used to treat infections caused by bacteria) or be discharged with a peripherally inserted central catheter (PICC) line (a long, thin, flexible tube that’s inserted into a vein in the upper arm and threaded into a larger vein above the heart). MD 3 stated “not treating with anything is appropriate because of the high rate of chronic bacteremia in the elderly, it almost makes less sense to discharge with oral antibiotics because of the likelihood of resistance”. MD 3 stated the difference in the two cases is the presence of fever. MD 3 stated it is appropriate when you don’t treat on the first encounter, for ESBL than to treat. MD 3 stated most of the time, when patients are not treated, they don’t come back to the hospital. MD 3 stated the standard practice is we see all the results and still send the patient home. During a review of the California Advocates for Nursing Home Reform (CANHR) Reference titled, “ Challenging Hospital Discharge Decisions” dated January 12, 2024, (https://canhr.org/challenging-hospital-discharge-decisions/). Discharge Planning Services. Medicare certified hospitals must: “ ...Have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support persons as active partners in the discharge planning for post-discharge care; ...Discuss the evaluation results with the patient or representative; ...Reevaluate and modify discharge plans as needed ...””

“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: 45977 Based on interview and record review, the hospital failed to have an organized nursing service for five of fifteen sampled patients (Patient 1, Patient 8, Patient 9, Patient 10 and Patient 11) when: 1. Patient 1 was found unresponsive (not responding to stimuli) after nursing staff administered Hydromorphone (strong opioid pain medication) intravenously (in the vein). Patient 1 was not assessed or re-assessed in accordance with the policy and procedure titled “Pain Assessment & Management- Patients 14 and Older” for pain, before or after that administration of Hydromorphone.(refer to A398) 2. Nursing staff did not conduct 14 pain reassessments for 3 of 3 admitted patients (Patient 8, 9 and 10) in the Emergency Department in accordance with the policy and procedure titled, “Pain Assessment & Management- Patients 14 and Older”. (refer to A398) 3. Patient 10 reported severe pain and was given the pain medication for moderate pain 10 separate times without staff contacting the attending provider or charting the reason for giving the lesser pain medication in accordance with physician order and the policy and procedures titled, “Pain Assessment & Management- Patients 14 and Older and Provider Orders”. (refer to A398) 4. Patient 8, 10 and 11 reported a moderate or severe pain score and subsequently, did not receive pain medication 14 times in total for all three patients, in accordance with the policy and procedures titled “Patient’s Rights and Responsibilities, Pain Assessment & Management- Patients 14 and Older and Provider Orders”. (refer to A398) 5. The hospital failed to follow their policy for “Pain Assessment & Management -Patients 14 and older” for Pt 1 when nurses did not assess and develop a care plan that met the primary care needs of the patient related to safety. (refer to A396) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care by the nursing staff.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 43258 Based on observation, interview, and record review, the hospital failed to provide pharmaceutical services that meet the needs of the patients as evidenced by: 1. The hospital failed to develop and implement systems to ensure the safe use of medications to minimize adverse drug events. Patient 1 received multiple doses of intravenous (IV, into the vein) opioids, a class of medication identified as high-risk/high-alert medications, exceeding the manufacturer’s recommended dose for the patient’s medical conditions, and suffered respiratory and cardiac arrest (stopping of the heart and breathing) leading to anoxic brain injury (death of brain cells due to oxygen deprivation to the brain) and subsequently expired 10 days later. (Refer to A 500) 2. The hospital failed to implement its Policy & Procedure (P&P) on high-risk/high-alert medications to incorporate external alerts and internal respective review to identify opioids, including hydromorphone, as high-risk/high-alert medications and develop safeguards to reduce the risk of errors. The hospital also did not take appropriate actions to prevent future adverse drug events after one patient, Patient 1, suffered anoxic brain injury and died in October 2023 as a result of unsafe opioid use. (Refer to A 491) 3. The hospital failed to consistently implement its Black Box Warning (BBW, the highest safety-related warning that medications can have assigned by the Food and Drug Administration) P&P and take precautions to address the warning and recommendations issued by external alerts and the FDA (U.S. Food and Drug Administration) pertaining to the heightened risks associated with the use of opioids. The cumulative effect of the systemic problems resulted in the hospital’s failure to ensure the provision of pharmaceutical services in a safe environment that met the needs of the patients.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45977 Based on interview and record review the hospital failed to follow their policy for “Pain Assessment & Management -Patients 14 and older” for one of 15 sampled patients (Patient (Pt) 1)) when nurses did not assess and develop a care plan that met the primary care needs of the patient related to safety. This failure had the potential to result in Patient 1’s care needs going unmet. Findings: During a concurrent interview and record review of Pt 1’s electronic health record (EHR- digital collection of medical information) on 5/18/24, at 12:40 p.m., Pt 1’s “History and Physical (H&P -- the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending)”, dated 10/11/23, and “Education [Nursing Care Plan]”, dated 10/13/2024, were reviewed with the Emergency Department Director (EDD), Emergency Department Clinical Supervisor (EDCS) and Emergency Department Educator (EDed). Pt 1’s H&P indicated Pt 1 was brought to the hospital “with a past medical history of ESRD [End Stage Renal (kidney) Disease] on dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly], diabetes [chronic disease that occurs when the body does not produce enough insulin or cannot effectively use the insulin it produces], and MI [Myocardial infarction - heart attack] s/p [status post -after] bypass [heart surgery], and stroke [brain attack] with left-sided residual weakness, hypertension [high blood pressure] who presents to the ED [Emergency Department] for significant pain, redness and abscess [an enclosed collected of infection and pus in/on the body] like masses on abdominal wall. Patient states she developed it 3 weeks ago and was admitted at ...[another] Hospital where she received IV [intravenous - by the vein into the blood stream] antibiotic for 4 days and was discharged on p.o. [oral] doxycycline [antibiotic medication] for 10 days which she has finished. Patient said even after taking antibiotic as prescribed, it continued to get worse to the point where she has significant pain on movement and getting up. ...”. EDD stated, Pt 1’s care plan addressed issues for skin integrity, nutrition, dialysis, gas exchange and potential for falling as the focused care problems for nursing interventions. EDD stated, pain was not included in the care plan. EDD stated, the care plan does not address pain as it was a reason for the admission. EDD stated, there should be a focus in the nursing care plan that addresses the patient’s pain. EDD stated, nurses are expected to develop a care plan that matches and guides the care of the patient. During an interview on 5/17/24, at 10:00 a.m., with the Chief Nursing Officer (CNO) and the Director of Inpatient Services (DIS), Pt 1’s care was reviewed. The CNO stated, the nursing care plan should address Pt 1’s main complaint for admission. The DIS stated, the nursing care plan should address the main care needs of the patient. The DIS stated, the nurses are expected to follow the policy to documenting and updating the care plan. During a review of the facility P&P “Pain Assessment & Management -Patients 14 and older”, dated 10/12/2023, the P&P indicated, “ ... provide safe and effective pain treatment for all patients, including safe opioid [medication] prescribing and, when appropriate, family preferences and cultural, spiritual, and / or ethnic beliefs/practices for pain management. This will be implemented in the pain management plan of care ... The patient’s care plan will reflect an active plan for the treatment of pain. ... A. The patient/family member/ caregiver will be provided with the following education: ... 1. Information regarding pain and the importance of effective pain management upon entry into the health care setting, prior to admission, or as soon as patient is stable enough to receive information. 2. The patient’s pain and the effective treatment is an important part of the treatment plan. ... “ The “Lippincott Manual of Nursing Practice 10th Edition,” dated 2014, page 16-17 indicated, “ Standards of practice General Principles... 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable ...b. These standards provide patients with a means of measuring the quality of care they receive ...5. A deviation from the protocol should be documented in the patient’s chart with clear, concise statements of the nurse’s decisions, actions, and reasons for the care provided, including any apparent deviation ... Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record ... Failure to formulate or follow the nursing care plan ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 45977 Based on interview and record review, the hospital failed to follow nursing standards of practice, facility policies and procedures for pain assessments and reassessments for five of fifteen sampled patients (Patient 1, Patient 8, Patient 9, Patient 10 and Patient 11), when: 1. Patient 1 was found unresponsive (not responding to stimuli) after nursing staff administered Hydromorphone (strong opioid pain medication) intravenously (in the vein). Patient 1 was not assessed or re-assessed in accordance with the policy and procedure titled “Pain Assessment & Management- Patients 14 and Older” for pain, before or after that administration of Hydromorphone. 2. Nursing staff did not conduct 14 pain reassessments for 3 of 3 admitted patients (Patient 8, 9 and 10) in the Emergency Department in accordance with the policy and procedure titled, “Pain Assessment & Management- Patients 14 and Older”. 3. Patient 10 reported severe pain and was given the pain medication for moderate pain 10 separate times without staff contacting the attending provider or charting the reason for giving the lesser pain medication in accordance with physician order and the policy and procedures titled, “Pain Assessment & Management- Patients 14 and Older and Provider Orders”. 4. Patient 8, 10 and 11 reported a moderate or severe pain score and subsequently, did not receive pain medication 14 times in total for all three patients, in accordance with the policy and procedures titled, “Patient’s Rights and Responsibilities, Pain Assessment & Management- Patients 14 and Older and Provider Orders”. These failures resulted in Patient 1 being found unresponsive and suffering avoidable pain. These failures resulted in Patient 8, 9,10 and 11 suffering avoidable pain and that could have negatively affected their well-being and had the potential to negatively affect treatment of pain for all patients by not adequately addressing patients’ pain, improper monitoring and missed reassessments. These patients were potentially placed at risk of harm and possible death. Findings: 1. During a review of Pt 1’s,”Hospitalist History & Physical [H&P],” dated 10/11/23, the “H&P” indicated, Pt 1 was admitted on 10/11/23, “ ... past medical history of ESRD [End Stage Renal (kidney) Disease] on dialysis [a mechanical procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly], diabetes [chronic disease that occurs when the body does not produce enough insulin or cannot effectively use the insulin it produces], and MI [Myocardial infarction - heart attack] s/p [status post -after] bypass [heart surgery], and stroke [brain attack] with left-sided residual weakness, hypertension [high blood pressure]. Pt 1 presented to the ED [Emergency Department] for significant pain, redness and abscess [an enclosed collected of infection and pus in/on the body] like masses on abdominal wall. Patient stated she developed it 3 weeks ago and was admitted at ...[another] Hospital where she received IV [intravenous - by the vein into the blood stream] antibiotic for 4 days and was discharged on p.o. [oral] doxycycline [antibiotic medication] for 10 days which she has finished. Patient said even after taking antibiotic as prescribed, it continued to get worse to the point where she has significant pain on movement and getting up. ...” During a concurrent interview and record review on 5/14/24, at 4:15 p.m., with the Emergency Department Director (EDD), Emergency Department Clinical Supervisor (EDCS) and Emergency Department Educator (EDed), Pt 1’s “Face sheet” (provides demographics of the patient, name, date of birth, admission date, chief complaint), “Pain Monitoring Flowsheet [PMF]”, and “electronic health records” (EHR), were reviewed for Pt 1’s admission dated 10/11/2023. The EDD stated, Pt 1 had an order for Hydromorphone IV (intravenous (IV) strong opioid pain medication) 1 mg (unit of measurement- milligrams) every four hours as need for severe pain of 8 out of 10 (Pain management scales utilizing the 0-10 descriptors, will be assessed as a pain rating of 0=no pain, 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain). The PMF indicated, Pt 1 received 1 mg of Hydromorphone on 10/12/23 at 11:49 p.m. for severe pain of 8 out 10. The PMF indicated, at 10/13/24 at 12:05 a.m., no pain reassessment number was documented but Pt 1 was “sleeping”. The PMF indicated a Richmond Agitation and Sedation Scale (RASS) [a tool used to rank sedation and agitation], “Alert and calm.” The EDD validated no pain assessment was documented. The PMF indicated, Pt 1 received 1 mg of Hydromorphone on 10/13/23 at 5:29 a.m., no pain assessment or reassessment was documented. The EDD validated the pain assessments and reassessments were not documented for administered medication. The EDD stated, the pain medications should be reassessed within 15 minutes for IV medications, if not sooner for medications affecting respiratory efforts, and 1 hour with medications by mouth. The EDD stated nurses are expected to follow the hospital policies and monitor patients for adverse reactions to pain medications. During a concurrent interview and record review on 5/15/24, at 10:45 a.m., with the Float Pool Registered Nurse 1 (RN 1) and Float Pool Nurse Manager (NM 1), Pt 1’s “Face sheet” (provides demographics of the patient, name, date of birth, admission date, chief complaint), “Pain Monitoring Flowsheet [PMF]”, “Hydromorphone -Black Box Warning” and “electronic health records” (EHR), were reviewed for Pt 1’s admission dated 10/11/2023. RN 1 stated, Pt 1 had an order for Hydromorphone IV 1 mg every four hours as need for severe pain of 8 out of 10 and she had given Hydromorphone 1mg IV at 10/12/23 at 11:49 p.m. and 10/13/23 at 5:29 a.m. for pain. RN 1 stated, she did not document the pain score for the Hydromorphone at 10/12/23 at 11:49 p.m. but stated she recalls she was sleeping although she also documented she was “alert and calm”. RN 1 did not comment when asked if Pt 1 was “sleeping” or “alert and calm”. RN 1 stated, she gave the Hydromorphone 1mg IV at 10/13/23 at 5:29 a.m. because Pt 1 requested the pain medication based on RN 1’s recollection. RN 1 stated, nothing was documented about giving the medication or the pain reassessment. RN 1 stated, she did not know the term “black box warning” for medications. RN 1 read “Hydromorphone -Black Box Warning”, which indicated, “Serious, life-threatening, or fatal respiratory depression may occur, especially during initiation or following a dosage increase. To reduce the risk of respiratory depression, proper dosing and titration of Hydromorphone”. RN 1 stated, Pt 1 should have been on a cardiac monitor and Pt 1’s respirations should be monitored. RN 1 stated, she came back to Pt 1 at 6:10 a.m. do perform a fingerstick to check her blood glucose but the patient was unresponsive at that time. RN 1 stated, she was not aware of Pt 1’s renal impairment or Pt 1 passing out on 10/11/2023 at 1:18 p.m. after receiving Fentanyl (strong opioid pain medication) 75 mcg (micrograms- unit of measurement) IV. NM 1 stated, nurses are expected to assess the pain of the patient and give medications for the pain. NM 1 stated, nurses should document what they are doing and reassess when giving opioids to the patient. NM 1 stated, if this is not done, then there could be bad outcomes for the patient. During a concurrent interview and record review on 5/17/24, at 10:00 a.m., with the Director of Inpatient Services (DIS), and Chief Nursing Officer (CNO), the facility policy and procedure (P&P) “Pain Assessment & Management -Patients 14 and older”, dated 10/12/2023), and the care of Pt 1 were reviewed. The DIS stated, nurses should document pain reassessments within 60 minutes as per the policy and assess patients for oversedation according to the indication for each medication. The DIS stated, nurses should monitor patients for oversedation when giving opioid medications. The CNO stated, she expects the nurses to follow hospital policies about assessing and reassessing for pain and document their actions and assessments. During a review of the facility P&P “Pain Assessment & Management -Patients 14 and older”, dated 10/12/2023, the P&P indicated, “ ... provide safe and effective pain treatment for all patients, including safe opioid [medication] prescribing and, when appropriate, family preferences and cultural, spiritual, and / or ethnic beliefs/practices for pain management. This will be implemented in the pain management plan of care. ... Pain management scales utilizing the 0-10 descriptors, will be assessed as a pain rating of 0=no pain, 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain. Patients’ denial of pain will be interpreted as 0.... Clinicians assess patients with pain as frequently as necessary to provide adequate pain relief and ensure patient safety. ... Pain intensity will be reassessed after each pharmacological [using medication] pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect, ... , IV [using a vein into the blood stream] medication is effective within 30 minutes and PO [by mouth]/ IM [injection to a muscle] medication is effective within 60 minutes. This re-assessment will be documented in the patient medical record using the appropriate pain scale. ... Evaluate and reassess for side effects of treatment risk factors for adverse events caused by the treatment. ... Risk Assessment and Monitoring for Opioid-induced Respiratory Depression (OIRD) and Opioid-induced Sedation (OIS). ... 1. Patients at highest risk include. but are not limited to: ... a. Patients with obstructive sleep apnea [stop breathing] or snoring ... b. Body mass index [tool that estimates body fat based on height and weight] greater than 40 ... c. Age greater than 60: risk of OIRD/ OIS increase with age ... d. Heart failure ... e. Concomitant [using together] sedatives received within 2 hours of opioid administration ... f. Post-operative abdominal or thoracic surgery ... g. Anesthesia time greater than 3 hours ... h. Continuous infusion of opioids ... i. Opioid naïve [patients who have not used pain medications over the last 180 days] ... 2.. Monitor patients for OIRD and OIS using the Richmond Agitation and Sedation Scale [a tool used to rank sedation and agitation], respiratory rate and respiratory pattern. ... “. During a review of the facility P&P “Black Box Warning (serious warning from the FDA for drugs that may cause serious harm or death)”, dated 2/10/22, the P&P indicated, “ PURPOSE: A. To identify medications having the Food and Drug Administration (FDA) designated Black Box Warning (BBW) applicable to “Hospital” facilities. B. To monitor and advocate the safe use of these medications. A. BBW- Refers to the most serious FDA warning. This is also known as a Boxed Warning. The warning provides safety details and may provide restrictions for use or distribution ... III. POLICY: A. All FDA releases of black box warning medications will be continuously reviewed and assessed ... E. Pharmacy Services will present, on an as-needed basis, the following to the P&T Committee contingent on the use of BBW medications: 1. The list ... identified BBW medications with risk reductions measures, the required elements for use and expected health care professional actions involving the identified medications. 2. Any revision of medication use guidelines. 3. Changes to monitoring procedures. 4. Use of alternative medication(s). 5. Deletion of the medication(s) from the formulary (a drug list). 6. Education plan for health care professionals ... 8. BBW notification will be placed in the electronic health record (EHR) to allow a view of the BBW for the pharmacist and nurse. In addition, the information will be placed in the appropriate field for the Automated Dispensing Cabinet (ADC) to reinforce the BBW for the user. 9. Health Care Professional Education ... b. Education will be provided ... v. The BBW designation will be placed into the EHR to alert the nurse of the use of the BBW medication on the medication administration record (MAR) and via the automated dispensing cabinet (computer-controlled systems that automate the dispensing of medications in hospitals) if applicable ...”. During a review of the drug manufacturer medication insert, “Hydromorphone”, dated 4/2024, the insert indicated, “ ... Serious, life-threatening, or fatal respiratory depression may occur, especially during initiation or following a dosage increase. To reduce the risk of respiratory depression, proper dosing and titration of Hydromorphone Hydrochloride Injection [high potency formulation (HPF)] are essential. ... Concomitant use of opioids [medications used to treat pain] with benzodiazepines [medications used to relieve anxiety] or other central nervous system (CNS) depressants, including alcohol, may result in profound sedation, respiratory depression, coma, and death. ... Renal Impairment: Initiate treatment with one-fourth to one-half the usual starting dose, depending on degree of renal impairment. ...Life-Threatening Respiratory Depression in Patients ... in Elderly, ... or Debilitated Patients: Monitor closely, particularly during initiation and titration. ... Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. ... “ During a review of the California Board of Registered Nursing Professional Reference titled, “California Code of Regulations” undated, (https://rn.ca.gov) indicated, “... A registered nurse shall directly provide ... Ongoing patient assessments as defined in the Business and Professions Code, Section 2725(d). Such assessments shall be performed, and the findings documented in the patient ’ s medical record, for each shift and upon receipt of the patient when he/she is transferred to another patient care area ... RN is accountable for an ongoing comprehensive assessment that includes data collection, analysis, and drawing conclusions/making judgments in order to ... formulate diagnoses and update diagnoses formulate or change the plan of care ... decide on specific activities to implement the plan of care (immediate and long-term) ... prioritize and coordinate delivery of care delegate to nursing care competent staff to deliver required care ... anticipate discharge planning/teaching needs... advocate for the patient as needed ... RN uses scientific knowledge and experience to make clinical judgments about observed abnormalities and changes based on a series of complex, independent and collaborative decision making activities ... RN is responsible/accountable to see actual and potential patient needs/health problems are addressed and get recorded on the plan of care ...”. 2. During a review of Patient 8’s “ED (Emergency Department) Provider Note (EPN)” dated 5/10/24, the EPN indicated Patient 8 was admitted on 5/10/24 for “ ... Chief Complaint: Influenza (highly contagious virus) signs and symptoms ... Patient brought in by ambulance for flu like symptoms, fever, chills, increased pain to right foot with fixator (an external frame device placed on the leg that is made of metal and keeps bones in place) noted ... Disposition: Admission ... Clinical Impression: 1. Diabetic ulcer (an open sore or wound) of the right foot associated with type 1 diabetes mellitus (a chronic (life-long) disease that prevents your pancreas from making insulin), with necrosis (death of your body tissue) of muscle, unspecified part of foot. 2. ESRD (End stage renal disease- the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). 3. Fever, unspecified cause ...”. During a review of Patient 8’s “Medication List (ML)” dated 5/10/24 to 5/17/24, the ML indicated, “ ...Acetaminophen for mild pain, Fentanyl (strong opioid pain medication ) 25 mcg (micrograms- unit of measurement) every 6 hours for breakthrough pain (sudden increase in pain), Fentanyl 50 mcg every 6 hours for breakthrough pain, Hydromorphone (strong opioid pain medication ) .25 mg (milligrams- unit of measurement) PRN every 4 hours for breakthrough pain, Hydromorphone .25 mg every 4 hours for severe pain, Morphine (Strong opioid pain medication) 1 mg for severe pain, Hydrocodone (Strong opioid pain medication) 5 mg every 6 hours for severe pain ...”. On 5/17/24 at 8:30 a.m., Patient 8’s MAR was requested from facility but was not provided. Patient 8 chart was received but the MAR was not included. During a review of Patient 8’s “ED Care Timeline (ECT)”, dated 5/10/24 to 5/13/24, the ECT indicated, Patient 8 received pain medication without a pain reassessment on “ ... 5/10/24 at 11:11 p.m., Medication given: Fentanyl (Pain medication) 50 mcg (microgram- unit of measurement), (no pain assessment) Route: Intravenous (in the vein); no reassessment documented ...”. The ECT indicated, on “ ... 5/11/24 at 2:03 a.m., Medication given: Fentanyl 50 mcg (no pain assessment); no reassessment documented ... 5:51 a.m., Medication given: Fentanyl 50 mcg (no pain assessment); no reassessment documented ...”. The ECT indicated, on “ ... 5/12/24 at 5:18 a.m., Medication given: Fentanyl 25 mcg (no pain assessment); no reassessment documented ... 9:11 a.m., Medication given: Oxycodone (Pain medication) 5 mg (milligrams- unit of measurement), route: Oral (by mouth). Pain assessment: 10 severe. Pain type: Acute pain. Pain location: foot; no reassessment documented ... 12:39 p.m., Medication given: Fentanyl 25 mcg, route: Intravenous: Pain Assessment: 10 severe; no reassessment documented ...”. The ECT indicated, on “ ... 5/13/24 at 6:46 a.m., Medication given: Oxycodone 5 mg, route: oral. Pain assessment: 10 severe; no reassessment documented ....”. During a review of Patient 10’s “ED (Emergency Department) Provider Note (EPN)” dated 5/6/24, the EPN indicated Patient 10 was admitted on 5/5/24 for “ ... Chief Complaint: Respiratory short of breath ... from skilled nursing home ... more difficulty breathing than normal ... associated cough ... Disposition: Admission ... Clinical Impression: 1. Acute Dyspnea (shortness of breath) ... 2. Interstitial lung disease (disease that causes scarring of the lungs) ...”. During a review of Patient 10’s “Medication Administration Report (MAR)”, dated 5/7/24 to 5/16/24, the MAR indicated, “ ...Hydrocodone-acetaminophen (Brand name- pain medication) 5-325 mg (milligrams- unit of measurement), 1 tablet ... Frequency: every 6 hours PRN (as needed) Route: oral. PRN reason: Moderate Pain ... Start: 5/6/24 at 9:26 a.m. ... Hydromorphone (Brand name- pain medication) injection .5 mg ... Frequency: every 4 hours PRN. Route IV (intravenous- in the vein). PRN reason: Severe Pain ...Start: 5/9/24 at 1:47 p.m. ...”. During a review of Patient 10’s “ED Care Timeline (ECT)”, dated 5/6/24 to 5/8/24, the ECT indicated, Patient 10 received pain medication without a pain reassessment on “ ... 5/6/24 at 11:55 p.m., Medication given Hydrocodone-acetaminophen (Pain medication), route oral. Pain Assessment: 7 Severe; no reassessment documented ...”. The ECT indicated, “ ...5/8/24 at 9:59 a.m., Medication given Hydrocodone-acetaminophen, route oral. Pain Assessment: 10 Severe; no reassessment documented ... 3:58 p.m., Hydrocodone-acetaminophen, route oral. Pain Assessment: Pain Assessment: 6 moderate; no reassessment documented...”. During a review of Patient 9’s “ED Provider Note (EPN)”, dated, 5/5/24, the EPN indicated Patient 9 was admitted on 5/5/24 for “ ...Chief Complaint: swelling groin ...history of diabetes mellitus (a disease that affects how the body uses blood sugar), anasarca (severe generalized swelling of the body) and chronic kidney disease (CKD- a long-term condition where the kidneys do not work as well as they should) ... Disposition: Admission ... Clinical impression: 1. acute kidney injury superimposed (a secondary issue) by CKD. 2. Hypervolemia (fluid overload) ...”. During a review of Patient 9’s “Medication Administration Report (MAR)”, dated 5/7/24 to 5/16/24, the MAR indicated, “ ...Hydromorphone (Brand name- pain medication) injection 1 mg ... Frequency: every 4 hours PRN. Route IV (intravenous- in the vein). PRN reason: Moderate Pain, Severe Pain ...Start: 5/5/24 at 1:47 p.m. ... Oxycodone-acetaminophen (Brand name- pain medication 10-325 mg, Dose: 1 tablet. Frequency: every 4 hours PRN. Route: oral. PRN reason: Severe Pain. Start: 5/6/24 at 12:54 p.m. ...”. During a review of Patient 9’s “ED Care Timeline (ECT)”, dated 5/5/24 to 5/7/24, the ECT indicated, Patient 9 received pain medication without a pain reassessment on “ ... 5/5/24 at 10:56 p.m., Medication given Hydromorphone 1 mg, route Intravenous. Pain Assessment: 9 Severe; no reassessment documented ...”. The ECT indicated, on “ ... 5/6/24 at 3:54 a.m., Medication given Hydromorphone 1 mg, route Intravenous. Pain Assessment: 10 Severe; no reassessment documented ...”. The ECT indicated, “ ... 5/7/24 at 4:16 a.m., Medication given: Oxycodone-acetaminophen (Pain medication) 10-325 mg, route: oral. Pain assessment: 9 severe; no reassessment documented ... 9:52 p.m., Medication given: Hydromorphone 1 mg, route Intravenous. No Initial Pain Assessment: no reassessment documented ...”. During an interview on 5/17/24 at 8:45 a.m., with the Emergency Department Director (EDD), the EDD stated every patient that received pain medication needed to have a pain reassessment. The EDD stated pain reassessment are important because a patient could have respiratory issues or an allergic reaction after medication administration. The EDD stated pain not being reassessed was a patient safety issue and inadequate patient care. The EDD stated nursing staff did not follow the policy and procedure, “Pain Assessment and Management- Patients 14 and Older”. During a concurrent interview and record review on 5/17/24, at 10:00 a.m., with the Director of Inpatient Services (DIS), and Chief Nursing Officer (CNO), the facility policy and procedure (P&P) “Pain Assessment & Management -Patients 14 and Older”, dated 10/12/2023, was reviewed. The DIS stated, nurses should document pain reassessments within 90 minutes as per the policy and assess patients for oversedation according to the indication for each medication. The DIS stated, nurses should monitor patients for oversedation when giving opioid medications. The CNO stated, she expects the nurses to follow hospital policies about assessing and reassessing for pain and document their actions and assessments. During an interview on 5/17/24 at 2:30 p.m., with ED Registered Nurse (RN) 3, RN 3 stated he was the nurse for Patient 8 in the ED on 5/13/24. RN 3 stated Patient 8 was in pain and he gave him Oxycodone. RN 3 stated he was “supposed” to do a pain scale before he gave the Oxycodone and a pain reassessment after he gave Patient 8 the medication. RN 3 stated he did not do either and they were not charted. During a review of the facility’s Policy and Procedure (P&P) titled, “Pain Assessment & Management- Patients 14 and Older”, dated 10/12/23, the P&P indicated, “PURPOSE: A. To demonstrate [Hospital Name] commitment to a patient’s right to effective pain management. B. To establish standards of nursing care and practice that defines the role and responsibilities of the RN to provide pain management at all facilities ... III. POLICY: A. It is the policy ... to provide safe and effective pain treatment for all patients ... B. Pain is whatever the person experiencing says it is ... Pain is always subjective ... E. Pain management tool is a reliable and validated tool used to measure clinical pain intensity and approved for use ...IV. PROCEDURE: ... 5. Assess and reassess pain using one of the following scales as appropriate. a. 0-10 pain intensity scale ... The appropriate pain rating scale is used to determine an appropriate pain management modality ... C. Implementation ... 2. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider ... D. Evaluation/Reassessment of Pain Management ...2. Pain intensity will be reassessed after each pharmacological pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect, but no longer than 90 minutes after intervention. Generally, intravenous (IV- in the vein) medication is effective within 30 minutes and by mouth or intramuscular medication is effective within 60 minutes. This re-assessment will be documented in the patient medical record using the appropriate pain scale ... 5. Evaluate and reassess for side effects of treatment and risk factors for adverse events caused by treatment ... V. DOCUMENTATION: ... 2. Subsequent reassessments should include the following: intensity, location, response to treatment, modalities (the way in which something happens or is experienced) and type of pain assessment scaled used ...VI. PATIENT EDUCATION: ... 2. The patient’s pain and the effective treatment is an important part of the treatment plan ...”. Review of Nursing World.org Professional Reference titled, “The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition”, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, “ ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...”. 3. During a review of Patient 10’s “ED (Emergency Department) Provider Note (EPN)” dated 5/6/24, the EPN indicated Patient 10 was admitted on 5/5/24 for “ ... Chief Complaint: Respiratory short of breath ... from skilled nursing home ... more difficulty breathing than normal ... associated cough ... Disposition: Admission ... Clinical Impression: 1. Acute Dyspnea (shortness of breath) ... 2. Interstitial lung disease (disease that causes scarring of the lungs) ...”. During a review of Patient 10’s “ED notes (EDN)”, dated 5/8/24 at 4:36 p.m., the EDN indicated, “ ...Patient states he feels anxious and upset and requesting anxiety medication. Visibly agitated and verbally aggressive towards staff. Patient also requesting pain med, 6/10 generalized pain ... 3:58 p.m.: Medication given for anxiety, patient still upset and requesting to speak with supervisor. Notified. ...4:33 p.m.: Patient is still agitated and angry ... Patient noted to be argumentative and irritated ... MD (Medical Doctor) contacted for additional anxiety medications. Pending response ...”. During a review of Patient 10’s “Physician Orders (PO)”, dated 5/6/24 to 5/16/24, the PO indicated: “ ...Hydrocodone-acetaminophen (Brand name- strong opioid pain medication) 5-325 mg (milligrams- unit of measurement) ... ordered dose: 1 tablet ... Route: Oral (by mouth) ... Frequency: Every 6 hours PRN (as needed) for Moderate pain ... Scheduled start date/time 5/6/24 at 9:26 a.m. ... End Date/Time: (still active order) ...”. “ ...Hydromorphone (Brand name- strong opioid pain medication) ... Ordered dose: .5 mg ... Route: Intravenous ... Frequency: Every 4 hours PRN for Severe pain, please give only if unable to tolerate oral medications ... Scheduled Start Date/Time: 5/9/24 at 1:47 p.m. ... Admin Instructions: ... If oral and IV medications are both ordered: Oral PRN pain medications are to be given if patient tolerating oral intake ...”. Patient 10 did not have an oral medication ordered for severe pain; IV Hydromorphone injection .5 mg was given seven times since the scheduled start date/time of 5/9/24. During review of Patient 10’s “Pain flowsheet (PF)” dated 5/17/24, the PF indicated, on “ ...5/11/24 at 9:01 a.m., Pain Assessment: 8 severe. Medication given: 1 tab Hydrocodone-acetaminophen 5-325 mg by mouth ... 3:35 p.m., Pain Assessment: 8 severe. Medication given: 1 tab Hydrocodone-acetaminophen 5-325 mg by mouth ...”. The PF indicated, on “ ... 5/13/24 at 6:12 a.m., Pain Assessment: 8 severe. Medication given: 1 tab Hydrocodone-acetaminophen 5-325 mg ...”. The PF indicated, on “ ... 5/14/24 at 3:04 p.m., Pain Assessment: 8 severe. Medication given: 1 tab Hydrocodone-acetaminophen 5-325 mg ...”. The PF indicated, on “ ... 5/15/24 at 8:31 a.m., Pain Assessment: 9 severe. Medication given: 1 tab Hydrocodone-acetaminophen 5-325 mg ... 6:41 p.m., Pain Assessment: 8 severe. Medication given: 1 tab Hydrocodone-acetaminophen 5-325 mg...”. Patient 10’s pain flowsheet was requested on 5/17/24 at 8:30 a.m. but was not provided. During an interview on 5/17/24, at 10:00 a.m., with the Chief Nursing Officer (CNO), the CNO stated, she expects the nurses to follow hospital policies and procedures in relation to patient pain and their medications. During an interview on 5/17/24 at 1:20 p.m., with RN 4, RN 4 stated she was the nurse for Patient 10 on 5/11/24 on the step-down unit of the hospital. RN 4 stated the point of the patient pain scale assessment was to give the appropriate medication to the patient for pain control. RN 4 stated Patient 10 did state his pain was severe but wanted Hydrocodone-acetaminophen instead of the Hydromorphone. RN 4 stated Patient 10 would say he had severe pain of an 8, “but looking at him he is just sitting there calm”. RN 4 stated to her, Patient 10 did not “look like” he was in severe pain. RN 4 stated she never contacted the physician and Patient 10 did not have anything ordered by mouth for severe pain. During an interview on 5/17/24 at 1:45 p.m., with the Step-down Nurse Manager (SDNM), the SDNM stated the RN should have documented that the Patient was having severe pain but was requesting a less potent medication. The SDNM stated a nurse should believe what the patient said their pain level to be and not go off of how they “look”. The SDNM stated the physician should have been notified of the patient repeated request for Hydrocodone-acetaminophen with a severe pain score. The SDNM stated that Hydromorphone was what Patient 10 had ordered for severe pain and if staff needed a severe pain medication by mouth the physician should have been notified as well. The SDNM stated there was no note in Patient 10’s electronic health record that showed the physician was contacted or the patient requested a less potent pain medication. The SDNM stated staff did not follow the facilities policy and procedure “”Pain Assessment & Management- Patients 14 and Older”. During a review of the facility’s Policy and Procedure (P&P) titled, “Pain Assessment & Management- Patients 14 and Older”, dated 10/12/23, the P&P indicated, “PURPOSE: A. To demonstrate [Hospital Name] commitment to a patient’s right to effective pain management. B. To establish standards of nursing care and practice that defines the role and responsibilities of the RN to provide pain management at all facilities ... III. POLICY: A. It is the policy ... to provide safe and effective pain treatment for all patients ... B. Pain is whatever the person experiencing says it is ... Pain is always subjective ... 2. As prescribed by the provider, the RN may use their clinical judgment to: a. Determine the analgesic and dose to administer based on the scale of pain intensity. Upon patients request a nurse may administer a less potent analgesic ... and document the alteration from the scale of pain intensity and the electronic health record (EHR) ... C. Implementation: ... 2. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider. A. Exception: A patient may request or agree upon a less potent medication (if ordered) or a lower dose of medication; however, this must be documented in the EHR as to the variance to order ... E. Pain management tool is a reliable and validated tool used to measure clinical pain intensity and approved for use ...IV. PROCEDURE: ... 5. Assess and reassess pain using one of the following scales as appropriate. a. 0-10 pain intensity scale ... The appropriate pain rating scale is used to determine an appropriate pain management modality ... C. Implementation ... 2. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider ... VI. PATIENT EDUCATION: ... 2. The patient’s pain and the effective treatment is an important part of the treatment plan ...”. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders”, dated 8/25/23, the P&P indicated, “ ...I. PURPOSE...C. To provide guidelines for the receipt, documentation, authentication and use of verbal or telephone orders ...III. POLICY ...M. ... acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order within the prescribed period ...”. 4. During a review of Patient 8’s “ED (Emergency Department) Provider Note (EPN)” dated 5/10/24, the EPN indicated Patient 8 was admitted on 5/10/24 for “ ... Chief Complaint: Influenza (highly contagious virus) signs and symptoms ... Patient brought in by ambulance for flu like symptoms, fever, chills, increased pain to right foot with fixator (an external device placed on the leg that is made of metal and keeps bones in place) noted ... Disposition: Admission ... Clinical Impression: 1. Diabetic ulcer (an open sore or wound) of the right foot associated with type 1 diabetes mellitus (a chronic (life-long) disease that prevents your pancreas from making insulin), with necrosis (death of your body tissue) of muscle, unspecified part of foot. 2. ESRD (End stage renal disease- the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own). 3. Fever, unspecified cause ...”. During a review of Patient 8’s “Medication List (ML)” dated 5/10/24 to 5/17/24, the ML indicated, “ ...Acetaminophen 325 mg (milligram- unit of measurement) for mild pain, by mouth, Fentanyl (strong opioid pain medication) 25 mcg (micrograms- unit of measurement) every 6 hours for breakthrough pain (sudden increase in pain) via intravenous (IV- in the vein), Fentanyl 50 mcg every 6 hours for breakthrough pain via IV, Hydromorphone (strong opioid pain medication) .25 mg (milligrams- unit of measurement) PRN every 4 hours for breakthrough pain via IV, Hydromorphone .25 mg every 4 hours for severe pain via IV, Morphine (Pain medication) 1 mg for severe pain via IV, Hydrocodone (Pain medication) 5 mg every 6 hours for severe pain by mouth ...”. On 5/17/24 at 8:30 a.m., Patient 8’s MAR was requested from facility but was not provided. Patient 8 chart was received but the MAR was not included. During a review of Patient 8’s “ED (Emergency Department) Care Timeline (ECT)”, the ECT indicated, Patient 8 was assessed as having a severe pain assessment score and no pain medication was administered on, “ ...5/10/24 at 8:06 p.m. Pain Assessment: Pain scaled used: 0 - 10. Rank your current pain where 0 is no pain and 10 is severe pain: 10 severe. Pain location: leg. Pain orientation: right. Pain quality: aching, pressure. Pain duration: continuous. Pain on-set: ongoing. No pain medication administered ...”. The ECT indicated, on” ... 5/11/24 at 7:35 a.m., Pain Assessment: Pain Scaled Used. Rank your current pain where 0 is no pain and 10 is severe pain: 9 severe. Pain location: leg. No pain medication documented ...”. The ECT indicated on, 5/15/24 at 4 a.m., Pain Assessment: 8 severe. No pain medication documented ...”. During a review of Patient 10’s “ED (Emergency Department) Provider Note (EPN)” dated 5/6/24, the EPN indicated Patient 10 was admitted on 5/5/24 for “ ... Chief Complaint: Respiratory short of breath ... from skilled nursing home ... more difficulty breathing than normal ... associated cough ... Disposition: Admission ... Clinical Impression: 1. Acute Dyspnea (shortness of breath) ... 2. Interstitial lung disease (disease that causes scarring of the lungs) ...”. During a review of Patient 10’s “ED Progress Note (PN)”, dated 5/6/24 at 3:17 a.m., the PN indicated, “ ...Patient complain of pain on abdomen and chest and asking for pain med, RN (registered nurse) notified MD (Medical Doctor) ...”. During a review of Patient 10’s “ED Care Timeline (ECT)”, dated 5/5/24 to 5/8/24, the ECT indicated a pain medication was not given to Patient 10 until he received Hydrocodone-acetaminophen (brand name- pain medication) 5-325 mg (milligrams- unit of measurement) 1 tablet on 5/6/24 at 3:18 p.m. (no pain assessment documented). During a review of Patient 10’s “ED Notes (EDN)”, dated 5/7/24 at 9:11 a.m., the EDN indicated, “ ...patient (10) ... alert and oriented ... Reports unspecified chest pain ...”. During a review of Patient 10’s “EDN”, dated 5/8/24 at 4:36 p.m., the EDN indicated, “ ...Patient states he feels anxious (nervous) and upset and requesting anxiety medication. Visibly agitated and verbally aggressive towards staff. Patient also requesting pain med, 6/10 generalized pain ... 3:58 p.m.: Medication given for anxiety, patient still upset and requesting to speak with supervisor. Notified. ...4:33 p.m.: Patient is still agitated and angry ... Patient noted to be argumentative and irritated ... MD (Medical Doctor) contacted for additional anxiety medications. Pending response ...”. During a review of Patient 10’s “Medication Administration Report (MAR)”, dated 5/7/24 to 5/16/24, the MAR indicated, “ ...Hydrocodone-acetaminophen (Brand name- pain medication) 5-325 mg (milligrams- unit of measurement), 1 tablet ... Frequency: every 6 hours PRN (as needed) Route: oral. PRN reason: Moderate Pain ... Start: 5/6/24 at 9:26 a.m. ... Hydromorphone (Brand name- pain medication) injection .5 mg ... Frequency: every 4 hours PRN. Route IV (intravenous- in the vein). PRN reason: Severe Pain ...Start: 5/9/24 at 1:47 p.m. ...”. During a review of Patient 10’s “ED Care Timeline (ECT)”, dated 5/5/24 to 5/8/24, the ECT indicated, on “ ...5/5/24 at 9:30 p.m., Pain Assessment: 8 Severe. Pain location: Chest. No pain medication documented ...”. The ECT indicated, on “ ... 5/6/24 at 6:11 a.m., Pain Assessment: Moderate. No pain medication documented ... 5:34 p.m., Pain Assessment: 5 Moderate. Pain type: Acute pain. Pain location: Chest. No pain medication documented ...”. The ECT indicated, on “ ...5/7/24 at 6:11 a.m., Pain Assessment: 4 Moderate. No pain medication documented. (RN 6) ... 7 a.m., Pain Assessment: 4 Moderate. No pain medication documented. (5/17/24 at 8:30 a.m., RN 6 request for interview and facility did not make her available) ...”. The ECT indicated, on, “ ...5/8/24 at 6:43 a.m., Pain Assessment 6 Moderate. Pain type: Chronic pain. Pain location: Head. No pain medication documented ...”. The ECT indicated, on “ ...5/9/24 at 9:40 a.m., Pain Assessment: 7 severe. No pain medication documented ...”. During a review of Patient 11’s “ED (Emergency Department) Provider Note (EPN)” dated 5/13/24, the EPN indicated Patient 11 was admitted on 5/13/24 for “ ... Chief Complaint: Difficulty breathing ... shortness of breath and weakness starting this morning ... Disposition: Admission ... Clinical Impression: 1. Acute on chronic congestive heart failure (a condition that develops when your heart doesn’t pump enough blood for your body’s needs) ... 2. Pleural effusion (water on the lungs) ...”. During a review of Patient 11’s “Electronic Health Record (EHR)”, dated 5/13/24 to 5/16/24, the EHR indicated, Patient 11 pain medications ordered were Oxycodone-acetaminophen 10-325 mg for severe breakthrough pain, Hydromorphone .5 mg for severe breakthrough pain and acetaminophen for mild pain. On 5/17/24 at 8:30 a.m., Patient 11’s MAR was requested from facility but was not provided. Patient 8 chart was received but the MAR was not included. During a review of Patient 11’s “ED Care Timeline (ECT)”, dated 5/13/24 to 5/16/24, the ECT indicated, on “ ... 5/13/24 at 2:48 p.m., Pain Assessment: 4 Moderate; Pain type: Acute pain. Pain location: Head. No pain medication documented .... 6:33 p.m., Pain Assessment: 8 Severe; Pain type: Acute pain. Pain location: Head. No pain medication documented ...”. The ECT indicated, “ ... 5/14/24 at 9:30 a.m., Pain Assessment: 5 Moderate; Pain type: Acute pain. Pain location: Head. No pain medication documented ...”. The ECT indicated, “ ...5/15/24 at 6:24 p.m., Pain Assessment: 8 Severe; Pain type: Acute pain. Pain Location: Abdomen (stomach). Pain Quality: Aching, Cramping, Constant. No pain medication documented...”. During an interview on 5/17/24 at 8:45 a.m., with the Emergency Department Director (EDD), the EDD stated, when a patient was assessed to have had moderate to severe pain and never given a pain medication to relieve that pain, that patient was in bed “suffering”. The EDD stated patients deserve the right to be free from pain. The EDD stated the issue of a patient’s reported pain not being addressed was a patient’s rights issue. The EDD stated this was not quality patient care. The EDD stated staff were not following Hospital policy and procedures for pain and patient rights. During an interview on 5/17/24 at 8:53 a.m., with Nurse Manager (NM) 2, NM 2 stated he agreed with the EDD, those patients were “suffering” and this was a patient’s rights issue. The NM 2 stated the patients with reported pain not being addressed with medications could deteriorate (become worse). During an interview on 5/17/24, at 10:00 a.m., with the Chief Nursing Officer (CNO), the CNO stated, she expects the nurses to follow hospital policies and procedures in relation to patient pain and their medications. During a concurrent interview and record review on 5/17/24 at 12:05 p.m., with Registered Nurse (RN) 2, Patient 11’s “Electronic Health Record (EHR), dated 5/13/24 to 5/17/24 was reviewed. The EHR indicated, she was the nurse for Patient 11 on 5/15/24. RN 2 stated she did the pain assessment for Patient 11 and assessed severe pain. RN 2 stated she got a new pain medication order for the patient (Oxycodone-acetaminophen 10-325 mg, 1 tablet) but never gave that medication to the patient. RN 2 stated “I guess it just didn’t get done”. RN 2 stated by Patient 11’s pain not being addressed Patient 11 could have become more “ill”. During a review of the facility’s policy and procedure (P&P) titled, “Patient’s Rights and Responsibilities”, dated 2/10/22, the P&P indicated, “ I. PURPOSE: to define the rights and responsibilities of patients who receive services at (Name of Hospital). II. POLICY: A. The administration of (Name of Hospital) protects and supports the rights and responsibilities of our patients. This includes adults, geriatrics ... B. (Name of Hospital) does not discriminate on the basis of a person’s age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity ... C. (Name of Hospital) respects the rights of the patient, recognizes that each patient is an individual with unique health care needs and because of the importance of respecting each patient’s personal dignity provides considerate, respectful care focused upon the patient’s individual needs ... D. Each hospital affirms the patient’s right to make decisions regarding his/her medical care, including the decision to discontinue treatment, to the extent permitted by law ... F. In providing care, (Name of Hospital) have the right to expect behavior on the part of patients ... considering the nature of their illness, is reasonable and responsible ... I. Staff members are informed of their role and the implementation of these policies at the time of orientation and through in service education programs ... III. PATIENT RESPONSIBILITIES: A. All patients to the extent they are capable have the responsibility to: 1. Actively and honestly participate in communication with the healthcare team by: a. Expressing their personal needs upon admission and throughout the hospitalization ... c. Providing information about their illness ... d. Expressing their values ... IV. PATIENT RIGHTS: A. Patient rights are applicable to all hospital patients ... the hospital shall provide processes to support the following patient rights: ... 2. To receive considerate and respectful care, be made comfortable and maintain dignity in a safe setting ... 12. To receive reasonable responses to any reasonable requests made for service ... 19. To receive effective treatment of pain through a pain assessment and management process. A. If the patient suffers from severe, chronic, intractable pain and the particular physician does not agree that opiates are necessary, he/she must inform the patient that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates ... 25. To be free from neglect; exploitation ...”. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders”, dated 8/25/23, the P&P indicated, “ ...I. PURPOSE...C. To provide guidelines for the receipt, documentation, authentication and use of verbal or telephone orders ...III. POLICY ...M. ... acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order within the prescribed period ...”. During a review of the facility’s Policy and Procedure (P&P) titled, “Pain Assessment & Management- Patients 14 and Older”, dated 10/12/23, the P&P indicated, “PURPOSE: A. To demonstrate [Hospital Name] commitment to a patient’s right to effective pain management. B. To establish standards of nursing care and practice that defines the role and responsibilities of the RN to provide pain management at all facilities ... III. POLICY: A. It is the policy ... to provide safe and effective pain treatment for all patients ... B. Pain is whatever the person experiencing says it is ... Pain is always subjective ... E. Pain management tool is a reliable and validated tool used to measure clinical pain intensity and approved for use ...IV. PROCEDURE: ... 5. Assess and reassess pain using one of the following scales as appropriate. a. 0-10 pain intensity scale ... The appropriate pain rating scale is used to determine an appropriate pain management modality ... C. Implementation ... 2. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider ... D. Evaluation/Reassessment of Pain Management ...2. Pain intensity will be reassessed after each pharmacological pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect, but no longer than 90 minutes after intervention. Generally, intravenous (IV- in the vein) medication is effective within 30 minutes and by mouth or intramuscular medication is effective within 60 minutes. This re-assessment will be documented in the patient medical record using the appropriate pain scale ... 5. Evaluate and reassess for side effects of treatment and risk factors for adverse events caused by treatment ... V. DOCUMENTATION: ... 2. Subsequent reassessments should include the following: intensity, location, response to treatment, modalities (the way in which something happens or is experienced) and type of pain assessment scaled used ...VI. PATIENT EDUCATION: ... 2. The patient’s pain and the effective treatment is an important part of the treatment plan ...”. Review of Nursing World.org Professional Reference titled, “The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition”, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, “ ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...”. Review of National Institutes of Health.gov Professional Reference titled, “Access to Pain Management as a Human Right”, dated January 2019, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301399/#:~:text=The%20right%20of%20all%20people%20to%20have%20acknowledgment%20of%20their,by%20adequately%20trained%20health%20professionals.%E2%80%9D) indicated, “ ...The right of all people to have acknowledgment of their pain and to be informed about how it can be assessed and managed. “Article 3. The right of all people in pain to have access to appropriate assessment and treatment of the pain by adequately trained health professionals ...”.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 43258 Based on interviews and record and document reviews, the hospital failed to ensure the safe and appropriate use of medications with heightened risk of patient harm as evidenced by: 1. The hospital failed to implement its policy on high-risk/high-alert medications to incorporate external alerts and internal respective review to identify opioids, including hydromorphone and morphine, as high-risk/high-alert medications and develop safeguards to reduce the risk of errors. The hospital also did not take appropriate actions to prevent future adverse drug events after one patient, Patient 1, suffered anoxic brain injury (death of brain cells due to oxygen deprivation to the brain) and died in October 2023 as a result of unsafe opioid use. 2. The hospital failed to consistently implement its Black Box Warning (BBW, the highest safety-related warning that medications can have assigned by the Food and Drug Administration) policy and procedure (P&P) and take precautions to address the warning and recommendations issued by external alerts and the FDA (U.S. Food and Drug Administration) pertaining to the heightened risks associated with the use of opioids. This failure compromised the hospital’s ability to prevent serious patient harm from medication errors involving known high-risk medications. Findings: 1. During a concurrent interview and record review on 5/9/24 at 1:34 p.m. with Pharmacy Medication Safety Coordinator (PMSC), Patient 1’s physician’s orders were reviewed. PMSC confirmed Patient 1 had the following medication orders approved by the pharmacist without any clinical interventions: - Morphine 4 milligrams (mg, a unit of measurement) IV: 4 mg intravenous (IV, into the vein) once, ordered 10/11/23 at 6:52 p.m. - Hydromorphone 1 mg IV: 1 mg every 4 hours as needed for severe pain, ordered 10/11/23 to 10/12/23 at 1:51 p.m. - Hydromorphone 1 mg IV: 1 mg every 4 hours as needed for severe pain and breakthrough pain, ordered 10/12/23 at 1:50 p.m. Patient 1’s Medication Administration Record (MAR) indicated Patient 1 was administered IV morphine 4 mg on 10/11/23 at 6:59 p.m., hydromorphone 1 mg IV on 10/12/23 at 11:49 p.m. and 10/13/23 at 5:29 a.m. Patient 1 was found pulseless on 10/13/23 at 6:20 a.m. and a Code Blue (a code used in hospitals to indicate the need for immediate medical attention most often because of respiratory or cardiac arrest) was called. Patient 1 had to be intubated, admitted to the Intensive Care Unit (ICU, a hospital ward that provides specialized care to patients who are critically injured or ill), and subsequently died on 10/23/23. Patient 1’s Discharge Summary, dated 10/24/23, indicated, “Problems and Discharge Diagnoses ... respiratory arrest due to narcotics (opioids) ... Summary ... 10/15 ... MRI [magnetic resonance imaging, imaging test that produces detailed images of internal structures in the body] of the head suggests anoxic brain injury [death of brain cells after a complete oxygen deprivation to the brain]... Downtime unknown...” Hydromorphone and morphine belong to a class of drugs called opioids. IV opioids work in the brain to produce a variety of effects including pain relief. IV opioids are potent and potentially dangerous medications due to their potential to cause adverse events, such as over sedation, respiratory depression, and death in some cases. Institute for Safe Medication Practices (ISMP), a recognized nonprofit organization in the USA devoted to the prevention of medication errors, has identified opioids/narcotics as high-alert medications since 2014 to alert health care providers of the patient safety risks associated with their use. Based on error reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), reports of harmful errors in the literature, studies that identify the drugs most often involved in harmful errors, and input from practitioners and safety experts, ISMP created and periodically updates a list of potential high-alert medications. Practitioners responded to an ISMP survey designed to identify which medications were most frequently considered high-alert medications. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. During a review of the hospital’s P&P titled, “Medications- High Alert & High Risk for Patients 14 and Older,” dated 1/9/24, the P&P indicated that the hospital defined high-risk/high-alert drugs as, “Medications ... that have been shown to actually or potentially cause significant harm to patients, even when used as intended. This may be determined through retrospective review or practice; recommendations from organizations, such as the Institute for Safe Medication Practices (ISMP); or prospective analysis.” The purpose of the policy was, “To provide guidelines to ensure patient safety for the safe selection, storage, ordering, transcribing, preparation, monitoring, administration, use and medication system evaluation of medications which have been identified as ‘High-Alert/High-Risk.’” Morphine and hydromorphone were not identified as high-risk/high-alert medications on the policy. A review of Patient 1’s Discharge Summary, dated 10/24/23, indicated, “Problems and Discharge Diagnoses: respiratory arrest due to narcotics (opioids). During an interview with PMSC on 5/14/24 at 1:38 p.m. (7 months after Patient 1 suffered respiratory arrest from opioid use), PMSC stated the hospital identified certain medications used within the hospital as high-risk/high-alert that required special safeguards in place well beyond most other medications, but IV opioids including hydromorphone and morphine were not included on the hospital’s high-risk/high-alert medication list. 2. During a review of the hospital’s P&P titled, “Black Box Warning,” dated 2/10/22, indicated the purpose was, “To identify medications having the Food and Drug Administration (FDA) designated Black Box Warning applicable to [the hospital’s medical centers].” The policy also indicated the following: “A. All FDA releases of black box warning medications will be continuously reviewed and assessed. B. Pharmacy services, working in conjunction with the [hospital medication management committee], will identify those agents with objective risk reduction measures which require specific actions by the healthcare professional. C. The medication(s) will be evaluated by pharmacy services based on formulary status, relative risk, significance, site specific utilization and the patient population involved. The BBW medication list may be revised by pharmacy services as needed based on parameters including but not limited to increased use, revised indication for use, revisions to the BBW and results of new evidence from external sources ...” During a review of the hospital’s Emergency Department IV Opioid Prescribing Patterns, dated April 2024, the report indicated the hospital utilized hydromorphone 18.9% and morphine 47.7% of the time whenever IV opioids were administered. Hydromorphone and morphine are potent and potentially dangerous IV opioid medications due to their potential to cause serious, and potentially life-threatening adverse events. Given the high-risk nature of IV opioids, the manufacturer’s labeling includes a Black Box Warning that warns of the risk of respiratory depression and death when used in combination with other opioids. During an interview on 5/10/24 at 11:54 a.m. with PMSC, PMSC confirmed the hospital had a Black Box Warning medication list but hydromorphone and morphine were not included. A review of the manufacturer’s PI for IV Dilaudid (brand name for hydromorphone) indicated a Black Box Warning at the top of the Package Insert as follow: “WARNING: ADDICTION, ABUSE, AND MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; NEONATAL OPIOID WITHDRAWAL SYNDROME; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS ... Serious, life-threatening, or fatal respiratory depression may occur. Monitor closely, especially upon initiation or following a dose increase.” Under section 5.2, “Life-Threatening Respiratory Depression: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status. While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of DILAUDID INJECTION, the risk is greatest during the initiation of 2 therapy or following a dosage increase. Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy with and following dosage increases of DILAUDID INJECTION. To reduce the risk of respiratory depression, proper dosing and titration of DILAUDID INJECTION is essential.” A review of the hospital’s Black Box Warning list, revised and approved by the Pharmacy and Therapeutics Committee on 8/25/21, indicated that intravenous and oral opioids, including morphine and hydromorphone, were not included on the list. On 5/9/24 at approximately 5 p.m., a request was made for hospital to provide a policy for the safe use of narcotics/IV opioids. On 5/10/24 Risk Coordinator (RC) confirmed the hospital did not have a policy pertaining specifically to the use of opioids in the hospital. American Society of Health-System Pharmacists (ASHP), the largest professional association of pharmacists in the United States, has published minimum standard guidelines intended to serve as a basic guide for the provision of pharmacy services in hospitals. The “ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals,” dated 4/13/12, indicated pharmacists and other appropriate hospital personnel shall establish and regularly revise policies and procedures regarding medication error and adverse event prevention and reporting to ensure that patient care services provided by pharmacists and other pharmacy personnel are delivered in adherence to applicable state and federal laws and regulations, hospital privileging requirements, and national practice standards. Pharmacy management should actively work with or as a part of hospital or health-system leadership to develop and implement policies and procedures that provide safe and effective medication use for the patients served by the institution.””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 43258 Based on interviews and record reviews, the hospital failed to develop and implement systems to ensure the safe use of medications. Patient 1 received multiple doses of intravenous (IV, into the vein) opioids, a class of medication identified as high-risk/high-alert medications, exceeding the manufacturer’s recommended dose for the patient’s medical conditions, and suffered respiratory and cardiac arrest (stopping of the heart and breathing) leading to anoxic brain injury (death of brain cells due to oxygen deprivation to the brain) and subsequently expired 10 days later. Findings: A review of Patient 1’s medical record indicated she was seen in the Emergency Department (ED) on 10/11/23 with diagnoses including abdominal wall cellulitis (A deep infection of the skin caused by bacteria), left abdominal, flank and upper leg pain and swelling, and end stage renal disease (ESRD, the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) who received hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood) three times a week. During a concurrent interview and record review on 5/9/24 at 1:34 p.m. with Pharmacy Medication Safety Coordinator (PMSC), Patient 1’s physician’s orders were reviewed. PMSC confirmed Patient 1 had the following medication orders approved by the pharmacist without any clinical interventions: - Morphine 4 milligrams (mg, a unit of measurement) IV: 4 mg IV once, ordered 10/11/23 at 6:52 p.m. - Hydromorphone 1 mg IV: 1 mg every 4 hours as needed for severe pain, ordered 10/11/23 to 10/12/23 at 1:51 p.m. - Hydromorphone 1 mg IV: 1 mg every 4 hours as needed for severe pain and breakthrough pain, ordered 10/12/23 at 1:50 p.m. Hydromorphone and morphine belong to a class of drugs called opioids. IV opioids work in the brain to produce a variety of effects including pain relief. IV opioids are potent and potentially dangerous medications due to their potential to cause adverse events, such as over sedation, respiratory depression, and death in some cases. Patient 1’s Medication Administration Record (MAR) indicated Patient 1 was administered IV morphine 4 mg on 10/11/23 at 6:59 p.m., hydromorphone 1 mg on 10/12/23 at 11:49 p.m. and 10/13/23 at 5:29 a.m. Patient 1 was found unresponsive and pulseless on 10/13/23 at 6:20 a.m. and a Code Blue (a code used in hospitals to indicate the need for immediate medical attention most often because of respiratory or cardiac arrest) was called. Patient 1 had to be intubated, admitted to the Intensive Care Unit (ICU, a hospital ward that provides specialized care to patients who are critically injured or ill), and subsequently died on 10/23/23. Patient 1’s Discharge Summary, dated 10/24/23, indicated, “Problems and Discharge Diagnoses ... respiratory arrest due to narcotics (opioids) ... Summary ... 10/15 ... MRI [magnetic resonance imaging, imaging test that produces detailed images of internal structures in the body] of the head suggests anoxic brain injury [death of brain cells after a complete oxygen deprivation to the brain]... Downtime unknown ...” During a concurrent interview and record review on 5/9/23 at 11:02 a.m. with PMSC, the manufacturer’s Package Insert (PI) for IV Dilaudid (brand name for hydromorphone) was reviewed. The PI indicated, under section 5.2, “Life-Threatening Respiratory Depression”: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status. While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of DILAUDID INJECTION, the risk is greatest during the initiation of 2 therapy or following a dosage increase. Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy with and following dosage increases of DILAUDID INJECTION. To reduce the risk of respiratory depression, proper dosing and titration of DILAUDID INJECTION is essential. Under Section 2.1, “Dosing and Administration: The usual starting dose for intravenous administration is 0.2 mg to 1 mg every 2 to 3 hours. Patients with hepatic [liver] and renal [kidney] impairment should be started on a lower starting dose ... 8.6 Renal Impairment ... start patients with renal impairment on one-fourth to one-half the usual starting dose depending on the degree of impairment. Patients with renal impairment should be closely monitored during dose titration.” PMSC stated the hydromorphone 1 mg dose (double the dose indicated by the manufacturer) did not seem like a high dose, despite the manufacturer’s dosing guidelines for renally impaired patients. During an interview on 5/9/24 at 1:40 p.m. with Director of Pharmacy (DOP), DOP stated the manufacturer’s PIs were a starting place for determining a dose but that medications were often dosed off label. No evidence-based clinical justification was provided to support the appropriate dosing of hydromorphone and morphine for Patient 1. During an interview on 5/10/24 at 11:05 a.m. with PMSC, PMSC stated morphine was a drug that should have been avoided in renal patients due to the dangerous buildup of metabolites (a substance made when the body breaks down drug) leading to respiratory depression, sedation, lowered blood pressure and slowing of the heart rate. He stated if he received an order for morphine for a renal patient, he would have called the doctor to ask for an alternative. The Merck Manuals, medical references that cover a wide range of medical topics, including disorders, tests, diagnoses, and drugs, which have been published since 1899, indicates that many drugs, particularly water-soluble drugs and their metabolites, are eliminated largely by the kidneys in urine. Therefore, drug dosing depends largely on kidney function. In people whose kidney function has declined, the “normal” dosage of a drug that is eliminated primarily through the kidneys may be too much and may cause side effects. Therefore, health care practitioners sometimes must adjust the drug dosage based on the amount of decline in the person’s kidney function. People with impaired kidney function require lower drug doses than those with normal kidney function. Health care practitioners have several ways to estimate the decline in kidney function. A more accurate estimate of kidney function by using the results of tests that measure the level of creatinine (a waste product) in the blood and sometimes also the urine. They use these results to calculate how effectively creatinine is removed from the body (called creatinine clearance, which reflects how well the kidneys are functioning. A review of Patent 1’s labs, dated 10/11/23, indicated she had a creatinine clearance (CrCl) of 21.77 milliliters/minute (mL/minute, a unit of measurement). During an interview on 5/10/24 at 11:20 a.m., PMSC demonstrated the pharmacy order review process for patient with compromised kidney function by creating a “test patient” with a CrCl of 6 mL/min (indicating severe renal impairment) and an order for IV hydromorphone 10 mg administered as a single dose. PMSC confirmed the system generated an alert only for doses of 4 mg and above (Eight to 80 times the starting dose indicated by the manufacturer). PMSC stated the maximum dose allowed by the system should have been more conservative. According to UpToDate Lexi-Drug, a drug information provider for health care professionals, IV morphine dosing for altered kidney function indicated, “As kidney function deteriorates ... patients may experience CNS (central nervous system) depression, sedation, and severe and prolonged respiratory depression, which may be delayed in presentation ... CrCl 15 to <30 mL/minute: Avoid use. If necessary, administer 25% to 50% of usual initial dose; may also consider extending dose interval. Titrate cautiously to response. CrCl <15 mL/minute: Avoid use.” During an interview on 5/14/24 at 9:59 a.m. with Pharmacist 1, Pharmacist 1 stated when medication orders were reviewed for appropriateness, the same process was followed for routine and one-time orders for all areas of the hospital. He stated the same verification process was used and steps were not bypassed for one-time orders. He stated a one-time dose of hydromorphone 1 mg from the ED was on the high end and would alert him to look further to see what was going on with a patient to warrant such a dose. American Society of Health-System Pharmacists (ASHP), the largest professional association of pharmacists in the United States, has identified minimum standard guidelines intended to serve as a basic guide for the provision of pharmacy services in hospitals. The “ASHP Guidelines: Minimum Standard for Pharmacies in Hospitals,” dated 4/13/12, indicated, “Medication therapy monitoring includes a proactive assessment of patient problems and an assessment of the following: a. The therapeutic appropriateness of the patient’s medication regimen ... c. The appropriateness of the dose of the medication, as well as the route, method, and frequency of administration of the medication ... e. Medication-medication, medication-food, medication-dietary supplement, medication-laboratory test, and medication-disease interactions. f. Adverse drug reactions and other undesired effects ... h. Clinical and pharmacokinetic laboratory data to evaluate the efficacy and safety of medication therapy and to anticipate toxicity and adverse effects.” During a review of the hospital’s Policy and Procedure (P&P) titled, “Medications- Orders, Administration, Storage, Documentation,” dated 12/19/23, the P&P indicated, “V. Procedure ... B. Assess patient for factors that may place them at greater risk for adverse effects of the medication. Factors including, but not limited to, age, altered liver and kidney function ... may contribute to increased risk.” During a review of the hospital’s P&P titled, “Medications Orders - Pharmacist Order Review Process,” dated 1/8/24, the P&P indicated that the pharmacist would review all medication orders for appropriate medication prescribing, including medication dose, route of administration and drug selection, to ensure accuracy and patient safety. Under Section IV. Procedure ... D. “Pharmacists will apply appropriate clinical judgement in evaluating drug therapy. If there are questions or concerns with the medication prescribed, the physician will be contacted before administration to the patient. These concerns may include, but not limited to, the following ... 2. Appropriate drug selection and 4. Appropriate dosage and frequency ...” A review of Patient 1 ‘s clinical record indicated naloxone (an opioid antagonist, reversal agent for opioid overdose) was not administered during Code Blue despite the patient having had received a dose of hydromorphone IV 1 mg within one hour before the patient was found unresponsive. During an interview on 5/9/24 at approximately 2 p.m. with PMSC, PMSC confirmed that naloxone was not administered during the Code Blue when Patient 1 was found unresponsive. When asked if there was any potential negative outcome associated with administering naloxone during the Cold Blue, PMSC responded that the risk would have been very low and the benefit would have surely outweighed the risk. A review of the manufacturer’s PI for hydromorphone IV indicated that for clinically significant respiratory or circulatory depression secondary to hydromorphone overdose, an opioid antagonist (naloxone) should be administered. Institute for Safe Medication Practices (ISMP), a recognized nonprofit organization in the USA devoted to the prevention of medication errors, has identified opioids/narcotics as high-alert medications for over a decade to alert health care providers of the patient safety risks associated with their use. The “ISMP List of High-Alert Medications in Acute Care Settings,” dated 1/10/24, indicated, “High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.””

“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: 45580 Based on interview and record review, the hospital failed to provide stabilizing measures for two of 20 patients (Patient 1 and Patient 2) with identified emergency medical conditions (EMC- a medical condition that presents severe and sudden symptoms, and if they do not receive immediate medical treatment, their injuries could result in impairment, serious health complications, or loss of bodily functions) when: 1. Pt 1 expressed suicidal statements while being discharged and escorted out to the facility after discharge on 1/30/24. Patient (Pt) 1 was brought in by Emergency Medical Services (EMS) ambulance on 1/29/24 because he wanted to kill himself and “jump in front of a train”. A medical screening exam (MSE-a screening to determine whether a patient has an emergency medical condition) exam was provided by a QMP (Qualified Medical Provider), medical clearance was done, and mental health evaluation cleared Pt 1 for discharge on 1/30/24. During the discharge process, Pt 1 expressed he wanted “to kill himself” to the Registered Nurse (RN) 1, and RN 1 did not seek consultation with the Social Worker in accordance with hospital expectations and had Pt 1 escorted out of the hospital. (Refer to A2407, Finding 1) 2. Pt 2 was transported to the emergency department (ED) on 3/13/24 at 5:35 a.m. by ambulance with a chief complaint of hematemesis (vomiting of blood). Pt 2 was triaged (the process to quickly examine patients in the emergency department to decide which patients are the most critically ill and must be treated first) with an ESI (a 5-level emergency department process that sorts patients into 5 groups from 1 (most urgent) to 5 (least urgent) based on the severity of a patient’s illness and resources needed) of 3 and assigned to a hallway bed. Pt 2’s medical screening exam (MSE-when a request is made for examination or treatment for an emergency medical condition) was initiated on 3/13/24 at 5:58 a.m. by Medical Doctor (MD) 4 and orders were placed for medications (a drug used to diagnose, cure, treat, or prevent disease) and labs (testing a sample of blood, urine, or other substance from the body to help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time). While in the ED on 3/13/24 at 11:30 a.m., Pt 2 developed a fever (a higher temperature than normal) increased heart rate (more than 100 beats per minute), and low blood pressure (BP-below 90/60 [Normal BP 90/60 to 120/80]). MD 4 ordered additional medications, labs, and monitoring for Pt 2’s change in condition and stabilizing measures were not carried out in accordance with physician orders. (Refer to A2407, Finding 2) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and responsible manner.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45929 Based on interview and record review, the hospital failed to provide stabilizing measures for two of 20 patients (Patient 1 and Patient 2) with identified emergency medical conditions (EMC- a medical condition that presents severe and sudden symptoms, and if they do not receive immediate medical treatment, their injuries could result in impairment, serious health complications, or loss of bodily functions) when: 1. Pt 1 expressed suicidal statements while being discharged and escorted out to the facility after discharge on 1/30/24. Patient (Pt) 1 was brought in by Emergency Medical Services (EMS) ambulance on 1/29/24 because he wanted to kill himself and “jump in front of a train”. A medical screening exam (MSE-a screening to determine whether a patient has an emergency medical condition) exam was provided by a QMP (Qualified Medical Provider), medical clearance was done, and mental health evaluation cleared Pt 1 for discharge on 1/30/24. During the discharge process, Pt 1 expressed he wanted “to kill himself” to the Registered Nurse (RN) 1, and RN 1 did not seek consultation with the Social Worker in accordance with hospital expectations and had Pt 1 escorted out of the hospital. These failures resulted in Pt 1 attempting to hang himself with a sheet from a tree on the facility’s property immediately after being escorted out of the facility’s Emergency Department (ED) on 1/30/24. Pt 1 was not brought into the ED for stabilization and instead provided transportation to another hospital (Hospital B). 2. Pt 2 was transported to the emergency department (ED) on 3/13/24 at 5:35 a.m. by ambulance with a chief complaint of hematemesis (vomiting of blood). Pt 2 was triaged (the process to quickly examine patients in the emergency department to decide which patients are the most critically ill and must be treated first ) with an ESI (a 5-level emergency department process that sorts patients into 5 groups from 1 (most urgent) to 5 (least urgent) based on the severity of a patient’s illness and resources needed) of 3 and assigned to a hallway bed. Pt 2’s medical screening exam (MSE-when a request is made for examination or treatment for an emergency medical condition) was initiated on 3/13/24 at 5:58 a.m. by Medical Doctor (MD) 4 and orders were placed for medications (a drug used to diagnose, cure, treat, or prevent disease) and labs (testing a sample of blood, urine, or other substance from the body to help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time). While in the ED on 3/13/24 at 11:30 a.m., Pt 2 developed a fever (a higher temperature than normal) increased heart rate (more than 100 beats per minute), and low blood pressure (BP-below 90/60 [Normal BP 90/60 to 120/80]). MD 4 ordered additional medications, labs, and monitoring for Pt 2’s change in condition and stabilizing measures were not carried out in accordance with physician orders. These failures resulted in a delay of administering stabilizing measures, even after Pt 2 was admitted as an inpatient at 1:11pm and MD 5 assumed care. Stabilizing measures were not administered and Pt 2’s clinical status declined in the ED and was pronounced dead at 10:14 p.m. time on 3/13/24. Findings: 1. During a review of Pt 1’s “Emergency Medical Services (EMS, paramedics) Run Sheet (RS,-a documentation of ambulance transport)”, dated 1/29/24, the “RS” indicated EMS was called to respond to a “ ... psychiatric problem/abnormal behavioral ...”. The “RS” indicated Pt 1 “ ... stated he wants to kill himself ... and plans to jump in front of a train ...”. The “RS” indicated EMS transported Pt 1 to the facility and transferred Pt 1’s care to the facility’s ED on 1/29/24 at 7:16 p.m.. During a review of Pt 1’s “ED timeline (EDT)”, dated 1/29/24 to 1/30/24, the “EDT” indicated Pt 1 arrived in the ED at 6:47 p.m. and was placed on a 1799 hold (a California Health and Safety Code allowing a healthcare provider to detain an individual involuntarily for up to 24 hours, until a qualified mental health professional can evaluate the individual) at 6:54 p.m. The “EDT” indicated, “ ... 19:20 [7:10 p.m.] ... Assumed care of patient, asleep on bed, not in any acute distress, denies SI [Suicidal Ideation, ideas of killing oneself] or HI [Homicidal Ideation, ideas of killing someone else] ... [Registered Nurse {RN} 1] ... The “EDT’ indicated Pt 1 was medically cleared by Medical Doctor (MD) 2 and MD 2 placed an order to “ ... Notify Provider if patient becomes agitated or is escalating [becoming more intense or serious] ... Urine Toxicology (UR [urine] Drugs of Abuse scrn [screen, a sample of urine to find drugs present in the body] ... Social Work Consult ...” at 7:41 p.m. During a concurrent interview and record review on 4/4/24 at 10:14 a.m. with RN 7, RN 7 reviewed Pt 1’s “Electronic Medical Record (EMR)”, dated 1/29/24 to 1/30/24. RN 7 stated there were no urine toxicology results for Pt 1. During a review of Pt 1’s “Facility Encounters (FE)”, the “FE” indicated Pt 1 had visits to the facility’s ED on 7/27/23 for SI and was on a 5150 hold [a California code allowing a qualified mental health professional to detain an individual on an involuntary hold for up to 72 hours if the individual poses a danger to themselves or others, or gravely disabled {unable to provide their own food, clothing or shelter}], later cleared by the psychiatric Specialist On Call (SOC); on 2/1/23 for a laceration to the hand and was considered for admit for SI, later cleared by SOC; on 5/4/19 for SI and deliberately cutting himself, later cleared by SOC; and on 4/4/19 for SI with intent and left arm cutting, later cleared by SOC. During a concurrent interview and record review on 4/5/24 at 11:03 a.m. with the Psychiatric Specialist (PS), the PS reviewed Pt 1’s “SOC Consult (SC)”, dated 1/30/24, The PS stated she did the psychiatric assessment for Pt 1 on 1/30/24. The PS stated Pt 1 was depressed but did not want to die or kill anyone. The “SC” indicated pt 1 had been released from prison and was living with his girlfriend’s family for the past week and a half. The PS stated Pt 1 began drinking and using cocaine and marijuana and was subsequently kicked out of the house. The “SC” indicated, “ ... Patient stated he has no clothes, no ID, no cell phone, no job, no money. Came to ED for help. Stated he has suicide thoughts all the time but he denies any intent ... he is also COVID-19 + [positive] ... He stated he wants to feel better about himself but this is no where to start from. He has a meeting with his PO [parole officer] on Wednesday that he plans to keep but he has no where to stay or how to get there. He is depressed about relapsing on drugs ... He now has lost everything because of it ... Is anxious about the future, worries about failing drug testing and being thrown back to prison ...”. The PS stated Pt 1 stated he would feel safe if he had a place to stay and was open to drug rehab treatment. The PS stated patients in the ED admitted in the evening needing outpatient referrals usually waits the following morning for the Social Worker to provide resources and arranged referrals for outpatient needs. The PS stated he was clear with Pt 1 that he would get help from the hospital regarding resources. The “SC” indicated, “ ... Disposition Recommendation ... Discharge home with support ... Treatment and Medication Recommendations ... 1. Cleared for discharge to outpatient treatment 2. Social work consultation for outpatient resources, housing and aftercare 3. Refer to outpatient substance abuse treatment providers in the community ... Reconsult ATC [around the clock] psychiatry as needed ... Patient NO LONGER MEETS CRITERIA for involuntary commitment ... Case discussed with [RN 1] ...”. The PS stated he discussed the recommendations with Registered Nurse (RN) 1. The PS stated if Pt 1 had further suicidal statements or acting out, he would expect the nursing staff to call the SOC for another SOC consult. During a review of Pt 1’s “Provider Note (PN), dated 1/29/24 at 7:32 p.m. The “PN” indicated, “ ... ED Course ... Mon Jan 29, 2024 ... 1941 [7:41 p.m.] **Patient is medically cleared and awaiting social services/psychiatric evaluation** ... Patient progress: 0100 [1:00a.m.]: patient evaluated by SOC psychiatry, does not meet inpatient psych [psychiatric] criteria, recommends d/c [discontinue] 5150 and discharge ...”. During a concurrent interview and record review on 4/5/24 at 11:50 a.m. with MD 2, MD 2 reviewed Pt 1’s “SC”. MD 2 stated RN 1 only told her the 1799 hold was lifted and not about the other recommendations on the “SC”. MD 2 stated the “SC” was uploaded later into the medical record and not visible at the time of discharge. During a review of Pt 1’s “EDT”, the “EDT” indicated, “ ... 1/30/24 ... 01:20 [1:20 a.m.] ... SOC done and recommend discharge, informed [MD 2] about psychiatrist recommendations, 1799 discontinued, discharge instructions given but do not want to go and said he do not have a home to got to, asked if he want to go somewhere of his choosing still no address given for taxi voucher, refused to take his discharge paper, asked social worker but do not know also what kind of help we can give him, patient want to stay in ER [Emergency Room] as said because he do not have any place to go, stated call [sic] a taxi cab and he will go to a train track to kill himself. I told him we cannot do that [sic], patient was escorted outside by security ... RN 1 ...”. The “EDT” indicated Pt 1 was discharged at 2:37 a.m.. During an interview on 4/5/24 at 7:35 a.m. with Security Officer (SO) 1, SO 1 stated he was sent to the ED to escort Pt 1 out of the building. SO 1 stated Pt 1 was sitting outside the Special Care Unit (SCU, a unit to closely monitor psychiatric patients) and asked SO 1 why he was being discharged, because he was still suicidal. SO 1 stated Pt 1 verbalized if he was discharged, he will walk in front of a moving car. SO 1 stated he asked SO 2 assigned in the SCU if medical staff were aware of Pt 1’s statements and SO 2 stated “ ... yes ...”. SO 1 stated RN 1 told him Pt 1 was discharge and to escort Pt 1 outside. SO 1 stated as he walked Pt 1 out and before they got to the green zone (area of the ED just outside the ED lobby), Pt 1 stated he was going to walk in front of a moving car. SO 1 stated he told Pt 1 he could not do anything about the discharge. SO 1 stated Pt 1 followed him and continued to make remarks about being suicidal, having nowhere to go and no one to call. SO 1 stated he suggested to Pt 1 to go to a shelter, but Pt 1 stated he was COVID positive, and a shelter would not take him. SO 1 stated he attempted to reassure Pt 1 and directed him to the bus stop, but Pt 1 asked where the nearest freeway was located and SO 1 did not tell Pt 1. SO 1 stated he directed Pt 1 back to the bus stop. SO 1 stated he was concerned about Pt 1’s statements and turned around and saw Pt 1 turn back and crossed the hospital campus street into the ED parking lot. SO 1 stated Licensed Vocational Nurse (LVN) 1 was in the parking lot and came up to SO 1 and said she heard Pt 1’s suicidal statements. SO 1 stated LVN 1 asked him to call the ED Supervisor and SO 1 radioed security dispatch. SO 1 stated Pt 1 had a sheet he was wearing like a cape, and used the sheet to tie around his neck, made eye contact, jumped on top of the electrical box cage, and tied the other end of the sheet to the tree. SO 1 stated he called dispatch again, as Pt 1 jumped off the electrical box cage and hung himself. SO 1 stated he grabbed Pt 1 and tried to hold him up while LVN 1 tried to reach the sheet to untie it. SO 1 stated someone arrived with shears and LVN 1 cut the sheet. SO 1 stated Pt 1 said “... I told you I needed help and had nowhere to go ...” and stated he did not want to go back into the facility but to go somewhere else. Law enforcement officers and EMS were in the parking lot. EMS took him to another facility (Hospital B). During a concurrent interview on 4/5/25 at 9:15 a.m. with LVN 1 and Clinical Supervisor (CS) 1 , LVN 1 stated she was working in the ED lobby when she heard Pt 1 making suicidal statements as he was being escorted by SO 1 out of the facility through the ED lobby. LVN 1 stated she heard Pt 1 asking SO 1 why he was being discharged. LVN 1 stated she heard Pt 1 ask where he was supposed to go and stated he needed help. LVN 1 stated SO 1 told her he was instructed to walk Pt 1 out of the facility. LVN 1 stated she heard Pt 1 verbalize he wanted to walk in front of a moving car. LVN 1 stated she followed Pt 1 and SO 1 outside and Pt 1 was yelling he was going to jump off the parking garage. LVN 1 stated she went to get help inside and when she came back outside, SO 1 was yelling for help and running to the tree where Pt 1 hung himself. LVN 1 stated she climbed a fence next to the tree attempting to reach the sheet while SO 1 was holding Pt 1 up and tried to give slack to the sheet. LVN 1 stated someone gave her scissors and she cut the sheet to get Pt 1 down. CS 1 stated when Pt 1 was cleared by the PS and the 1799 and 5150 was lifted, and Pt 1 continued to make suicidal ideation statements to RN 1, the expectation was for RN 1 to notify the doctor to re-evaluate Pt 1. During a concurrent interview and record review on 4/5/24 at 3:48 p.m. with the Human Resource Business Partner (HRB), “Employee Relations Summary of Investigation (ERS)”, dated 2/17/24, was reviewed. The “ERS” indicated, “ ...Human Resource Department received a complaint from an Emergency Department employee ... After further investigation and chart review by the department it was determined that [RN 1] did not appropriately follow the discharge procedure nor did he escalate additional concerns from the patient ....”. The HRB stated this was his summary of the investigation regarding the discharge of Pt 1. During an interview on 4/8/24 at 9:18 a.m. with the Emergency Department Manager (EDM), the EDM stated according to the Emergency Medical Treatment and Active Labor Act (EMTALA), the ED was required to provide stabilization. The EDM stated the suicidal ideation’s statements made by Pt 1 while he was being discharged from the ED was the same as a patient being discharged with an unstable blood pressure and the expectation was to hold the discharge and have the patient re-evaluated by the physician. During a review of Pt 1’s “Hospital B Emergency Department Note (HBEDN)”, dated 1/30/24 at 7:17 a.m., the “HBEDN” was reviewed. The “HBEDN” indicated, “ ...Chief Complaint: Suicidal (Recently released from prison, seen at [Hospital A] for SI, + [positive] COVID-19 (Coronavirus disease- an infectious disease) so [Hospital A] could not place him subsequently discharged. After discharge pt [Pt 1] hang himself with a blanket from a tree. [Hospital A] staff were able to cut him down. Then was placed on hold by CPD [Police Department] and sent to [Hospital B] ... He is now complaining of some pain to his throat. CBC [complete blood count- is a blood test used to look at overall health and wide range of medical conditions], CMP [comprehensive metabolic panel - is a blood test that gives doctors information about the body’s fluid balance], ethanol (is a test that measures amount of alcohol in the blood) ... salicylate (is a test that measures the amount of salicylates [type of drug found in over the counter prescriptions] in the blood) were unremarkable. CT angio [angiogram] neck [computed tomography is a test used to provide detailed picture of the blood vessels, head, and neck) ... At this time patient is medically cleared. However, because the patient admits to suicidal ideation patient will be placed on a 5150 hold ...” During a review of Pt 1’s “HBEDN”, dated 1/30/24 at 1:34 p.m., the “HBEDN” was reviewed. The “HBEDN” indicated, “ ...Plan of care: Patient will be transferred to [name of facility- Mental Health Service] with the diagnosis attempt by hanging and suicidal ideations under the care of [name of physician] ...” During a review of Pt 1’s “Emergency Department Timeline from Hospital B (EDTB)”, dated 1/30/24, the “EDTB” was reviewed. The “EDTB” indicated, “ ... 16:36:25 [4:36] Accepted at [name of facility- Mental health service]: [name of physician] Male Day Room Requested Arrival: ASAP [as soon as possible] ... 1848 [6 p.m.] Patient discharged...” During a review of the facility’s policy and procedure titled, “Standard of Practice for Emergency Department (SP)”, dated 9/14/22, “SP” indicated, “ ... The patient will have a systemic and continuous assessment of their health status performed by a Licensed Nurse, utilizing the nursing process. The RN will ... Collect, document, and communicate data to the interdisciplinary team ... Advise the physician of any alterations in the patient’s psychological and/or physiological condition ...”. During a review of the facility’s policy and procedure titled, “Involuntary Detention of Mentally Disordered Persons - 5150/1799 Process (ID)”, dated 2/25/22, “ID” indicated, “ ... Medical clearance/stability is presumed to be a prerequisite to the application of WIC [Welfare and Institutions Code] 5150 guidelines ...”. During the review of the facility’s policy and Procedure titled, “Medical Staff Emergency Medical Treatment and Active Labor Act (EMTALA)”, dated 10/10/19, “EMTALA” indicated, “ ... Policy ... for every patient presenting to the Emergency Department ... Definitions ... Emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including ... psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention should reasonably be expected to result in ... Placing the individual ... in serious jeopardy ... For EMTALA purposes, a patient is stabilized when, within a reasonable degree of medical probability, no material deterioration of the condition is likely to result from, or occur, during the transfer or discharge of a patient from the facility ...”. 45580 2. During a record review of Pt 2’s “Patient Care Report (PCR),” dated 3/13/24, the PCR indicated at 4:45 a.m. the dispatch was notified of the need for ambulance services and at 4:56 a.m. the ambulance was at the patient’s bedside. The PCR indicated, “[Patient] is a 68 [year old] [male] [chief complaint] coffee ground emesis [with] [abdominal] pain [times] 1 day. [Patient] +[brand name-(Apixaban- blood thinner)] [blood thinner that reduces blood clotting], +[history] of bleeding ulcers, +hypotension. [Patient] extensive [history] of [gastrointestinal] bleeds ...[atrial fibrillation (A Fib-an irregular heartbeat)], paraplegic [the inability to voluntarily move the lower parts of the body], dementia [the impaired ability to remember, think, or make decisions]. [Patient] compliant [with] meds. [Patient] [by mouth] intake reduced ...” The PCR indicated at 5:24 a.m. a call was made to [name of Hospital A] with the estimated time of arrival. The PCR indicated at 5:31 a.m. Pt 2 arrived in the ED and transfer of care from emergency medical services (EMS) to RN 6 was at 6:05 a.m. During a concurrent interview and record review on 4/3/24 at 2:16 p.m. with the Emergency Department Manager (EDM), Pt 2’s “Electronic Medical Record (EMR),” dated 3/13/24 was reviewed. The EMR indicated, Pt 2 was triaged at 5:46 a.m. with an ESI of 3. The EDM stated the EMR indicated Pt 2’s MSE was initiated by MD 4 and physician orders were placed. The EMR indicated at 11:30 a.m. Pt 2 developed a fever and additional physician orders for acetaminophen STAT (meaning immediately) once at 11:54 a.m. and at 11:57 a.m., sodium chloride 0.9% [a salt formula] bolus [a medication given over a short period of time]1,000 mL [milliliters- unit of measurement] routine once, erythromycin (an antibiotic medication used to treat infections) 500 mg [milligrams-unit of measurement] tablet STAT once, lactic acid sepsis (used to diagnose lactic acidosis [is a severe medical illness in which blood pressure is low and too little oxygen is reaching the body’s tissues] and find out how severe it is), blood culture (a test that checks samples of blood for the presence of disease-causing germs); heart rate (the number of times the heart beats per minute), respiratory rate (the number of breaths a person takes per minute), manual BP [blood pressure], temperature and oxygen saturation (measures the amount of oxygen in the blood) routine every two hours and heart rate, respiratory rate, and oxygen saturation-Units where continuous monitoring available routine continuous. During a concurrent interview and record review on 4/3/24 at 2:30 p.m. with the EDM, Pt 2’s EMR, dated 3/13/24 was reviewed. The EMR indicated Pt 2 was accepted for inpatient admission by MD 5 at 12:44 p.m. and Pt 2 remained in the ED, in his assigned hallway bed , indicating Pt 2 was not moved to another area where Pt 2 could have been closely and continuously monitored. The EMR indicated there was no indication Pt 2 was placed on a cardiac monitor (a way of watching the electrical activity of your heart to ensure it is working normally). The EDM stated the EMR indicated Pt 2’s physician order for acetaminophen at 11:54 a.m., with a start time of 12:10 p.m. was administered at 1:16 p.m. (a time lapse of one hour and 6 minutes after the order was placed) and a reassessment of Pt 2’s temperature was not done. The EDM stated within an hour of acetaminophen administration, Pt 2’s temperature should have been rechecked and was not. The EMR indicated the next vital signs were documented at 6:33 p.m. (a time lapse of five hours and 17 minutes from the time of acetaminophen administration), also indicating Pt 2 was not monitored according to MD 4’s physician’s orders which indicated Pt 2’s vital signs should have been assessed every two hours with continuous oxygen saturation monitoring. During a concurrent interview and record review on 4/3/24 at 2:35 p.m. with the EDM, Pt 2’s EMR, dated 3/13/24 was reviewed. The EDM stated the EMR indicated Pt 2 had a physician’s order placed at 11:57 a.m. for sodium chloride bolus to correct hypotensive shock [a life-threatening condition when the systolic blood pressure is less than 90 mm Hg or MAP less than 65 mmHg] was administered at 1:19 p.m. (a time lapse of one hour and 16 minutes after the order was placed). During a concurrent interview and record review on 4/3/23 at 2:40 p.m. with the EDM, Pt 2’s EMR, dated 3/13/24 was reviewed. The EDM stated the EMR indicated, the lactic acid and blood cultures ordered at 11:57 a.m. were drawn at 1:29 p.m. (a time lapse of one hour and 26 minutes after the order was placed). Pt 2’s lactic acid resulted 4.2 at 1:56 p.m., which was a critical value (a test result which is significantly outside the normal range and may represent life-threatening values [normal range: 0.5-2.2]). During a concurrent interview and record review on 4/3/24 at 2:45 p.m. with the EDM Pt 2’s EMR dated 3/13/24 was reviewed. The EDM stated Pt 2’ physician order laboratory included Complete Blood Count (CBC) and Chemistry (CHEM) 10 (test used to look for patients overall health and find a wide range of medical conditions such as infection) were not drawn in a timely manner and was delayed because Pt 2 was a hard stick (a patient whose veins are difficult to locate) and the phlebotomist was not able to obtain the CBC and Chemistry 10 and did not notify the assigned RN to Pt 2. The EDM stated the RN should have used the chain of command and notified the clinical supervisor and physician if the labs were unable to be drawn to find another way to obtain Pt 2’s labs. During a concurrent interview and record review on 4/3/24 at 3 p.m. with the EDM, Pt 2’s EMR, dated 3/13/24 was reviewed. The EMR indicated Pt 2’s physician order for erythromycin placed at 11:57 a.m. by MD 4 was not administer and was discontinued at 1:13 p.m. by MD 5. The EMR indicated MD 5 ordered another antibiotic at 6:37 p.m., which was piperacillin-tazobactam (medication used to treat bacterial infections [the invasion and growth of germs in the body]) intravenous piggyback (IVPB-a small bag of IV medication that must be administered separately from the other IV fluids). The EMR indicated piperacillin-tazobactam was not administered. The EMR indicated there were no nurses’ notes indicating the reason Pt 2 was not administered the erythromycin and the piperacillin-tazobactam. The EDM stated the physician ordered antibiotic medications should have been administered to Pt 2 which could have helped improve Pt’s 2 medical condition. During a concurrent interview and record review on 4/3/24 at 3:10 p.m. with the EDM, Pt 2’s EMR, dated 3/13/24 was reviewed. The EMR indicated at 10:01 p.m. a physician note under Significant Event (any unintended or unexpected event, which could or did lead to harm of a patient) indicated, “I was notified by RN that the family noticed that the patient became unresponsive. Repeat lactic acid is up to 10.6. I assessed the patient at bedside. ED attending (name of MD 7) was also present in the room and talked to the daughter about the code status. Patient’s daughter states that patient’s code status is [do not resuscitate (to revive a person who has lost consciousness)/do not intubate (to put a tube in a person’s mouth or nose then down into the windpipe to assist with breathing) DNR/DNI] but she wants the patient to continue receiving medical treatment. Daughter also states that patient had a severe reaction to penicillin [medication used to treat infections] in the past. A dose of [piperacillin-tazobactam] was ordered by the day hospitalist but has not been given. Will change [piperacillin-tazobactam] to cefepime [medication used to treat bacterial infections] and [metronidazole-medication used to treat bacterial infections] and add vancomycin [medication used to treat bacterial infections] for broad spectrum coverage [effective against a wide range of germs]. Patient was also hypoxic [having too little oxygen-normal range is 95% to 100%] (SpO2 70s on [non-rebreather mask (NRB-a device used to assist in the delivery of oxygen]). Asked [respiratory therapist] to place patient on NRB and [high-flow nasal cannula (HFNC-an oxygen supply system capable of delivering up to 100% humidified [to warm and moisten the oxygen being inhaled by the patient] and heated oxygen at a flow rate of up to 60 liters per minute)]. Will also order another bolus of [sodium chloride 0.9%] 1 [liter (L-a unit measure of volume)] and repeat the lactate...” During a record review on 4/3/23 at 3:20 p.m. with the EDM, Pt 2’s EMR, dated 3/13/24 was reviewed. The EDM stated the EMR indicated, at 10:16 p.m. MD 6 documented a physician note under Significant Event, “I was notified by RN that patient became pulseless. I examined patient at bedside. Patient’s daughter was also present in the room. There were no breath or heart sounds on exam. Pulses absent. Pupil dilated and non-reactive to light. Patient was pronounced at 10:14 PM.” During a review of Pt 2’s “Discharge Summary Note (Note),” dated 3/14/24, the Note indicated, “ ...Findings and Hospital events leading to death: Patient was loaded with IV pantoprazole and started on pantoprazole drip. Serial hemogram [every] 6 [hour] was ordered. Patient was given additional normal saline [times] 1L. Chest xray was ordered and resulted left lower lobe consolidation. Lactic acid returned 4.2. Patient then developed fever; all findings concerning for aspiration pneumonia with sepsis. Patient had received 20 [milliliters (mL-one thousand mLs equal one liter)/kilogram (kg-a unit of measurement)] fluid bolus per sepsis guidelines and continued with normal saline infusion. Initial repeat vitals showed improvement. [urinalysis] was pending. Blood cultures were drawn. Patient was ordered piperacillin/tazobactam to cover both aspiration pneumonia and possible [extended spectrum beta-lactamase (ESBL-germs cannot be killed by many of the antibiotics used to treat infections)] [urinary tract infection (UTI)] related to chronic foley; noted allergy to amoxicillin with diarrhea but considered benefits of outweighing risks. Repeat hemogram and lactic acid were pending. Patient was waiting for [esophagogastroduodenoscopy (EGD-a medical procedure which allows doctors to inspect and observe the inside of the body without performing major surgery)] ...This morning, upon knowledge of patient’s expiration, I called patient’s family and spoke with patient’s daughter and answered all her questions ...Presumed cause of death: Acute respiratory failure with hypoxemia (hours) Aspiration pneumonia (hours) Severe sepsis (hours) Upper GI bleed (days) ...Coroner Notification: no ...Coroners Case: no ...Autopsy Ordered: no ...” During a telephone interview on 4/4/24 at 3:14 p.m. with MD 4, present during the interview were VPQ and MD 3, MD 4 stated he remembered Pt 2. MD 4 stated typical orders for a patient who presented with hematemesis included CBC, Chem 10, hemoglobin, platelets to determine the patient’s hemodynamic stability (indicates a patient has a stable pumping heart and a good circulation of blood). MD 4 stated Pt 2 presented with hematemesis and a history of atrial fibrillation (A Fib) and an EKG (electrocardiogram- test used to record the hearts electrical activity) should be ordered for patients with this history. MD 4 stated the patient should be monitored based on their presentation and vital signs. MD 4 stated all the labs in the ED was ordered STAT labs (labs should be drawn within an hour or less). MD 4 stated his expectations for labs to be drawn was within a couple hours of the physician order and drawn within the first few hours of the patient’s arrival to the ED. MD 4 stated the importance of timely lab draws was once they were ordered; the physician determined the patient’s management based on the lab results. MD 4 stated the frequency of the hemogram reassessments would depend on the first results. MD 3 stated he reviewed Pt 2’s ED visit thoroughly and there were no physician orders for imaging or EKG for Pt 2 while he was an ED patient. MD 4 stated he worked 10-hour shifts and at the end of his shift he would give report to the oncoming physician and if the patient had active orders pending, the oncoming physician followed up on the pending active orders or if the patient was admitted, he turned over the patient’s care to the hospitalist. MD 4 stated for Pt 2 he reported to the hospitalist over the phone. MD 4 stated when the hospitalist put in the admit orders for Pt 2, the hospitalist took over care of the patient. During a review of Pt 2’s “ED Provider Note (Note),” dated 3/13/24, the Note indicated at 8:36 a.m., “Considered CT abdomen, however no abdominal pain on exam and patient had a CT abdomen on 3/4/24 that was unremarkable.” During a concurrent interview and record review on 4/5/24 at 8:22 a.m., with RN 6, present during the interview were RN 7, Clinical Nurse Educator (CNE), and EDM, Pt 2’s “EMR”, dated 3/13/24 was reviewed. RN 6 stated she was assigned Pt 2 about an hour prior to shift change and was aware Pt 2 presented with hematemesis. RN 6 stated Pt 2 had orders for ondansetron (medication used to prevent nausea and vomiting) and pantoprazole ( medication used to treat heartburn) by way of intravenous (IV) but Pt 2 did not have an IV access. RN 6 stated she tried to do an IV cannulation (is a technique in which a cannula [a small plastic tube inserted into vein] is placed inside a vein to provide a venous access) a few times but was unsuccessful and asked another RN to assist her with Pt 2’s IV insertion, which was successful. RN 6 stated she was then able to administer both medications. RN 6 stated Pt 2 responded to her when she asked him questions and she remembered he was a hard stick for the IV insertion and was quadriplegic (partial or complete paralysis of both the arms and legs) . RN 6 stated Pt 2 was alone and did not have any family at bedside. RN 6 stated Pt 2 was assigned to YY-02, which was a hallway bed in the yellow zone (not urgent area of the ED). EDM stated YY-02 was located in a hallway and they were no longer using the hall space for patient assignments as of 3/14/24. RN 6 stated the charge nurse or clinical supervisor assigned the patients their ED space/room assignment. The EMR indicated at 6:03 a.m. RN 6 assigned herself as Pt 2’s RN and a Fall Risk Intervention indicated, “Place patient in highly visible area.” RN 6 stated the area Pt 2 was assigned was not highly visible from the nurse’s station. RN 6 stated the importance of having high fall risk patient placed in a highly visible areas was to prevent patient falls. RN 6 stated a high fall risk patient not assigned a bed in highly visible area increased the risk for patient fall. During a concurrent interview and record review on 4/5/24 at 8:45 a.m. with RN 6, Pt 2’s EMR, dated 3/13/24 was reviewed. The EMR indicated Pt 2 was ordered acetaminophen STAT with a start time of 12:10 p.m. RN 6 stated STAT medications were to be administered within an hour and routine medications were to be administered within 24 hours. RN 6 stated Pt 2 was administered acetaminophen one hour and six minutes after the start time. RN 6 stated the importance to administer the acetaminophen timely was to manage Pt 2’s elevated temperature. RN 6 stated Pt 2’s acetaminophen not administered timely placed Pt 2’s temperature to remain elevated which could be harmful. During a concurrent interview and record review on 4/5/24 at 8:55 a.m. with RN 6, Pt 2’s EMR, dated 3/13/24 was reviewed. RN 6 stated she was present when the phlebotomist attempted to draw Pt 2’s labs. RN 6 stated the phlebotomist was having a hard time drawing the labs and was unsuccessful. RN 6 stated her role was to notify the physician if Pt 2’s labs were not drawn timely but did not have to since the phlebotomist eventually was able to draw Pt 2’s labs. RN 6 stated she did not know if it was the same phlebotomist who successfully drew Pt 2’s labs or if it was a different phlebotomist. RN 6 stated the importance of making sure labs were drawn in a timely manner per physician’s order was to ensure the timely results of labs and the physician could determine the patient’s medical condition and to address any critical lab values which could potentially harm Pt 2. During an interview on 4/5/24 at 9:15 a.m. with RN 6, RN 6 stated once a patient was admitted, the RN would contact the patient’s primary contact and the assigned physician if the patient had a change in condition. During a telephone interview on 4/5/24 at 10:15 a.m. with RN 8, present were CNE 2 and the EDM, RN 8 stated the triage process started when a patient arrived in the ED. RN 8 stated she would ask the patient the reason for coming to the ED and assessed the patient’s current condition, vital signs, and pain level. RN 8 stated when a patient arrived in the ED by way of Emergency Medical Service (EMS- is a system that responds to emergencies in need of a highly skilled pre-hospital clinicians) she would receive report from the EMS, and she would assess the patient’s medical condition during tirage. RN 8 stated she would assign an ESI to the patient based on the patient’s reason for coming to the ED, signs and symptoms, and medical history. RN 8 stated an ESI 1 was indicated for patients who required immediate lifesaving treatments, ESI 2 was indicated for patients who required interventions immediately but were more stable than an ESI 1, ESI 3 was indicated for patients who presented with abdominal pain or chest pain with no cardiac history, ESI 4 was indicated for a patient who presented with a rolled ankle and required an x-ray, and ESI 5 was indicated for patients who came to the ED for a prescription refill. During a telephone interview on 4/5/24 at 10:25 a.m. with RN 8, present were CNE 2 and the EDM, RN 8 stated she remembered Pt 2, he came in for hematemesis, had a history of taking (brand name) [Apixaban- blood thinner] and was residing at a facility. RN 8 stated Pt 2 came in by EMS and there was no family at bedside. RN 8 stated Pt 2 was alert but confused and she was told by EMS Pt 2 did not have any emesis (the act of vomiting) while enroute to the hospital. RN 8 stated she assessed Pt 2’s vital signs, Pt 2 was tachycardic (heart beating faster than normal) with a heartrate of 106 [normal adult heart rate 60-100 beats per minute], blood pressure, breathing and temperature was normal, and was not actively vomiting. RN 8 stated she assigned Pt 2 an ESI 3. RN 8 stated if Pt 2 were to decompensate (when the body fails to maintain blood pressure and lead to decrease blood supply to body’s vital organs) she would escalate the condition and bring Pt 2 to a treatment room. During a telephone interview on 4/5/24 at 10:30 a.m. with RN 8, present were CNE 2 and the EDM, RN 8 stated the difference between urgent and emergent was, urgent meant the patient needed to be seen in a timely manner and emergent meant the patient needed to be seen immediately. RN 8 stated the reassessment of a patient who was considered urgent would depend on the patient’s presentation and vital signs would determine the frequency of monitoring the patient. RN 8 stated the reassessment of a patient who was considered emergent could be every 15 minutes with more frequent monitoring based on the patient’s presentation. During a telephone interview on 4/5/24 at 10:35 a.m. with RN 8, present were CNE 2 and the EDM, RN 8 stated she was not made aware of Pt 2’s demise until recently when the EDM informed her Pt 2 decompensated and passed away. RN 8 stated there has been new education and training recently, but she was not aware if it was due to Pt 2’s care while in the ED. RN 8 stated there has been training about ESI, EMTALA, and several other topics. RN 8 stated the education and training was provided in person, through online courses, and quizzes were provided to ensure staff knowledge and reassure their skill sets. During an interview on 4/8/24 at 9:30 a.m. with the EDM, with the Interim Emergency Department Director (IEDD) and CNE 2 present, the EDM stated physician’s orders should be carried out according to the physician’s orders. The EDM stated she expected STAT orders were carried out within an hour, routine orders within 24 hours, and timed orders were implemented plus or minus 15 minutes of the order placed. The EDM stated the importance of carrying out physician orders timely was to ensure if there were critical results, the hospital could act on it. The EDM stated if the physician orders were timely, the hospital could prepare the patient for a test or diagnostics, and if the labs were delayed or done too early, the results could impact the patient’s care. The EDM stated her expectations when a patient had physician’s order for vital signs every two hours then the patient’s vital signs should be assessed every two hours. The EDM stated the importance of following the physician’s orders of assessing the patient’s vitals every two hours was to see if there were any changes to the patient’s status. The EDM stated if a patient was not monitored every two hours according to the physician’s orders, the hospital staff could not see if there were any changes to the patient’s vital signs which could lead to patient harm. During an interview on 4/8/24 at 9:40 a.m. with the EDM, with the IEDD and CNE 2 present, the EDM stated her expectations when patients’ labs could not be obtained timely, was for the nurses to notify the physician. The EDM stated the importance of timely lab draws was to identify if the patient had any illness process going on in their body. During an interview on 4/8/24 at 9:45 a.m. with the EDM, with the IEDD and CNE 2 present, the EDM stated patients who were admitted and remained in the ED hallway beds were monitored for their oxygen saturation by their remote telemetry box (a portable device used to continuously monitor patients heart electrical activity and oxygen saturations) or vital sign machines (device used to monitor patients heart rate, blood pressure and temperature) which require to be plugged in an electrical an outlet.. The EDM stated her expectations for patients requiring continuous pulse oximetry monitoring was to have the patient monitored by their telemetry box or moved to a room. The EDM stated when the patient had physician orders for continuous pulse oximetry monitoring and were not monitored accordingly, the hospital staff would not recognize if the patient was desating (oxygen is getting lower). During an interview on 4/8/24 at 10 a.m. with the EDM, present were the IEDD and CNE 2, the EDM stated looking back on Pt 2’s care and having reviewed his chart, the EDM stated Pt 2 should have been monitored more closely and there should have been an escalation up the Chain of command when there were delays in care which did not help Pt 2’s medical condition. The EDM stated she did not know if any of their interventions could have saved Pt 2 and a doctor probably would not be able to say for certain as well. During an interview on 4/8/24 at 10:50 a.m. with the CNO, with the Chief Operating Officer (COO) present, the CNO stated her expectations when patients had orders in the ED were the orders should be carried out and followed according to the hospitals’ policies and procedures (P&P) for all patients whether they were ED or admitted patients in the ED. The CNO stated the hospital has set up oversight and monitoring to ensure admitted ED patients were provided the care they required. The CNO stated the hospital has dash boards available to leadership that show the required documentation, which ties to the standards of care, orders, and P&P of inpatients regardless of where the patient was in the hospital, all patients are monitored. During a review of the hospital’s P&P titled, “Medications-Orders, Administration, Storage, Documentation,” dated 12/19/23, the P&P indicated, “ ...To provide guidelines for the safe and accurate ordering ...administration ... documentation of medications ...Time critical scheduled medications: Medications where an early or late administration of greater than thirty minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect. Maintain total one-hour administration window where administration may occur up to 30 minutes before or after scheduled time ...Medications ordered “STAT” will be sent by Pharmacy within 30 minutes ... “Time” medications will be scheduled for future dispensing as per the prescriber’s order ...The timing of medication administration is based on the nature of the medication and its clinical application to ensure safe and timely administration ...Medications not eligible for scheduled dosing times are medications that require exact or precise timing of administration. Examples of medications not eligible for scheduled dosing times may include, but are not limited to ...Stat doses ...One -time dose ...Time critical ...Maintain total one-hour administration window where administration may occur up to 30 minutes before or after scheduled time. Examples of time critical scheduled medications include, but may not be limited to ...Antibiotics ...Pain medications ...Timed medications ...A new medication order should be administered as soon as it is available ...The patient’s response to medication will be monitored for effectiveness and side effects. Information such as vital signs, laboratory values, clinical signs and symptoms, as well as the patient’s perception, will be evaluated ...” During a review of the hospital’s P&P titled, “Chain of Command-Patient Care Issues,” dated 1/26/24, the P&P indicated, “ ...To provide guidance for [Name of Hospital organization] staff to address problems when a higher level of authority is necessary ...Chain of Command ...Questions involving patient care or policies and procedures are pursued via the staff to the unit-specific Charge Nurse or Clinical Supervisor or designee. Should further input be necessary, the Chain of Command continues to the unit-specific Manager, Director and Chief Nursing Officer (CNO) ...If necessary, the CNO will contact the CNO and facility Chief Operating Officer (COO) ...Nurse to Provider Chain of Command-Reporting of Medical Information ...Nursing personnel are responsible for reporting pertinent patient information to the patient’s designated attending provider ...If the designated attending provider fails to respond in an appropriate or timely manner, the nurse has the responsibility to follow the chain of command through the appropriate medical staff structure ...” During a review of the hospital’s P&P titled, “Provider Orders,” dated 8/25/23, the P&P indicated “ ...To provide guidelines for initiating and/or updating the physician’s therapeutic treatment plan ... Order Categories ...STAT-The process of obtaining the requested tests, studies or procedures are initiated and finalized within 1 hour of the request, except in cases where expedited technical processing cannot be done in less than an hour ...Timed-The process of obtaining the requested tests, studies or procedures are initiated and completed at the time ordered (i.e., collect at a specified time +/- 15 minutes.) ...The RN acknowledgement of orders indicates they assume responsibility for ensuring implementation of the order within the prescribed period ...The RN is to notify the Clinical Supervisor/Manager when unable to follow an order due to a lack of equipment and/or supplies ...If a nurse believes there is a conflict between the orders of consultants on a case or between the orders of a consultant and the attending physician, the nurse will contact the physician who wrote the order in conflict and call attention to it ... The RN ...must act prudently to deliver optimal patient care. Each licensed person is responsible for a knowledge base in his or her health care area. It is their responsibility to question inexact, illegible or potentially inappropriate physician’s orders. This includes, but is not limited to, medication dosages and administration ...” During a review of a professional resource from the Academy of Emergency Medicine, an article titled, “Introduction of a stat laboratory reduces emergency department length of stay,” dated April 2008, the article indicated, “ ...Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour ...” During a review of a professional resource from Biochem Med, an article titled, “Failure to review STAT clinical laboratory requests and its economical impact,” dated February 2016, the article indicated, “ ...Failure to follow-up laboratory tests or complete requests has been described one of the major processes contributing to unsafe patient care. Not only that this can lead to missed or delayed diagnosis but it has an adverse impact on patients’ outcomes followed by potential legal implications ...” During a review of a professional resource from Pediatric Quality Safety, the article titled, “A Quality Improvement Intervention Reduces the Time to Administration of Stat Medications,” dated April 2017, the article indicated, “ ...The delivery of urgent (“stat”) medications to hospitalized children is important for safe quality care. The goal of this study was to evaluate the effect of a set of interventions on the percentage of stat medications administered within 30 minutes of ordering ...Three interventions were employed to improve turnaround time. These interventions were started during the same period as part of an intervention set. First, improved communication systems between the physician and nurse and the nurse and the pharmacist were established. The doctor was made responsible for alerting the charge nurse when (s)he ordered a stat medication. This practice was not done previously, which sometimes led to stat orders being delayed in the nursing station among the pile of other non-stat orders. The charge nurse became responsible for calling the pharmacy after (s)he had scanned the stat order to the pharmacy to ensure that the pharmacy was aware of the order. The doctor, nurse, and pharmacist held each other accountable for the compliance with these interventions. For example, if the charge nurse was not notified about the existence of a stat order from the physician, (s)he reminded the physician of the communication protocol ...Second, a stat-dedicated electronic inbox was created in the pharmacy so that stat orders were clearly identifiable to the pharmacist, as opposed to being mixed in with the other orders. Orders that were scanned by the nurse were delivered via e-mail to a stat-dedicated inbox for the pharmacist to review. Third, stat medications were placed in a pink envelope to be delivered to the unit. The pink envelope would alert the pharmacy aid, whose job was to deliver medications from the pharmacy to the unit, that the medications enclosed in the pink envelope were high priority, and thus should be delivered first. Alost the first 2 interventions applied to all medications, the third was only applicable to medications coming from the pharmacy ...In summary, we found that a set of interventions increased the proportion of stat medications delivered within 30 minutes. Hospitals that have delays in their stat medications could consider adopting these interventions to decrease medication turnaround time ...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 45977 Based on observation, interview and record review, the hospital failed to have an effective governing body (GB) that is legally responsible for the conduct of the hospital when: 1. The hospital did not have a system in place to promote and protect patient rights. Thirteen of 25 patients’ (Pt 1, Pt 2, Pt 3, Pt 4, Pt 5, Pt 53, Pt 57, Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) rights were not protected and promoted. The hospital failed to ensure the right of patients to have care in a safe setting. The hospital failed to ensure the right of patients to be informed in advance of performing care in a language the patient understands. The hospital failed to ensure patients’ Civil Rights were protected. The hospital did not ensure patients’ right to make informed decisions. (Refer to A115) Because of the serious actual harm to Pt 1 and Pt 2 and the potential serious harm to Pt 3 and all patients placed in the north hallway without access to call lights and electrical outlets and all patients with cardiac monitoring that was not followed, and device malfunction, interpreter services, and not following providers orders, the hospital failed to provide care that was in a safe setting. The hospital failed to follow multiple policies and procedures and did not provide ongoing nursing care and monitoring to prevent the injuries that occurred to Pt 1 and Pt 2 and those that could have occurred to Pt 3 and all patients located in the north hallway, because of these serious issues, an Immediate Jeopardy (IJ- a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/15/24 at 2:05 p.m. with the Interim Chief Nursing Officer (ICNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), Director of Quality Outcomes (DQO), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 3/20/24 at 5 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) Incident reports were confirmed for Pt 1 and Pt 2 Pressure Injuries and a review of records show wound consults and care is being provided. 2) Pressure injury risk policy was reviewed and deemed appropriate. Education was put out to all RNs and LVNs in the ED so that all patients that are admitted and still holding in the ED receive the same care as those admitted into an inpatient room. A written test was given to check staff competency. Staff must score 100% or reeducation will be provided and staff must test again. 3) Monitoring will be done on all patients receiving care in the ED to confirm skin assessments, 2 RN validation, proper photo of wounds, Braden score every shift, appropriate interventions, and appropriate documentation is being done. Charts checked for advance directives, allergies, and care plans; patients check to see if they have call lights, restraints being monitored per orders and providers being notified when there is a missed order. 4) Restraint policy reviewed and deemed appropriate, reeducation went out to all staff in the ED. ED CN will observe every 4 hours to confirm all restraints are on and being monitored per policy for 100 percent of ED patients with restraint orders will be monitored until compliance can be demonstrated for 30 days. Written test was given after education was provided a 100 percent is required to pass. Reeducation will be given if needed. 5) Hallway areas used for surge of patients was identified to not have call lights and facility corrected this issue along with their Safety Team to make sure electrical outlets would be available for patient equipment. Weekly rounding will be done by the Safety Team to assess presence of all necessary environmental elements in surge locations. Pt 4 was provided a call light and an electrical outlet. 6) Medications and respiratory care treatments policy was reviewed and deemed appropriate. Respiratory Care Practitioners (RCPs) began receiving immediate education to ensure patients in the ED received their nebulizer treatments and for them to follow order if not to notify the provider of whey they were not administered. Audits to be done to provide evidence that patients are receiving care in a safe setting. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/25/24 at 2:30 p.m. with the facility Chief Nursing Officer (CNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level. 2. The hospital did not have a system in place to ensure registered nurses (RNs) followed hospital policies and procedures and provide care in accordance with professional nursing standards. RN 1 administered 200 units of insulin lispro (short acting insulin) intramuscularly (in the muscles) without a physician’s order to PT 6. Nurses did not complete required training and competencies. Nursing staff failed to administer blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”. The hospital restraint policy was not followed in the care of patients. Physician orders for cardiac monitoring were not followed in the Emergency Department (ED). RNs did not follow pain management policies in the care of patients. (refer to A385) 3. The hospital failed to meet emergency needs of patients in accordance with the hospital’s policies and procedures when the hospital failed to implement Emergency Department policies and procedures and failed to have ongoing monitoring for one of 34 patients (Patient 33) when nurses did not accurately assess the emergency severity index for Patient (Pt) 33. Pt 33 was brought in by level 1 (meaning urgent) ambulance transport on 3/13/24 at 5:35 a.m. with chief complaints of hematemesis, severe abdominal pain, low blood pressure and history of chronic urinary infections and atrial fibrillation and was not placed on a cardiac monitor and frequent monitoring was not implemented in accordance with hospital policy and procedures (P&P). The physician did not prioritize and recognize the severity of Pt 33’s signs and symptoms and did not consider Pt 33’s past medical history and did not order additional diagnostic tests to determine the underlying reasons for Pt 33’s illness. Nurses placed the patient on a gurney in a hallway that did not provide direct line of sight and did not conduct monitoring and vital signs in accordance with the Pt 33’s needs and in accordance with ED policy and procedure. (refer to A1100) Because of the serious actual harm to Pt 33 related to not following Emergency Department policies and procedures and not providing ongoing nursing care and monitoring and not providing the medical services to address Pt 33’s clinical signs and symptoms, an Immediate Jeopardy (IJ a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/22/24 at 5 p.m. under CFR 482.55(a)(3) A1104 (Code of Federal Regulations- a set of requirements issued by a federal government agency to implement laws) with the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality Regulatory (VPQR), Vice President of Quality Outcomes (VPQO), Director of Quality Outcomes (DQO), and the Director of Accreditation and Licensure (DAL).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 3/26/24 at 12:02 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) An incident report completed for Pt 33 and case referred to Medical and Nursing Peer Review; 2) All ED staff received a case review of IJ concerns including the need for a comprehensive assessment of all patients entering the ED, integration of patients past medical history, ensuring continued assessment of presumptive diagnosis (identifies the likely condition of the patient) and consideration of alternative causes of abnormal vital signs. 3) Policies for ESI and Triage reviewed and deemed appropriate. Mandatory training on Triage Competency, which includes assigning an accurate ESI designation was assigned to all ED Registered Nurses. 4) ED Standards of Practice Policy reviewed and deemed appropriate added 3 inpatient Registered Nurses to every shift in the ED and 2 additional Patient Care Technicians are scheduled on every shift for monitoring, vs, and turning of patients. Written test was given to staff. 5) Cardiac Monitoring policy reviewed and deemed appropriate to ensure policy is being followed additional staff will be used (see 4). Education provided on cardiac monitoring and documentation. Written test was given to staff. 6) Provider Order policy reviewed and deemed appropriate staff educated on following orders and process if there is a delay in labs or other testing. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/27/24 at 4:30 p.m. with the facility Chief Nursing Officer (CNO), Vice President of Quality (VPQ), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level. 4. The hospital failed to have an effective, on-going, hospital-wide, data-driven Quality Assessment and Performance (QAPI) program. The governing body, hospital leadership and QAPI committee were aware and had data indicating high-volume, high-risk and problem-prone areas in the Emergency Department and other areas of the hospital and did not develop and implement perfomance improvement projects to address safety and quality. (refer to A263) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe and professional manner.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42321 Based on observation interview and record review the facility failed to protect and promote each patient’s rights for 14 of 25 patients (Pt 1, Pt 2, Pt 3, Pt 4, Pt 5, Pt 53, Pt 56, Pt 57, Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) when: 1. Pt 1 arrived in the Emergency Department (ED) on 12/13/23 and was admitted to the hospital on the same day (12/13/23). Pt 1 remained in the ED for three days as an inpatient until Pt 1 was moved to the Medical Surgical (MS) unit on 12/16/2023. On 12/16/23 Pt 1 was identified to have a pressure ulcer. Wound was assessed as a stage three (3) pressure ulcer on 12/22/23 by wound nurse. ED RNs did not perform skin assessments on Pt 1 from 12/13/23 through 12/16/23 and did not identify skin breakdown in accorance with hospital policy and procedure. ED RN’s stated validated, they did not focus on skin interventions on Pt 1 while the patient was in the ED. (refer to A144) 2. Pt 2 arrived in the ED on 2/29/24 and was admitted to the hospital on the same day (2/29/24). Pt 2 remained in the ED for three days as an inpatient until Pt 2 was moved to MS unit on 3/3/24. On 3/3/24 a wound consult was done and a “deep tissue injury (a form of pressure injury or pressure sore, where blood flow to the area is absent or significantly diminished)” was located on the sacral/coccyx area (buttocks) for Pt 2. ED RNs did not perform skin assessments on Pt 2 from 2/29/24 through 3/3/24 and did not identify skin breakdown in accorance with hospital policy and procedure.ED RN’s stated validated, they did not focus on skin interventions on Pt 2 while the patient was in the ED. (refer to A144) 3. Pt 3 came to the ED on 3/8/24 with chief complaint of altered mental status. Pt 3 observed on 3/13/24 in hallway bed in ED with right wrist restraint and posey vest untied and still connected to the patient and no monitoring of the patient. Per RN 22 restraints were still necessary. Pt 3 was moved to inpatient bed on 3/13/24. (refer to A144) 4. Patient 53 and Patient 57 were placed in hallway beds as they awaited inpatient hospital beds. Pt 53 was admitted to the hospital on 3/8/24 and remain in a hallway bed for six days. The hallway beds were not equipped with standard electrical outlets and were not equipped with call lights for patients. Pt 57’s infusion pump battery died twice while his medication was running since there were no outlets to plug into. (refer to A144) 5. Pt 4 had physician order for breathing treatments every 6 hours. Pt 4 arrived to the ED on 3/10/24 and while awaiting an inpatient bed and was placed in the hallway. Pt 4 was not notified of these treatments and there was no subsequent physician notification. (refer to A144) 6. Pt 53 did not receive interpreting services in their appropriate language, when Pt 53 was admitted to the hospital on 3/8/24 and remained in the Emergency Department (ED). The EHR had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that indicated Pt 53 needed an interpreter in Mon Khmer (Cambodian language) for written and spoken language and this was not provided to Pt 53. (refer to A144) 7. RN 25 used a defective tube feeding pump when carrying out an order for tube feeding for Pt 5, when the prescribed order was for a continuous feeding of 30 ml per hour but Patient 5 received the feeding at a rate of 300 mL per hour. (refer to A144) 8. Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46 had orders in ED for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and were either not place on a cardiac monitor or the cardiac monitoring strips (the record of the electrical activity of the heart) were not read and documented by the licensed nurses. This placed these six patients at risk of injury or death. (refer to A144) 9. Facility failed to ensure the rights of patients to make informed decisions for one of six sampled patients (Pt 34) when Pt 34’s Condition of Admission (COA) was not signed by Patient 34 on 12/20/23 and no other documentation in the record indicated Pt 34 was informed of the Conditions of Admission. (refer to A131) 10. The hospital failed to ensure the patient right to be informed in advance of furnishing or discontinuing patient care for one of two patients (Patient 53) when hospital staff were aware of Patient 53’s Cambodian Mon Khmer language, inability to speak or understand English, and the Electronic Health Record (EHR) was formatted to alert caregivers about using Interpreter Services, and staff did not utilize Interpreter Services to provide care to Patient 53 in accordance with hospital policy and procedure. Nurses providing care to Patient 53 did not inform Patient 53 in advance of medication administration, procedures and other nursing interventions. On 3/12/24 Registered Nurse (RN) 21 performed a bladder scan procedure to determine the volume of urine in the bladder and performed an in and out urinary catheter procedure without first ensuring informed consent was given by Patient 53. Patient 53 was admitted to the emergency department (ED) on 3/8/24 and was discharged on 3/14/24 as an admitted in-patient but remained in the ED and hospital records do not indicate Patient 53 was aware and informed of this change in admission status. (refer to A117) 11. The facility failed to ensure the patient rights for one of one patients (Patient 3), when Patient 3 was observed to have two different types of restraints on but not fastened to bed frame on his right side in accordance with hospital policy and procedure. (refer to A167) Because of the serious actual harm to Pt 1 and Pt 2 and the potential serious harm to Pt 3 and all patients placed in the north hallway without access to call lights and electrical outlets and all patients with cardiac monitoring that was not followed, and device malfunction, interpreter services, and not following providers orders, the hospital failed to provide care that was in a safe setting. The hospital failed to follow multiple policies and procedures and did not provide ongoing nursing care and monitoring to prevent the injuries that occurred to Pt 1 and Pt 2 and those that could have occurred to Pt 3 and all patients located in the north hallway, because of these serious issues, an Immediate Jeopardy (IJ- a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called under A-0144 482.13 (c)(2)- The patient has the right to receive care in a safe setting, on 3/15/24 at 2:05 p.m. with the Interim Chief Nursing Officer (ICNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), Director of Quality Outcomes (DQO), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 3/20/24 at 5 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) Incident reports were confirmed for Pt 1 and Pt 2 Pressure Injuries and a review of records show wound consults and care is being provided. 2) Pressure injury risk policy was reviewed and deemed appropriate. Education was put out to all RNs and LVNs in the ED so that all patients that are admitted and still holding in the ED receive the same care as those admitted into an inpatient room. A written test was given to check staff competency. Staff must score 100% or reeducation will be provided and staff must test again. 3) Monitoring will be done on all patients receiving care in the ED to confirm skin assessments, 2 RN validation, proper photo of wounds, Braden score every shift, appropriate interventions, and appropriate documentation is being done. Charts checked for advance directives, allergies, and care plans; patients check to see if they have call lights, restraints being monitored per orders and providers being notified when there is a missed order. 4) Restraint policy reviewed and deemed appropriate, reeducation went out to all staff in the ED. ED CN will observe every 4 hours to confirm all restraints are on and being monitored per policy for 100 percent of ED patients with restraint orders will be monitored until compliance can be demonstrated for 30 days. Written test was given after education was provided a 100 percent is required to pass. Reeducation will be given if needed. 5) Hallway areas used for surge of patients was identified to not have call lights and facility corrected this issue along with their Safety Team to make sure electrical outlets would be available for patient equipment. Weekly rounding will be done by the Safety Team to assess presence of all necessary environmental elements in surge locations. Pt 4 was provided a call light and an electrical outlet. 6) Medications and respiratory care treatments policy was reviewed and deemed appropriate. Respiratory Care Practitioners (RCPs) began receiving immediate education to ensure patients in the ED received their nebulizer treatments and for them to follow order if not to notify the provider of whey they were not administered. Audits to be done to provide evidence that patients are receiving care in a safe setting. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/25/24 at 2:30 p.m. with the facility Chief Nursing Officer (CNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level. The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 45977 Based on interview and record review, the hospital failed to have an effective, on-going, hospital-wide, data-driven Quality Assessment and Performance (QAPI) program when the governing body, hospital leadership and QAPI committee were aware and had data indicating high-volume, high-risk and problem-prone areas in the Emergency Department and other areas of the hospital and did not develop and implement perfomance improvement projects to address safety and quality. (refer to A283) The cumulative effect of these systemic problems resulted in the hospital’s inability to provide care in a safe and quality setting.”

“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: 45977 Based on interview and record review, the hospital failed to have an organized nursing service when: 1. Registered Nurse (RN) 1 administering 200 units of insulin lispro (short acting insulin) intramuscularly (in the muscles) without a physician’s order, which led to Patient (PT) 6 experiencing hypoglycemia and having to be administered Dextrose 5% and 50% solution (medications administered into the vein to treat low blood sugar). (Refer to A-0405) 2. The hospital failed to ensure one of seven sampled staff (RN 17) who worked in the facility’s float pool (staff who move around between different units and departments to meet staffing needs) did not complete the required biannual skills validation training (process of assessing, verifying, and documenting an individual’s competencies in a specific area) for Advanced cardiac life support (ACLS - a course designed to equip healthcare providers with the skills and knowledge needed to respond effectively to medical emergencies). (Refer to A-0397) 3. The nursing staff failed to administer blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patients sampled, Pt 22 was administered blood products and the intravenous (IV) (into the blood stream) line was not prepared before giving the blood. (Refer to A-0410) 4. Two of four hospital patients on restraints (Patient (Pt) 24 and Pt 3) had no monitoring documentation by nursing staff and/or monitoring was not being done per policy. (refer to A398) 5. Six of 25 hospital patients (Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) sampled from the emergency department (ED) had orders for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and one of the six Pt 35 had no cardiac monitor on and the other five patients did not have cardiac monitoring strips (the record of the electrical activity of the heart) reviewed and documented in there electronic health records (EHR). (refer to A398) 6. Four of 25 hospital patients (Pt 4, Pt 36, Pt 37, and Pt 56) sampled from the ED, when Pt 4, Pt 36, Pt 37, and Pt 56 were not administered nebulizer treatments (a drug used to relax breathing muscles and permits air to flow more easily in and out of the lungs) as ordered by the physician. (refer to A398) 7. Two of four hospital patients (Pt 5 and Pt 8) were not properly assessed and vital signs (SpO2- oxygen levels) were not monitored per policy and procedure. (refer to A398) 8. Four of four hospital patients (Pt 1, Pt 8, Pt 4, and Pt 55) sampled were given pain medication and the hospital failed to follow pain management services consistent with professional standards of practice and hospital policies and procedures when: Pt 1 numeric pain scale (a pain screening tool used to assess pain severity 0 no pain, one-three mild pain, four-six moderate pain, seven-nine severe pain, 10 worst pain) was assessed at eight out of 10 and Licensed Vocational Nurse (LVN) 2 administered Oxycodone 24 milligrams (mg-a unit of measurement) ordered for moderate pain and did not notify the physician to obtain pain medication appropriate for Pt 1’s assessed level of pain; Pt 4, Pt 8, and Pt 55 were given pain medication and pain reassessments were not completed by nursing staff. (refer to A398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care by the nursing staff.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 42321 Based on interviews and record review, the hospital failed to meet emergency needs of patients in accordance with the hospital’s policies and procedures when the hospital failed to implement Emergency Department (ED) policies and procedures and failed to have ongoing monitoring for one of 34 patients (Patient 33) when nurses did not accurately assess the emergency severity index (ESI-the process to categorized patients from level 1, the most critically ill, to level V, the least critically ill ) for Patient (Pt) 33. Pt 33 was brought in by level 1 (meaning urgent) ambulance transport on 3/13/24 at 5:35 a.m. with chief complaints of hematemesis (vomiting of blood), severe abdominal pain, low blood pressure and history of chronic urinary infections (a repeated or prolonged bladder infection)and atrial fibrillation (irregular heartbeat) and was not placed on a cardiac monitor (a device used to watch the electrical activity of the heart to ensure it is working normally) and frequent monitoring was not implemented in accordance with hospital policy and procedures (P&P). The physician did not prioritize and recognize the severity of Pt 33’s signs and symptoms and did not consider Pt 33’s past medical history and did not order additional diagnostic tests to determine the underlying reasons for Pt 33’s illness. Nurses placed the patient on a gurney in a hallway that did not provide direct line of sight and did not conduct monitoring and vital signs in accordance with the Pt 33’s needs and in accordance with ED policy and procedure. (refer to A1104) Because of the serious actual harm to Pt 33 related to not following Emergency Department policies and procedures and not providing ongoing nursing care and monitoring and not providing the medical services to address Pt 33’s clinical signs and symptoms, an Immediate Jeopardy (IJ a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/22/24 at 5 p.m. under CFR 482.55(a)(3) A1104 (Code of Federal Regulations- a set of requirements issued by a federal government agency to implement laws) with the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality Regulatory (VPQR), Vice President of Quality Outcomes (VPQO), Director of Quality Outcomes (DQO), and the Director of Accreditation and Licensure (DAL).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 3/26/24 at 12:02 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) An incident report completed for Pt 33 and case referred to Medical and Nursing Peer Review; 2) All ED staff received a case review of IJ concerns including the need for a comprehensive assessment of all patients entering the ED, integration of patients past medical history, ensuring continued assessment of presumptive diagnosis (identifies the likely condition of the patient) and consideration of alternative causes of abnormal vital signs. 3) Policies for ESI and Triage reviewed and deemed appropriate. Mandatory training on Triage Competency, which includes assigning an accurate ESI designation was assigned to all ED Registered Nurses. 4) ED Standards of Practice Policy reviewed and deemed appropriate added 3 inpatient Registered Nurses to every shift in the ED and 2 additional Patient Care Technicians are scheduled on every shift for monitoring, vs, and turning of patients. Written test was given to staff. 5) Cardiac Monitoring policy reviewed and deemed appropriate to ensure policy is being followed additional staff will be used (see 4). Education provided on cardiac monitoring and documentation. Written test was given to staff. 6) Provider Order policy reviewed and deemed appropriate staff educated on following orders and process if there is a delay in labs or other testing. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/27/24 at 4:30 p.m. with the facility Chief Nursing Officer (CNO), Vice President of Quality (VPQ), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level. The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality healthcare 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: 47888 Based on observation, interview and record review, the hospital failed to ensure the patient right to be informed in advance of furnishing or discontinuing patient care for one of two patients (Patient 53) when hospital staff were aware of Patient 53’s Cambodian Mon Khmer language, inability to speak or understand English, and the Electronic Health Record (EHR) was formatted to alert caregivers about using Interpreter Services, and staff did not utilize Interpreter Services to provide care to Patient 53 in accordance with hospital policy and procedure. Nurses providing care to Patient 53 did not inform Patient 53 in advance of medication administration, procedures and other nursing interventions. On 3/12/24 Registered Nurse (RN) 21 performed a bladder scan procedure to determine the volume of urine in the bladder and performed an in and out urinary catheter procedure without first ensuring informed consent was given by Patient 53. Patient 53 was admitted to the emergency department (ED) on 3/8/24 and was discharged on 3/14/24 as an admitted in-patient but remained in the ED and hospital records do not indicate Patient 53 was aware and informed of this change in admission status. These failures resulted in not protecting and promoting Patient 53 ’ s right to safe and quality care, had the potential to injure and cause harm and potentially violated Patient 53 ’ s civil rights to be provided equitable and fair care in the hospital, including the potential for abuse. Findings: During a review of Patient 53’s “Electronic Health Record (EHR)” dated 3/8/24 to 3/14/24, the EHR indicated, Patient 53 arrived at the Emergency Department (ED) on 3/8/24 at 3:02 p.m. and was admitted to the hospital on 3/8/24 at 11:11 p.m., for Altered Mental Status (a change in the mental function that stems from illness, disorders and injuries that have affected the brain) and a Urinary Tract Infection (bladder infection that can cause mental changes or confusion). The EHR indicated that even though the patient was admitted, she remained in the Emergency Department (ED) and was never moved into an inpatient bed on a hospital unit. Patient 53 was in ED yellow-hallway bed 11 and ED north-hallway bed 11 during her stay. The EHR had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that never changed which indicated Patient 53 needed an interpreter in Mon Khmer (Cambodian Language) for written and spoken language. During a review of Patient 53’s “ED Timeline (EDT)”, dated 3/9/24, the EDT indicated, “ ...Acute Speech Language Pathology Swallow Assessment- Speech and Language Pathologist (SLP) 1 ... COGNITION/BASELINE SWALLOW: Patient Alert and cooperative, not able to answer orientation question ... Patient does not speak often, but can speak in her own language when she wants to ... Patient with a history of dementia (the loss of thinking, remembering, and reasoning, to such an extent that it interferes with a person’s daily life and activities) ... SPEECH/LANGUAGE/VOICE: Unable to fully assess, patient did not vocalize except on two instances when suspected to be expressing pain as Physical Therapy was extending her left leg. No dysarthria (when the muscles you use for speech are weak or you have difficulty controlling them) suspected, however not able to confirm with such limited utterances ... vocal quality clear. Is interpreter needed: Yes. ...What type: Phone ... Name: Phone Malfunctioning ...”. During a review of Patient 53’s “Nurses Note (NN)”, dated 3/11/24 at 10:44 p.m., the NN indicated, “ ...Assumed care of patient ... patient is Mon Khmer speaking. Family [family member name] at bedside to help with initial assessment. Patient has a Glasgow Coma Scale of 15. Alert and Oriented x1. Patient has no current complaints ... Patient reports no pain ... Patient verbalizes no needs at this time ...”. During a review of Patient 53’s “ED Timeline (EDT)”, dated 3/12/24, the EDT indicated, “ ...Bladder Scan (non-invasive ultrasound of the bladder)[greater than 583]. Medical Doctor called with telephone order to do in and out catheterization (Intermittent, or in and out, catheterization is a medical technique used to help empty the bladder. A catheter can be passed through the urethra, after which the bladder is emptied) ... Orders acknowledged: In and Out Catheterization ... In and Out Catheterization Volume: 600 mL (milliliters- unit of measurement) ...”. During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated Patient 53 was her patient during her day shift. RN 9 stated Patient 53 was non-verbal and would nod yes or no when she spoke to her in English. RN 9 stated she never used an interpreter because Patient 53 answered “yes or no to English”. RN 9 stated the Emergency Department (ED) hallway the patient was in was not safe for her due to her communication needs. RN 9 stated “she doesn’t even speak English like that, just yes or no”. RN 9 stated Patient 53 could not yell “help” if needed. RN 9 stated she never used a Cambodian Mon Khmer interpreter to communicate with the patient. During a concurrent observation and interview on 3/14/24 at 3:15 p.m., with Patient 53 in the ED North Hall, hospital staff retrieved a portable iPad interpreter (portable electronic device where the interpreter was called from) per the request of Surveyor. Patient 53 smiled and waved. Patient 53 appeared to respond to the questions of the interpreter appropriately but spoke very softly. Patient 53 waited for the interpreter to stop talking and then she would answer. The hallway was noisy and the interpreter could not hear Patient 53 and the call was terminated due to the interpreter not able to hear. During an interview on 3/14/24 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the EHR banner indicated Patient 53 needed a Mon Khmer interpreter. LVN 3 stated she did not speak Mon Khmer and never used an interpreter for any of Patient 53’s care. LVN 3 stated Patient 53 could understand “a little English I think”. LVN 3 stated that was what she was told in nurse-to-nurse report. LVN 3 stated she had given Patient 53 medications, changed her brief and repositioned her and never used a Mon Khmer interpreter to communicate with her over the course of her shift. During an interview on 3/14/24 at 7 p.m., with Patient 53’s Family Member (FM) 1, FM 1 stated Patient 53 spoke Cambodian (Mon Khmer) only and did not speak or understand English. During a concurrent interview and record review on 3/21/24 at 3 p.m., with the Emergency Department Director (EDD), Resident 53’s “EHR”, dated 3/8/24 to 3/14/24 was reviewed. The EDD stated the EHR indicated nursing staff never used an interpreter when communicating with Patient 53. The EDD stated interpreters, when used with a patient, need to be charted. The EDD stated per the EHR an in-person, video and/or audio interpreter was never used for Patient 53. The EDD stated that if an interpreter were used it would have been charted in the “Interpretation Flowsheet” and there was nothing there. The EDD stated not communicating with Patient 53 in Mon Khmer was unsafe for the patient and violated her rights as a patient. The EDD stated she had the right to be informed of every aspect of her care and she was not. During a review of Patient 53’s “Interpretation Flowsheet (IF)” dated 3/14/24 (after discharge), the IF indicated, “ ....Interpretation: Interpretation Type- [Blank] ...”. During an interview on 3/25/24 at 11:35 a.m., with RN 21, RN 21 stated she was Patient 53’s nurse on 3/12/24 RN 21 stated she knew Patient 53 spoke Cambodian but she did not use a Cambodian interpreter because Patient 53 was “kind of” responding to English. RN 21 stated she performed the bladder scan and the in and out catheterization on Patient 53. RN 21 stated she explained the procedure to Patient 53 in “basic words for her to understand” in English. RN 21 stated she “felt like” Patient 53 knew what she was going to do. RN 21 stated Patient 53 said yes and smiled. RN 21 stated she was not a certified Cambodian interpreter and she never used a Cambodian interpreter to communicate with the patient for the bladder scan nor in and out catheterization. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated interpreters are vital to communication and meeting patients’ needs. The CNO stated if communication occurred without an interpreter in the language needed this would result in inadequate care given to the patient. The CNO stated with patient needs not met, this could result in harm to the patient and is a patient safety concern. The CNO stated that policy and procedure on interpreters was not followed by staff. During a review of the facility’s Policy and Procedure (P&P) titled, “Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired “, dated 8/10/23, the P&P indicated, “PURPOSE: A. To define the communication system that is used for patients who have Limited English Proficiency (LEP) ... B. To provide guidelines for coordinating timely response in meeting the assessed special language needs of individual patients ... C. To comply with Americans with Disabilities (ADA), Title VI of the Civil Rights Act of 1964 and Health and Safety Code of California ... 1. Health and Safety Code of California requires licensed general acute care hospitals to provide language assistance services to patients with language or communication barriers ... II. DEFINITIONS: A. Communication Barrier: Applies to a person who ... speaks another language that hinders communication ... F. Language Service Line: Language services are available via phone 24 hours a day, 7 days a week ... G. Non-English or LEP: Those individuals whose native language is other than English and who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers ... III. POLICY: It is the policy of Community Medical Centers (CMC) to provide equal access to and equal participation in health care interactions for persons ... with LEP ... B. CMC recognizes that individuals must be able to communicate effectively with their health care providers in order to importation the quality of the information, the outcome of the patient encounter and to increase patient compliance and patient satisfaction of care and services ... C. It is the policy of CMC to use competent medical interpreters during ... treatment situations ... following modalities (methods): in-person, video and/or audio ... E. Staff shall verbally notify patients of their right to interpretation services available at no cost to them. F ... situations in which the presence of an interpreter ... is necessary to ensure thorough and accurate communication including “critical medical information” listed ... 1. Explaining a medical procedure or intervention ... 3. When explaining and describing medical conditions, tests, treatment options, medications ... 4. When providing a diagnosis, prognosis and recommendation for treatment ... 5. When providing instructions for medications ...follow-up treatments ... H. The patients primary language is to be noted in the patients EHR ... VI. DOCUMENTATION: ... E. The staff member documents the following information in the EHR upon concluding the interpreter session including when interpretation was provided by a family member: 1. Start date 2. Start time 3. End time 4. Language spoken 5. Interpreter session type 6. Interpretation provided ... F. Staff member documents the use of communication devices and adaptive equipment used ...”. During a review of the facility’s Policy and Procedure (P&P) titled, “Urinary Catheters, Indwelling and Intermittent- Adult & Adolescent “, dated 2/9/23, the P&P indicated, “PURPOSE: ... B. To implement the current evidence-based guidelines for the insertion, maintenance, removal and reinsertion of urinary catheters ... D. To define the roles and responsibilities of licensed personnel such as Registered Nurses (RN), Licensed Vocational Nurses (LVN) ... in regard to the maintenance of ... catheters ... E. To provide guidelines for monitoring a patient post urinary catheter removal, including direction on when catheter reinsertion should be considered ...II. DEFINITIONS: ...B. Intermittent (straight) Urinary Catheter: A drainage tube that is inserted in the bladder and removed as soon as urine is drained ... E. Bladder Scan Volume: A bladder scan volume measurement that is not linked to the timing of a patient’s void ... IV. POLICY: Alternatives to catheterization should be the first choice for all patients requiring bladder management. Examples of alternatives include: 1. Intermittent (straight) catheterization ... E. Bladder scans may be performed as indicated or needed (PRN) ... V. PROCEDURE: ... 4. ... b. Interpretation of bladder scan results, unless otherwise ordered by the provider: ... iii. If the scanned bladder volume is greater than 500 mL, the RN should contact provider and obtain an order for insertion of an indwelling urinary catheter. Leave the indwelling catheter in place if the output is confirmed to be greater than 500 mLs ... VII. PATIENT TEACHING: A. Provide [Hospital] approved on-line patient education materials ... refer to Frequently Asked Questions (FAQs) on the Patient/Family Education Forum for English and Spanish. 2. Provide patient education regarding the need for bladder scanning and what to expect ...”. Review of professional reference, “American Journal of Medicine- Interpreters in Health Care: A Concise Review for Clinicians”, dated April 2020, (found at https://www.sciencedirect.com/science/article/pii/S0002934320300127 ) indicated, “ ...Conclusion: It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained health care interpreter is often the most important step in fulfilling this duty ...”.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 49884 Based on interview and record review, the facility failed to ensure the rights of patients to make informed decisions for one of six sampled patients (Pt 34) when Pt 34’s Condition of Admission (COA) was not signed by Patient 34 on 12/20/23 and no other documentation in the record indicated Pt 34 was informed of the Conditions of Admission. This failure had the potential for Pt 34 to be uninformed about the care she would receive during her hospital admission. Findings: During a concurrent interview and record review on 3/21/24 at 10:15 a.m. with the” Director of Women and Newborn Services and Labor and Delivery (DWD)” Pt 34’s electronic medical record (EMR) was reviewed. Pt 34 was admitted on 12/20/23 and discharged on 12/23/23. The medical record indicated, on 12/20/23 at 4:38 p.m. Pt 34 was admitted to labor and delivery (L&D) at 39 weeks and 0 days gestation (period of time from conception to birth) for late decelerations (a decrease in fetal heart rate following a contraction of the uterus) during non-stress test (monitoring an unborn baby’s heart rate), ad to induce labor (prompting the uterus to contract before labor begins on its own for a vaginal birth). The DWD stated a COA was not signed by Pt 34 for the admission on 12/20/23. The DWD stated, each patient visit should have a COA signed. The DWD stated it was her expectation for all patients admitted to L&D to have a signed COA for their admission. During a concurrent interview and record review on 3/22/24 at 9:15 a.m. with the Admitting Registration Manager (ARM), Pt 34’s “EMR Admission Records” dated 12/20/23 to 12/23/23 were reviewed. The ARM validated Pt 34’s COA was not signed, for the admission on 12/20/23 to discharge date of 12/23/23. The ARM stated the hospital’s, did not follow the policy for Pt 34’s COA. The ARM stated the admission and registration staff were responsible to complete the COA with the patient. During an interview on 3/22/24 at 9:20 a.m. with the Corporate Admitting Director (CAD), the CAD stated there were two separate parts to the COA, COA part one and COA part two. The CAD stated the COA part one provided consent to treat the patient for the reason they came to the hospital. The CAD stated the patient would initial and date the COA. The CAD stated the COA part two gave permission to bill insurance for treatment and had a section for signatures, date, and time. The CAD stated in the Emergency department (ED), COA part one was completed when patient arrived to the front lobby for registration and the COA part two was completed after the medical screening exam (a medical exam in the ED) was completed. During an interview on 3/22/24 at 9:25 a.m. with the ARM, the ARM stated the ED admission and registration had 24-hour staff in the department. The ARM stated the L&D triage (sorting and allocation of treatment) unit was separate from the ED unit. The ARM stated, the L&D triage unit did not have admission/registration staff and would call the main admitting and registration department staff or ED admitting and registration staff when a patient was admitted for the COA to be completed The ARM stated main admitting department hours were Monday through Friday 5 a.m. to 6 p.m. The ARM stated ED admitting, and registration staff were available 24 hours a day. The ARM stated if a COA was not signed at admission, hospital process was to continue to attempt to get a signature until throughout their hospital stay. The ARM staff said no COA was attempted once patient expired. Pt 34 was admitted through the L&D triage unit. The ARM stated, main admitting and registration staff should have had patient sign documents when they completed her registration for admission. The ARM stated main admitting staff or ED admission and admission and registration staff ion staff should have followed up to ensure COA was signed before patient discharged. The ARM stated admission and registration staff had been trained to follow up with patients and get a signature. The ARM stated her expectation was if Main Admitting staff did not obtain the COA that the ED admitting staff should follow up with patient to obtain consents. The ARM stated patients would not have the information that they need if they did not sign the COA. During a review of the facility’s policy and procedure (P&P) titled, “Conditions of Admissions Consent to Outpatient Care”, dated 12/1/20, indicated, “ ... documents the patient’s consent to hospitalization and routine services, documents financial responsibility for payment of hospital charges for services rendered ... POLICY ... [Hospital] is responsible for obtaining the patient’s or representative’s consent for hospital services ... Consent for Hospital Services ... Consent for hospitalizations ...COA document to be obtained at every inpatient encounter and some outpatient encounters [i.e., Emergency Department (ED), Observation, Obstetrics (OB) etc.] ... ... A. Once the COA ...documents are complete a copy is given to the patient/ patient representative. personnel will scan the document into the HER into the patient’s encounter.” ...”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42321 Based on observation, interview, and record review, the hospital failed to ensure patients received care in a safe setting for 14 of 25 patients (Pt 1, Pt 2, Pt 3, Pt 4, Pt 5, Pt 53, Pt 56, Pt 57, Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) when: 1. Pt 1 arrived in the Emergency Department (ED) on 12/13/23 and was admitted to the hospital on the same day (12/13/23). Pt 1 remained in the ED for three days as an inpatient until Pt 1 was moved to the Medical Surgical (MS) unit on 12/16/2023. On 12/16/23 Pt 1 was identified to have a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). Wound was assessed as a stage three (3) pressure ulcer on 12/22/23 by wound nurse. ED RNs did not perform skin assessments on Pt 1 from 12/13/23 through 12/16/23 and did not identify skin breakdown in accordance with hospital policy and procedure. ED Registered Nurse’s (RN) stated validated, they did not focus on skin interventions on Pt 1 while the patient was in the ED. These failures resulted in Patient 1 not being provided safe care in the ED and to developed an avoidable stage three pressure injury on his spine. 2. Pt 2 arrived in the ED on 2/29/24 and was admitted to the hospital on the same day (2/29/24). Pt 2 remained in the ED for three days as an inpatient until Pt 2 was moved to MS unit on 3/3/24. On 3/3/24 a wound consult was done and a “deep tissue injury (a form of pressure injury or pressure sore, where blood flow to the area is absent or significantly diminished)” was located on the sacral(triangle-shaped bone in the lower spine)/coccyx area (buttocks) for Pt 2. ED RNs did not perform skin assessments on Pt 2 from 2/29/24 through 3/3/24 and did not identify skin breakdown in accordance with hospital policy and procedure. ) ED RN’s stated validated, they did not focus on skin interventions on Pt 2 while the patient was in the ED. These failures resulted in Patient 2 not being provided safe care in the ED and to developed an avoidable wound to the sacral/coccyx area. 3. Pt 3 came to the ED on 3/8/24 with chief complaint of altered mental status (a disruption in how your brain works that causes a change in behavior). Pt 3 observed on 3/13/24 in hallway bed in ED with right wrist restraint and posey vest (a type of medical restraint used to restrain a patient to a bed or chair) untied and still connected to the patient and no monitoring of the patient. Pt 3 was moved to inpatient bed on 3/13/24. This failure resulted in Patient 3’s rights being violated and his safety put at risk with the potential for the patient to harm himself. 4. Pt 53 and Pt 57 were placed in hallway beds in the ED as they awaited inpatient hospital beds. Pt 53 was admitted to the hospital on 3/8/24 and remained in a hallway bed for 6 days. The hallway beds were not equipped with standard electrical outlets and were not equipped with call lights for patients. Pt 57 stated his infusion pump battery died twice while his medication was running since there were no outlets to plug into. This failure resulted in not protecting Pt 53 and Pt 57’s right to have safe and quality care and had the potential to cause harm. 5. Pt 4, Pt 36, Pt 37 and Pt 56 had physician ordered breathing treatments. Pt 4 arrived to the ED on 3/10/24 and while awaiting an inpatient bed and was placed in the hallway. Pt 4 had physician ordered breathing treatments every 6 hours that were not administered. Pt 4 was not notified of these breathing treatments and there was no subsequent physician notification. This failure resulted in not protecting and promoting Patient 4’s right to safe and quality care, with the potential to cause harm from withholding Physician ordered breathing treatments. 6. Pt 53 did not receive interpreter services in their appropriate language, when Pt 53 was admitted to the hospital on 3/8/24 and remained in the Emergency Department (ED). The electronic health record (EHR) had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that indicated Pt 53 needed an interpreter in Mon Khmer (Cambodian language) for written and spoken language and this was not provided to Pt 53. These failures resulted in not protecting and promoting Patient 53’s right to safe and quality care, had the potential to injure and cause harm and potentially violated Patient 53’s civil rights to be provided equitable and fair care in the hospital, including the potential for abuse. 7. RN 25 used a defective tube feeding pump when carrying out an order for tube feeding for Pt 5, when the prescribed order was for a continuous feeding of 30 ml per hour but Patient 5 received the feeding at a rate of 300 milliliter (mL, unit of measurement) per hour. This failure resulted in not protecting Patient 5’s right to safe and quality care, with the potential to injure and cause harm due to the use of a known defective feeding pump. 8. Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46 had orders in ED for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and were either not place on a cardiac monitor or the cardiac monitoring strips (the record of the electrical activity of the heart) were not read and documented by the licensed nurses. This placed these six patients at risk of injury or death. Because of the serious actual harm to Pt 1 and Pt 2 and the potential serious harm to Pt 3 and all patients placed in the north hallway without access to call lights and electrical outlets and all patients with physician ordered cardiac monitoring that was not followed, and device malfunction, interpreter services, and not following providers orders, the hospital failed to provide care that was in a safe setting. The hospital failed to follow multiple policies and procedures and did not provide ongoing nursing care and monitoring to prevent the injuries that occurred to Pt 1 and Pt 2 and those that could have occurred to Pt 3 and all patients located in the north hallway, because of these serious issues, an Immediate Jeopardy (IJ- a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called was called under A-0144 482.13 (c)(2)- The patient has the right to receive care in a safe setting, on 3/15/24 at 2:05 p.m. with the Interim Chief Nursing Officer (ICNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), Director of Quality Outcomes (DQO), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 3) on 3/20/24 at 5 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) Incident reports were confirmed for Pt 1 and Pt 2 Pressure Injuries and a review of records show wound consults and care is being provided. 2) Pressure injury risk policy was reviewed and deemed appropriate. Education was put out to all RNs and Licensed Vocational Nurses (LVNs) in the ED so that all patients that are admitted and still holding in the ED receive the same care as those admitted into an inpatient room. A written test was given to check staff competency. Staff must score 100% or reeducation will be provided and staff must test again. 3) Monitoring will be done on all patients receiving care in the ED to confirm skin assessments, 2 RN validation, proper photo of wounds, Braden score (scale to identify a patients risk for pressure injuries) every shift, appropriate interventions, and appropriate documentation is being done. Charts checked for advance directives, allergies, and care plans; patients check to see if they have call lights, restraints being monitored per orders and providers being notified when there is a missed order. 4) Restraint policy reviewed and deemed appropriate, reeducation went out to all staff in the ED. ED Charge Nurse (CN) will observe every 4 hours to confirm all restraints are on and being monitored per policy for 100 percent of ED patients with restraint orders will be monitored until compliance can be demonstrated for 30 days. Written test was given after education was provided a 100 percent is required to pass. Reeducation will be given if needed. 5) Hallway areas used for surge of patients was identified to not have call lights and facility corrected this issue along with their Safety Team to make sure electrical outlets would be available for patient equipment. Weekly rounding will be done by the Safety Team to assess presence of all necessary environmental elements in surge locations. Pt 4 was provided a call light and an electrical outlet. 6) Medications and respiratory care treatments policy was reviewed and deemed appropriate. Respiratory Care Practitioners (RCPs) began receiving immediate education to ensure patients in the ED received their nebulizer (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) treatments and for them to follow order if not to notify the provider if they were not administered. Audits to be done to provide evidence that patients are receiving care in a safe setting. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed onsite on 3/25/24 at 2:30 p.m. with the facility Chief Nursing Officer (CNO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality (VPQ), the Director of Accreditation and Licensure (DAL), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial non-compliance at the Condition level. Findings: 1. During a review of Patient 1’s (Pt 1) “Hospitalist History and Physical (H&P)”, dated 12/13/23, the H&P indicated Pt 1 was diagnosed with anemia (condition in which the body does not have enough healthy red blood cells) requiring transfusions (the process of receiving blood or blood products), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) on hemodialysis (a machine filters wastes, salts and fluid from blood when kidneys are no longer functioning to do so adequately), and a history of laryngeal cancer (a disease where cancer forms in the part of throat between tongue and windpipe) with tracheostomy (a cut in the windpipe to create a new opening) and avascular necrosis of bones of both hips (a disease that results from the temporary or permanent loss of blood supply to the bone), and hip pain. Pt 1 was admitted for missing five to six hemodialysis appointments. During an interview on 3/13/24 at 3:26 p.m. with Registered Nurse 2 (RN 2), RN 2 stated, Pt 1 arrive to the Medical Surgical (MS) unit from the ED with “wounds” that were not documented. RN 2 stated he documented Pt 1’s wound when he arrived to the medical surgical unit. RN 2 stated skin interventions were not started until arriving to the medical surgical unit. RN 2 stated skin interventions should be started at admission. RN 2 stated, it was important to start skin interventions to prevent pressure injuries. During an interview on 3/14/24 at 3:29 p.m. with RN 17 an ED RN, RN 17 stated nurses are assigned both admitted patients and emergency patients at the same time. RN 17 stated a focused assessment based on complaint was required for stabilization of an emergency patient. RN 17 stated a complete head to toe assessment including skin was required for an admitted patient. RN 17 stated if a skin assessment was not done a wound may be missed or a patient’s wound could get worse. RN 17 stated turning patients or a complete skin assessment may not be done because nurses are working out of ratio. RN 17 stated he does not turn patients in the ED. RN 17 stated if skin interventions are not started after admission a patient may develop a pressure injury if they have a low Braden score (scale used to identify the risk of a pressure ulcer for a patient, low score indicates higher risk). During a concurrent interview and record review on 3/15/24 at 9:35 a.m. with the Medical Surgical Manager (MSM), Pt 1’s “Skin Integrity Accordion (SIA)” dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1: a.m. was reviewed. The “SIA” indicated, no skin care interventions were started in the ED. The MSM stated no wound care was started in the ED for pressure injuries. The MMA stated, no skin interventions were started in the ED. During a concurrent observation and interview on 3/15/24 at 11:19 a.m. with Pt 1 in his hospital room, he was observed lying in bed with a bedside table over bed. Pt 1 had a dressing on his throat. Pt 1 spoke by placing a hand over throat area covered by the dressing. Pt 1 stated he had several wounds. Pt 1 stated, he did not walk. Pt 1 stated, he does not eat by mouth. Pt 1 stated, he had a tube in his stomach. Pt 1 pointed to the tube feeding pump at bedside. During an interview on 3/15/24 at 9:36 a.m. with the MSM, the MSM stated, all nurses can stage a wound. MSM stated hospital policy was, patients arrived in the medical surgical unit (MS) and two nurses completed a skin assessment. MSM stated during skin assessments photos were taken of any skin breakdown and the nurse should stage the wound. MSM stated, the physician was to be notified of skin breakdown or wounds. MSM stated documentation of skin assessment was to be charted in the electronic medical record (EMR). MSM stated a skin integrity order set was activated by nursing staff for skin care interventions. MSM stated the order set activates the care plans for skin. MSM stated if wound nurse consultation criteria were met the physician would order or give verbal order at that time. MSM stated, a Registered Dietitian consult was ordered at that time. MSM stated skin interventions were based on a patient’s Braden scale. MSM stated the nurse entered wound information into the Internal Reporting Intranet System (IRIS). MSM stated policy required physician notification for all skin breakdown or significant changes to a pressure injury. During an interview on 3/15/24 at 9:39 a.m. MSM, MSM stated when a patient transferred into the medical surgical unit (MS) from another unit and an undocumented wound is discovered. MSM stated she immediately talked to the other department to do a gap analysis (identifying difference between current knowledge, skills, and/or practices and desired best practice). MSM stated she also investigated gaps in documentation that lead to pressure injuries. MSM stated a Root Cause Analysis (RCA) (a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions) is then completed. MSM stated she had to discuss hospital acquired pressure injuries (HAPI) in the monthly committee meetings. MSM stated the committee tracked present on admission (POA) or acquired (received) on site wounds. MSM stated Pt 1’s wound was investigated, and a root cause analysis was completed. MSM stated, the investigation determined there was no documentation stating wound was POA. MSM stated, the hospital’s root cause analysis investigation determined Pt 1’s wound was an avoidable hospital acquired pressure injury (HAPI). MSM stated RCA determined a delay of care due to, failure to notify physician of pressure injury to get a wound consultation order. MSM stated nursing staff failed to identify that no documentation from previous unit of a POA pressure injury was present upon transfer of Pt 1 from Emergency Department. During an interview on 3/15/24 at 9:38 a.m. with the MSM, MSM stated wound nurses are involved in stage three (full thickness tissue loss), stage four (full thickness tissue loss with exposed bone, tendon, or muscle) unstageable (full thickness pressure injuries where the base is covered yellow/white or by thick black, dry, dead tissue) or deep tissue injury (purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure/or shear)wounds. MSM stated wound nurses had 72 hours after a wound consultation was ordered to see patient. MSM stated wound nurses were available Monday through Friday. MSM stated wound nurses then created a plan of care with physician to treat wounds. During a concurrent interview and record review on 3/15/24 at 9:42 a.m. with MSM, Pt 1’s “Admit, Discharge, Transfer events” (ADT) dated 12/13/23 9:51 a.m. to 12/23/23 at 3:46 p.m. was reviewed. The “ADT” indicated, Pt 1 was in the ED from 12/13/23 to 12/16/23. MSM stated patient arrived in ED on 12/13/23 at 9:45 a.m. and was admitted on 12/13/23 at 8:59 p.m. MSM stated, patient was held in the ED until 12/16/23 at 6:14 p.m. when he was transferred to the inpatient medical surgical unit. MSM stated patient was held for over three days in the ED. During a concurrent interview and record review on 3/15/24 at 9:45 a.m. with the MSM, Pt 1’s “Wound Skin Integrity Flowsheet Data (WSI)”, dated 12/13/23 at 6:49 p.m. to 12/20/23 at 3:00 p.m. was reviewed. The “WSI” indicated, when Pt 1 arrived in MS and first nursing assessment was completed at 12/16/23 on 9:48 p.m. a healing pressure ulcer to the lumbar (lower) spine, thoracic (middle) spine area that was present on admission (POA) was documented. MSM stated on 12/16/23 MS nurse assessed a pressure ulcer when Pt 1 arrived in MS, he documented it as a healing pressure ulcer to the spine that was present on admission to the hospital. During a concurrent interview and record review on 3/15/24 at 9:47 a.m. with the MSM, Pt 1’s “Skin Integrity Accordion (SIA)” dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The “SIA” indicated, Pt 1’s initial skin assessment was documented at 9:49 p.m. MSM stated, Pt 1 was transferred to the medical surgical unit (MS) on 12/16/23. MSM stated skin and initial skin assessment was documented at 9:49 p.m. MSM stated the nurse photographed the wound and completed an IRIS report. MSM stated nurse documented a Braden score of 13 indicating Pt 1 was a moderate risk for pressure injury. MSM stated the nurse identified and documented the wound as a healing wound, to lumbar spine thoracic spine (lower back) that was present on arrival to the hospital. MSM stated nurse did not notify the physician at discovery of the wound. MSM stated, skin integrity order set for pressure reduction and wound prevention interventions were started. MSM stated foam dressing was applied to spine area at wound location, to reduce pressure. MSM stated physician notification of wounds is her expectation. MSM stated staging of wounds is her expectation. MSM stated hospital policy was not followed. MSM stated not following policy could cause an advancement of the wound, a decline in functional status or a longer length of hospital stay. During concurrent interview and record review on 3/15/24 at 9:50 a.m. with the MSM, Pt 1’s “Wound Specialist Consult Note (WSCN)”, dated 12/22/23 at 1:56 p.m. was reviewed. The “WSCN” indicated, Pt 1 had a small stage three pressure injury to the spinal bony prominence of the lumbar spine (lower back). MSM stated wound nurse determined Pt 1 had a small stage three pressure injury to the spinal bony prominence of the lumbar spine (lower back). MSM stated wound nurse noted surrounding tissue was deep purple, red, and non-blanchable (describe). MSM stated physician notification, and subsequent wound specialist consultation was entered eight days after admission to the hospital. MSM stated Pt 1 had been on the medical surgical unit for six days prior to wound consultation. MSM stated the wound care specialist was the first nurse to stage the wound. MSM stated the root cause analysis determined a delay in care for a wound specialist consultation. During an interview on 3/13/24 at 3:26 p.m. with the Emergency Department Director (EDD), EDD stated ED nurses were trained to do a focused assessment not a full head to toe assessment. EDD stated admitted patients need a full head to toe assessment. EDD stated there may be a gap in learning. EDD stated ED nurses may not differentiate ED patients versus the admitted patients and that may mean the admission tasks were getting missed, such as skin interventions and wound assessments. EDD stated patients can be in the ED for many days, waiting for an inpatient room. EDD stated his expectation was ED nurses should follow policy, assess patients’ skin, and let physician know about any wounds. EDD stated his expectation was for nurses to do a full head to toe assessment including skin/wounds for all admitted patients. EDD stated his expectation was for nurses to start skin interventions based on their assessment and evidence showed this was not happening. EDD stated if skin interventions were not initiated pressure injuries could occur. EDD stated if wounds were not assessed and treated it could lead to a longer hospital admission and infection. During a concurrent interview and record review on 3/20/24 at 12:18 P.M. with RN 3, P1’s “SIA”, for 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The “SIA” indicated, on 12/15/24 at 8 a.m. RN 3 assessed Pt 1 in the ED. RN 3 documented “bruising to arm and other scab to great toe.” RN 3 stated she photographed the wound to the great toe per policy. RN 3 stated she did not complete the IRIS per policy. RN 3 stated the only wounds she saw were what she documented. RN 3 stated she knew how to compete a head-to-toe assessment including a skin assessment. RN 3 stated she gave the patient a Braden Score of 11 which indicated high risk for pressure injury. RN 3 stated there should have been skin interventions completed with a Braden Score that low. RN 3 stated, no turns or skin interventions were documented in her charting. RN 3 stated she was busy in the ED. RN 3 stated she often had to work out of ratio and that may be a reason some activities were not completed such as proper skin interventions. During a concurrent interview and record review on 3/22/24 at 7:53 a.m. with RN 4, Pt 1’s “SIA”, dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The “SIA” indicated, on 12/15/24 at 7:45 p.m. RN 4 assessed Pt 1 in the ED. RN 4 documented “bruising to arm, petechiae [small red or purple spots caused by bleeding into the skin], infiltration [permeation of a liquid into something by filtration]”. RN 4 stated she did not take any photos of skin. RN 4 stated she charted a Braden scale of 14 for the patient, and skin interventions should have been started. RN 4 stated she did not see any skin activities, or any dressing information charted. RN 4 stated there should have been skin interventions completed, such as a waffle mattress (special pressure relieving mattress) or turning schedule, to prevent skin breakdown. RN 4 stated sometimes she was assigned up to six patients in the ED and they got very busy, things may get missed. RN 4 stated not completing skin interventions could lead to patients getting pressure injuries and those could get infected, patient could get septic (bacteria make toxins that cause the immune system to attack the body’s own organs and tissues). During a concurrent interview and record review on 3/25/24 at 12:04 p.m. with RN 5, Pt 1’s “SIA”, dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The “SIA” indicated, on 12/16/24 at 9:10 a.m. RN 5 assessed Pt 1 in the ED. RN 5 “documented bruising to arm”. RN 5 stated based on her charting the only skin issues she saw were bruising to the arm. RN 5 stated she assessed and scored the patient a Braden score of 14. RN 5 stated that based on her charting no skin interventions or turning were completed. RN 5 stated that she had been assigned as many as eight patients at a time while working in the ED. RN 5 stated she believed this was unsafe. RN 5 stated she believed skin interventions could be missed when working in the ED. RN 5 stated a skin wound that went untreated could lead to sepsis. During a concurrent interview and record review on 3/26/24 at 9:35 a.m. with the MSM, Patient 1’s (Pt 1) “SIA”, dated 12/13/23 at 6:50 p.m. to 12/28/23 at 1:56 p.m. was reviewed. The “SIA” indicated Pt 1 was on the MS unit for six days before the physician was notified, the pressure injury was staged, or a wound nurse consultation was ordered. MSM stated, Pt 1’s initial assessment in MS unit was on 12/16/23 at 9 p.m. the pressure injury was documented and photographed. MSM stated the nurse did not stage the wound or notify the physician. MSM stated nursing staff assessed Pt 1 every shift for multiple days from 12/16/23 to 12/22/23 on am shift (7 a.m.-7p.m.) and pm shift (7:30-700 a.m.). MSM stated there was no documentation that Pt 1’s physician was notified, or a wound consultation was completed. MSM stated this resulted in Pt 1 having a delay in wound consultation. MSM stated on 12/16/23 at 9:00 p.m. the nurse should have notified the physician and entered a wound nurse consultation. MSM stated every shift from 12/16/23 to 12/22/23 nursing staff could have notified the physician and entered a wound consultation.MSN stated a delay of care resulted by not notifying the physician or entering a wound nurse consultation. MSN stated her expectation was for staff to follow policy. MSM stated not following policy may result in a worsening in a patient’s pressure injury. During a concurrent interview and record review on 3/26/24 at 4:19 p.m. with Emergency Department Manager (EDM), Pt1’s, “SIA”, dated 12/13/23 at 6:50 p.m. to 12/17/23 at 1 a.m. was reviewed. The “SIA” indicated, no skin interventions were charted from 12/13/23 to 12/16/23. EDM stated she was very familiar with Pt 1. EDM stated no skin assessment was completed by ED nurses until 12/14/23 at 12:07 p.m. EDM stated Pt 1 was admitted on 12/13/23 at 9:59 p.m. EDM stated the first patient assessment was documented on 12/14/23 at 12:07 p.m. EDM stated, no skin interventions were documented on 12/14/23 at 12:07 p.m., 12/14/23 at 8:50 p.m., 12/15/23 at 8 a.m., 12/15/23 at 7:45 p.m., and 12/16/23 at 9:10 a.m. EDM stated patient was transferred to medical surgical unit on 12/16/23 and skin interventions began at 7:02 p.m. EDM stated, the same interventions that were done once he was transferred to the MS unit should have been completed when he was admitted and held in the ED. EDM stated the Braden score assigned by the ED nurses during their assessments would indicate that this patient required skin interventions to prevent skin breakdown. EDM stated her expectation was for nurses to follow the policy. EDM stated according to nursing documentation the nurses did not follow policy and procedure (P&P) for skin. EDM stated when nurses are not following P&P there was a potential for skin breakdown and development of a hospital acquired pressure injury (HAPI). EDM stated, “the bottom line is, HAPI’s aren’t Happy.” EDM stated there is an evolution of boarders (admitted/held) patients in the ED. EDM stated nurses need to do better and make sure all skin is cared for. During a review of the facility’s policy and procedure (P&P) titled, “Pressure Injury Assessment, Prevention, Staging and Treatment”, dated 08/11/22, P&P indicated, ... “. All patients should be assessed upon admission, then every shift, and with condition changes using the Braden scale for Predicting Pressure Score Risk ...B. Prevention measures are to be applied based on the assessed level of risk ...C. Patients with a subscale identified as a score of 1 or 2 are considered at risk for developing pressure injuries ...D. Upon identification of a suspected pressure injury, whether present on admission or hospital-acquired, the RN shall photograph, describe and document the injury location ...The pressure injury will be staged by an RN and they will complete an Incident Reporting Intranet System (IRIS) report .... E. Notify the Clinical Supervisor and/or WS [wound specialist] of all unstageable, stage 3, or stage 4 pressure injuries ... F. Notify the physician of any skin breakdown and of any significant changes to pressure injury ... G. All pressure injury treatment requires a physician order ...H. Obtain a nutritional consult ... I. The RN may implement all aspects of the policy ... PROCEDURE A. Risk Assessment ... B. Prevention 1. Skin Care ... 2. Nutrition ... 3. Moisture Control ... 4. Pressure Reduction-Positioning a. turn and position all patients at a risk for pressure injury every 2 hours, unless contraindicated ...C. Prevention by Risk Levels 1. Not at risk- greater than 18 or if no subscale scores 1 or 2 ...2. If the patient scores a 1 or 2 in the sensory perception subscale ...3. If a patient scores a 1 or 2 in the moisture subscale ...4. If the patient scores a 1 or 2 in the activity subscale ...b. turn every 2 hours with a 30-degree tilt or more often if on bed rest ...5. If the patient scores a 1 or 2 in the mobility subscale ...D. Staging/Treatment 1. Stage all pressure injuries according to the amount of tissue loss ...h. document findings in the EHR ...Documentation ...A. Document the following ... 1. Braden Scale Score ...2. Assessment ...5. Physician notification of any changes ...7. Nutrition consumed ...E. Upload images of the patient’s wounds into the EHR” ... During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility’s policy and procedure (P&P) titled, “Pressure Injury Assessment, Prevention, Staging and Treatment”, dated 08/11/22, ...Section III part A. indicated, Patient’s with a total score of less than nine are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk, for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear ...” 2. During an interview on 3/13/2024 at 12 p.m., Registered Nurse (RN) 21 stated, Patient (PT) 2 had been admitted to the Unit 5 Medical Surgical on 3/3/24 and on 3/3/2024 and had developed a pressure injury that required a wound care consult. During an interview on 3/13/24 at 3:26 p.m. with Registered Nurse 2 (RN 2), RN 2 stated, he had patients arrive to the Medical Surgical (MS) unit from the ED with “wounds” that were not documented. RN 2 stated he documented the wound when the patient arrived to the MS unit. RN 2 stated skin interventions were not started until arriving to the medical surgical unit. RN 2 stated skin interventions should be started at admission. RN 2 stated, it was important to start skin interventions to prevent pressure injuries. During an interview on 3/13/24 at 3:26 p.m. with the Emergency Department Director (EDD), EDD stated ED nurses were trained to do a focused assessment not a full head to toe assessment. EDD stated admitted patients need a full head to toe assessment. EDD stated there may be a gap in learning. EDD stated ED nurses may not differentiate ED patients versus the admitted patients and that may mean the admission tasks were getting missed, such as skin interventions and wound assessments. EDD stated patients can be in the ED for many days, waiting for an inpatient room. EDD stated his expectation was ED nurses should follow policy, assess patients’ skin, and let physician know about any wounds. EDD stated his expectation was for nurses to do a full head to toe assessment including skin/wounds for all admitted patients. EDD stated his expectation was for nurses to start skin interventions based on their assessment and evidence showed this was not happening. EDD stated if skin interventions were not initiated pressure injuries could occur. EDD stated if wounds were not assessed and treated it could lead to a longer hospital admission and infection. During an interview on 3/14/24 at 3:29 p.m. with RN 17 an ED RN, RN 17 stated nurses are assigned both admitted patients and emergency patients at the same time. RN 17 stated a focused assessment based on complaint was required for stabilization of an emergency patient. RN 17 stated a complete head to toe assessment including skin was required for an admitted patient. RN 17 stated if a skin assessment was not done a wound may be missed or a patient’s wound could get worse. RN 17 stated turning patients or a complete skin assessment may not be done because nurses are working out of ratio. RN 17 stated he does not turn patients in the ED. RN 17 stated if skin interventions are not started after admission a patient may develop a pressure injury if they have a low Braden score (scale used to identify the risk of a pressure ulcer for a patient, low score indicates higher risk). During a record review of Pt 2’s “ADT [Admission Discharge Transfer] Events,” undated, the record indicated, Pt 2 had been admitted to inpatient care in the Emergency Department (ED) on 2/29/2024 at 10:57 a.m. Pt 2 arrived at 5 MS unit on 3/3/2024 at 8:08 p.m. During a record review of Pt 2’s “History and Physical (H&P-the complete assessment of the patient and the problem),” dated 3/5/24, the H&P indicated, “ ... Patient...[year old] female with history of Parkinson’s Disease [progressive disorder of the nervous system], hyperlipidemia [elevated levels of cholesterol and in the blood], ... chronic kidney disease, hypothyroidism [underactive thyroid gland that does not make enough hormone], and obesity, presents to the emergency department with complaint of a persistent non productive cough that has been ongoing since knee surgery on 1/4/24. Pt also c/o [complaint of] associated shortness of breath. There are no other complaints. ... She will be admitted to the medical floor for further tx. [treatment] ... Skin: turgor [elasticity] normal. No rashes or lesions. ... “ During a record review of Pt 2’s “Skin Integrity Accordion Report,” undated, the report indicated, skin had been assessed in ED as intact 2/29/24 at 11:00, 3/1/24 at 8:00 a.m., 3/2/24 at 5 a.m. and 3/2/2024 at 9:50 p.m., and 3/3/2024 at 9:40 a.m. The Braden Scale for Predicting Pressure Sore Risk (a tool used for early identification of patients at risk for forming pressure ulcers - a lower Braden score indicates a higher risk for pressure ulcer development, generally, a score of 18 or less indicates at-risk status) were assessed at 2/29/24 at 11 a.m. as 17, 3/1/24 at 8:00 a.m. as 17, 3/2/24 at 5 a.m. as 17, and 3/3/2024 at 9:40 a.m. as 17. There was no documented evidence of repositioning, turning and pressure reduction was completed by nursing staff during Pt 2’s stay in ED from 2/29/24 to 3/3/24. Patient 2 remained in ED until 3/3/24 at 8:08 p.m. and was transferred to a room in 5 Med/Surg. On 3/3/24 at 9:20 p.m., incision noted on knee and dressing applied and a Braden scale of 16 was assessed. During an interview on 3/14/24 at 3:30 p.m., with RN 11, RN 11 stated a skin assessment of the patient should be done at admission and once per shift when a patient is admitted as inpatient. RN 11 stated, “we should do them [skin assessments] and put interventions in place but they do not get done.” During a record review of Pt 2’s “Physician orders” dated 3/05/24, the physician orders indicated a Wound Specialist consult was ordered on 3/5/2024 at 2:31 a.m. During a record review of Pt 2’s “Wound Specialist Consult Note,” dated 3/5/24 at 10:17 a.m., the note indicated, “ ... Patient’s chart reviewed. The patient is being consulted today for, “deep tissue injury.” ... Wound Review ...Chart and photos reviewed by the wound specialist. An area of intact purple tissue discoloration noted to the sacral [buttocks] region. Slight erythema [redness of the skin caused by increased blood flow that occurs with any skin injury] to the peri wound ... Reduce/relieve pressure at the interface between bony prominences and the support surface. Reposition the patient at least every 2 hours for pressure redistribution. Please make sure that the patient in on a newer [BRAND NAME] mattress [mattress to relieve pressure and prevent wounds] ... Recommend physician add the wounds to the patient problem list.” During an interview on 3/28/24 at 9:05 a.m., with the Chief Nursing Officer (CNO), the CNO stated, staff follow the policy to assess the skin of patients who have been admitted to inpatient status. The CNO stated, as per the policy, two nurses should assess the skin of patients and document the results to ensure the accuracy of the information. During a review of the facility’s policy and procedure (P&P) titled, “Pressure Injury Risk Assessment, Prevention, Staging and Treatment,” dated August 11, 2022, the P&P indicated, “... PURPOSE ... A. To provide staff with a valid and reliable pressure injury risk assessment tool for admitted patients. ... All patients shall be assessed upon admission, then every shift, and with condition changes using the Braden Scale for Predicting Pressure Sore Risk. ... C. Patients with a subscale identified as a score of 1 or 2 are considered at risk for developing pressure injuries. The nurse will identify and implement an individualized plan of care that addresses the interventions appropriate to reduce the risk factors. ... 2. The initial skin assessment upon admission and/or transfer from another unit will be conducted with 2 licensed staff members. ... 4. Develop a plan of care based on the areas of risks, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, positioning, and the support surface. If the risk is from malnutrition, address this problem, etc. ... B. Prevention (All patients regardless of score) ... 4. Pressure Reduction-Positioning ... a. Tum and position all patients at risk for pressure injury every 2 hours, unless contraindicated due to medical condition or medical treatments. ... e. Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the patient when choosing a support surface ....” During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility’s policy and procedure (P&P) titled, “Pressure Injury Assessment, Prevention, Staging and Treatment”, dated 08/11/22, ...Section III part A. indicated, Patient’s with a total score of less than nine are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk, for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear ...” 3. During a review of Patient 3’s “Electronic Health Record (EHR)” dated 3/8/24 to 3/13/24, the EHR indicated, Patient 3 was admitted on 3/9/24 for Altered Mental Status (AMS- a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted, he remained in the Emergency Department (ED) Green Zone Hallway bed. The EHR indicated due to Patient 3’s AMS and interference with his medical treatment, his safety was at-risk and therefore placed in non-violent restraints that started on 3/8/24. During an observation on 3/13/24 at 11:50 a.m., in the Emergency Department (ED) Green Zone bay Green Hall (GH)-04 (room number), Patient 3 was lying on a gurney with his right hand loose on his chest and left hand tied down to the frame of the gurney by restraints. Patient 3 had a Posey Vest (type of medical restraint that is on a patient’s torso, used to restrain a patient to a bed) and soft-wrist restraints (type of medical restraint used to restrain a patient to a bed) on that were not secured to the gurney frame on his right side. During a concurrent observation and interview on 3/13/24 at 12 p.m., with the Emergency Department Director (EDD) in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. EDD stated the restraints needed to be fastened to the bed frame and they were not on the patient’s right side. EDD stated it was dangerous for the patient to not be restrained as Physician ordered. During a concurrent observation and interview on 3/13/24 at 12:05 p.m., with the Registered Nurse (RN) 22 in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. RN 22 stated Patient 3 still needed to be in restraints due to confusion, an attempt to get out of bed and was “pulling stuff off”. RN 22 stated she was unaware that the restraint was not fastened to the gurney until it was pointed out to her “just now”. RN 22 stated this was not safe for Patient 3 and he could have hurt himself. RN 22 stated it was “impossible” to assess all of her patients on time because she was out of ratio with 6 patients for the day. RN 22 said it was not safe for patients when she was responsible for 6 patients at a time. During an interview on 3/14/24 at 1 pm, with the EDD, the EDD stated Patient 3 could harm himself with the restraint not being fastened to the bed frame on the right side. The EDD stated “we” did not follow the restraint policy. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated non-violent restraints are for the patient and staff to remain safe. CNO stated Patient 3 could have harmed himself because his right arm was free and the restraint was not fastened to the bed. CNO stated Patient 3’s safety was put at-risk and staff did not follow the policy and procedure (P&P) “Restraint and Seclusion”. During a review of the instruction for use “Posey Limb Holders- Application Instructions for Wrist and Ankle (PLH)”, dated 2023, the PLH indicated, “ ...Limb holder for limiting limb movement. For bed and stretcher use only. INDICATIONS FOR USE: Patients assessed to be at risk of disrupting life-saving treatments (e.g., pulling lines/tubes) or in danger to injury to themselves or to others. Follow your hospitals restraint policies and procedures which are in compliance with CMS (Centers for Medicare & Medicaid Services- federal agency that enforces rules in relation to high quality health care) guidelines and state laws ... APPLICATION INSTRUCTIONS: ...attach straps to frame ... to restrict patients range of motion ... attach at different points along the frame ... using quick-release ties ... ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...”. During a review of the instruction for use “Posey Criss-Cross Vests (PCCV)” dated 2009, the PCCV indicated, “ ...DESCRIPTION OF PRODUCT: A versatile vest with tie ends. For bed ...application ... INDICATIONS FOR USE: .... Patients requiring a positioning device to assist medical treatment ...APPLICATION INSTRUCTIONS: ... 3. Secure straps to the ... bed frame, out of the patients reach ... WARNING: Make sure straps cannot slide, loosen, or tighten if the patient pulls on them or if the patient bed ...is adjusted ...The patient may suffocate if the straps tighten. If the straps loosen, serious injury or death may occur from ... patient escape ... or suffocation if the patient becomes suspended in the restraint ...ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...”. During a review of the facility’s P&P titled, “Restraint and Seclusion”, dated 6/8/23, the P&P indicated, “I. PURPOSE: A. To provide a standardized process in the use of restraints ... while protecting and preserving patient rights, dignity, safety and well-being ... B. To meet and comply with regulatory requirement ... E. Non-Violent Restraint: Restraints applied to support the management of care when the patient is interfering with medical treatment and safety (not aggressive but attempting to remove essential lines or equipment that would put the patient at risk of harm) ... IV. PROCEDURE: A. Restraint Application 1. Restraint shall be applied/removed in accordance with the following: ... B. Restraints will be applied with safe and appropriate techniques. C. Restraint devices are to be applied/removed in accordance with manufacturers instructions and used in a manner consistent with their intended purpose. D. Restraints will be secured to the frame if being used while the patient is in bed ... E. Restraints shall be secured so that they may be released quickly in the event of an emergency. F. Restraint devices are to be applied/removed in a manner that preserves the dignity, comfort and well-being of the patient ... 6. ... D. NON-VIOLENT RESTRAINTS: 1. Restraints are utilized for the non-violent patient. Must have clinical justification to protect patient from unsafe situation (e.g. pulling at tubes/lines) ... 4. Non-violent restraints available ... a. soft restraints b. Posey vest ...”. 4. During a review of the Hospital’s “CDPH (California Department of Public Health) Program Flex (PF)”, dated 3/13/24, the PF indicated, “ ... Facility: [Hospital Name] Flex Description: ED North Hall Space Flex ... Approval Date: Pending approval, submitted on 2/28/24 ...”. During an observation on 3/13/24 at 1140 a.m., in the ED North Hall, there were 12 patients in gurneys located on one wall of the hallway. Patients in the hall did not have access to call-lights and had access to only one electrical outlet. One patient was bed bound (confined to the bed only), deemed to be non-verbal (Patient 53) and only understood Cambodian (Mon Khmer). During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated she was responsible for multiple patients in the ED North Hall, including Patient 53. RN 9 stated there were no call lights for patients in the hall. RN 9 stated the North Hall was dangerous for patients and the hall was “impossible” to deliver safe patient care. RN 9 stated there were no outlets for infusion pumps (a medical device that delivers fluids, such as nutrients and medications, into a patient’s body in controlled amounts) and they would “die all day”. During a concurrent observation and interview on 3/13/24 at 3:52 p.m., with the Emergency Department Director (EDD) in the ED North Hall (NH), Patient 53 was reaching her hand out of the gurney in bay NH-11. EDD stated the facility had nowhere to put inpatients and that was why they had to use this hallway. EDD stated the hallway was not safe for patients, especially with communication barriers. EDD stated the hospital was not licensed to use the NH but had requested a “waiver” that was not approved yet. EDD stated the hospital had been using the NH since December 2023. During an interview on 3/13/24 at 3:57 p.m., with Patient 57, Patient 57 stated his infusion pump went “dead” twice today while his medications were running. Patient 57 stated there “are no plugs around here on the walls”. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated the ED NH was a patient safety issue. The CNO stated the lack of electrical outlets and the lack of ability for patients to notify their nurse via call bell or light was a concern. Policy was requested regarding the use of the ED NH but was not provided. During a review of the Hospital’s “Safe Start Risk Assessment- Department: ED (SSR)”, dated 2/28/24, the SSR indicated, “Description of service: Utilization of North Hallway for patient care of ED and admitted patients ... Go Live Date: Currently in use roughly 5 days per week ... Plan: Surges with 100+ admissions have had to use alternative care areas ... North Hallway ... Some patients receiving IV (intravenous- in the vein) fluids in the waiting area. When we need physical space. 70-90 is the new normal for holding patients. Use space ... for admitted patients. There is one outlet ...Regulatory Impact: Licensing- Applying for a flex letter with the State. Will be used as space to provide patient care in a space where patient care is not provided. Can ask for up to a year ...Identify Issues/Risks: Safety team doing a root analysis regarding the power strips in this area ...”. 5. During a review of Patient 4’s “History and Physical Examination (H&P- initial exam)”, dated 3/10/24, the H&P indicated, “ ...Chief Complaint pain in the abdomen ... Plan: Admit to medicine and start IV (intravenous- in the vein) fluid, IV [antibiotics], oxygen and bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), pain medication as needed ...”. During a review of Patient 4’s “Medication Administration Report (MAR)”, dated 3/9/24 to 3/15/24, the MAR indicated, “ ...Albuterol [Brand Name] 2.5 mg [milligrams- unit of measurement]/3 mL [milliliters- unit of measurement] nebulizer solution [liquid medication that could be inhaled and exhaled directly into the lungs] ... Frequency: every 6 hours ... Route: Nebulization [electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece] ... Start: 3/10/24 ... End: 3/14/24 at 4:28 p.m. .... -Medication Not Given 17 separate times: --3/10/24- 4:42 p.m., 9:24 p.m., --3/11/24- 5:03 a.m., 9:48 a.m., 4:54 p.m., 9:44 p.m., --3/12/24- 4:25 a.m., 10 a.m., 4 p.m., --3/13/24- 1:04 a.m., 4:47 a.m., 10 a.m., 6:55 p.m., 10 p.m., --3/14/24- 3:53 a.m., 11:38 a.m., 4:56 p.m. ...”. During a review of Patient 4’s “MAR Flowsheet #1- #7 (MF)”, dated 3/11/24 to 3/13/24, the MF indicated: 1. MF 1- 3/11/24 at 9:44 p.m., route: nebulization ... user: [Respiratory Care Provider (RCP) 2] Delivery: Not Given- Hall 2. MF 2- 3/12/24 at 4:25 a.m., route: nebulization ... user: [RCP 2] Delivery: Not Given- Hall 3. MF 3- 3/12/24 at 10 a.m., route: nebulization ... user: [ RCP 3] Delivery: Not Given Comment: Hall 4. MF 4- 3/12/24 at 4 p.m., route: nebulization ... user: [RCP 3] Delivery: Not Given- Comment: Hall 5. MF 5- 3/13/24 at 1:04 a.m., route: nebulization ... user: [Registered Nurse (RN) 21] Comment: patient in the hallway, no available room for breathing treatment 6. MF 6- 3/13/24 at 4:47 a.m., route: nebulization ... user: [RCP 4] Delivery: Not Given- Hall Bed 7. MF 7- 3/13/24 at 10 p.m., route: nebulization ... user: [RCP 5] Delivery: Not Given- Comment: Patient in hall bed. During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated she was responsible for multiple patients in the ED North Hall and Patient 4. RN 9 stated patients that are in the hallway with nebulizer treatments ordered do not receive them. RN 9 stated “it’s a rule” that the RCP’s do not administer them. RN 9 stated those nebulizer treatments “just get skipped”. RN 9 stated that she did not notify the Physician when Patient 4 did not get her nebulizer treatment and thought the RCP was supposed to. During an interview on 3/14/24 at 4 p.m., with Patient 4, Patient 4 stated she found out she had nebulizer treatment ordered by a Doctor in the Emergency Department through her patient online portal. Patient 4 stated staff never told her those treatments were ordered for her and why. Patient 4 stated she never received any nebulizer treatments while admitted in the ED. During an interview on 3/22/24 at 9:15 p.m., with the Director of Respiratory Therapy (DRT), the DRT stated RCP staff had guidance that was outdated and would not administer patients nebulizer treatments in hallway ED beds.DRT stated that guidance has changed and now will complete nebulizers in the halls. DRT stated RCP staff should have educated patients and told them about their nebulizer treatments and they did not. DRT stated staff should have notified the ordering Physician of the nebulizer treatment not given and they did not. DRT stated RCP staff did not follow facility policy and procedures (P&P) “Respiratory Care Orders/Administration/Documentation, Provider Orders and Medications, Orders, Administration, Storage, Documentation”. During an interview on 3/22/24 at 10 a.m., with RCP 3, RCP 3 stated Patient 4 was in the hallway and she refused the nebulizer treatment for her due to her being admitted to the ED hallway. RCP 3 stated RCP’s did not do nebulizer treatments in the ED hallways for any patients. RCP 3 stated “we were told not too”. RCP 3 stated she did not tell Patient 4 she was ordered a nebulizer treatment and did not educate her. RCP 3 stated she did not notify the ordering Physician that Patient’s 4 treatment was not given her treatment. RCP 3 stated patient’s medical condition could get worse by not giving the treatments and not notifying the Physician. RCP 3 stated a patient’s safety would be put at-risk. RCP 3 stated she did not follow hospital policy and procedure. During an interview on 3/22/24 at 11:30 a.m., with the RCP Manager (RCPM), the RCPM stated it was normal practice for RCP’s to not complete any nebulizer treatment for any patient in a hallway bed. RCPM stated that practice put patient safety at risk and a patient could deteriorate. RCPM stated patients have a right to be a part of their care and RCP’s should have been notifying them of their treatments. RCPM stated staff did not follow the hospital policies and procedures RCP’s are supposed to follow. During a review of Pt 36’s “Hospitalist History and Physical (HH&P)”, dated 3/13/24, the HH&P indicated, “ ...Chief Complaint ...Respiratory short of breath ...Pt c/o (complaint of) shortness of breath ...With a SpO2 [is a measurement of the percentage of oxygen in the blood, relative to the maximum it could carry]. 88% on room air [A normal SpO2 level for a healthy person is between 96% and 99%] ... Plan Methylprednisolone [a drug used to treat various medical conditions including lung or breathing problems] 20mg [milligrams-unit of measurement] IV (intravenous- administered into the vein) TID (three times a day) ... ipratropium/albuterol [a drug used to help control symptoms of lung disease by opening the lung airways] as needed ...” During a review of Patient 36’s “Medication Administration Report (MAR)”, dated 3/21/24 , the MAR indicated, “ ...Ipratropium-albuterol 2.5 mg /3 mL [milliliters- unit of measurement] nebulizer solution [liquid medication that is turned into a mist that can be inhaled and exhaled directly into the lungs] ... Frequency: every 6 hours ... Route: Nebulization [a device that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece] ... Start: 3/14/24 at 12:01 a.m. ...End: 3/16/24 at 10:05 p.m. ...” The Ipratropium-albuterol was not given on 3/14/24 at 12:05 a.m., 5:18 p.m., 9:40 p.m., and on 3/15/24 at 4:00 a.m. During a review of Pt 36’s “MAR Flowsheet #1- #4 (MF)”, dated 3/21/24, the “MF” indicated, “ ...MF 1- 3/14/24 at 1205 a.m., route: nebulization ... user: [Respiratory Care Provider (RCP) 2] Delivery: Not Given ...Comment: In Hallway ... MF 2- 3/14/24 at 5:18 p.m., route: nebulization ... user: [RCP 2] Delivery: Not Given ...Comment: In Hallway ... MF 3- 3/14/24 at 9:40 p.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed ... MF 4- 3/15/24 at 4:00 a.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed ...” During a review of Pt 37’s “HH&P”, dated 3/11/24, the “HH&P” indicated, “ ...Chief Complaint ...Difficulty breathing ...cough ...pleurisy [inflammation of the pleura, the two thin layers of tissue that separate the lungs from the chest wall. This can cause a sharp chest pain while breathing] ...ESRD [End Stage Renal Disease- a medical condition when the kidney’s stop to function] ... Who is here for acute hypoxic respiratory failure [AHRF-a severe form of low oxygen in the body] ... Plan ...As needed cough and expectorant [a type of cough medicine used to help clear mucus [phlegm] from your airway]...” During a review of Pt 37’s “MAR”, dated 3/21/24, the MAR indicated, “ ...Acetylcysteine [a drug used to relieve chest congestion due to thick mucus secretions in the lungs] 200 mg /3 ml nebulizer solution ... Frequency: every 6 hours ... Route: Nebulization ... Start: 3/12/24 at 4:00 a.m. ...End: 3/18/24 at 12:55 a.m. ...” The Acetylcysteine was not given on 3/13/24 at 12:31 a.m., 4:41 a.m., 10:00 a.m., 7:37 p.m., 11:03 p.m., and on 3/14/24 at 3:58 a.m., and 10:00 a.m. During a review of Pt 37’s “MAR Flowsheet #1- #3 (MF)”, dated 3/21/24, the MF indicated, “ ...MF 1- 3/13/24 at 7:37 p.m., route: nebulization ... user: [(RCP) 4] Delivery: Not Given ...Comment: not given by day shift, next dose close, MF 2- 3/13/24 at 11:03 p.m., route: nebulization ... user: [RCP 4] Delivery: Not Given ...Comment: Patient in dialysis, patient in hallway bed, MF 3- 3/14/24 at 3:48 a.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed..” No documentation was provided for date 3/13/24 at times of 12:31 a.m., 4:41 a.m., 10:00 a.m. or date 3/14/24 at 10:00 a.m. the reason why nebulization medication was not administered. During a review of Pt 56’s “Hospitalist History and Physical (HH&P)”, dated 3/12/24, the H&P indicated, “ ... Chief complaint ...difficulty breathing ...Pt c/o shortness of breath ...history of Idiopathic Pulmonary Fibrosis (IPF-a rare, chronic lung disease that causes lung tissue to thicken and stiffen and makes breathing more difficult) ...Plan ... [brand name] [Levalbuterol- a drug used to treat shortness of breath that commonly occur with lung problems] neb x1 (1 time) ...” During a review of Pt 56’s MAR, dated 3/13/24, the MAR indicated, “ ...Levalbuterol [Brand name] ...1.25 mg nebulizer solution ...Frequency: Once ...Route: Nebulization ...Start: 3/12/24 3:37 a.m. ...End: 3/13/24 3:37 a.m. ...” The Levalbuterol was not given on 3/12/24- 5:26a.m. During a review of Pt 56’s MF#1, dated 3/21/24, the MF indicated, “ ...MF 1- 3/12/24 at 5:26 a.m., route: nebulization ... Delivery: Not Given ...Comment: Hallway During an interview on 3/15/24 at 10:49 a.m., with Respiratory Care Provider (RCP) 1, RCP 1 stated nebulizer treatments were not administered in the hospital’s hallways. RCP 1 stated he did not administer nebulizer treatments to patients in the hospital’s hallways. RCP 1 stated it was not a common practice to administer nebulizer treatments in the hospital’s hallways. RCP 1 did not know the reason not to administer nebulizer treatments in the hospital hallways. During a review of the facility’s Policy and Procedure (P&P) titled, “ Respiratory Care Orders/Administration/Documentation “, dated 10/13/17, the P&P indicated, “PURPOSE: To ensure safe preparation, administration and documentation of medication with appropriate modality used by Respiratory Care Practitioners (RCP). II. POLICY: A. The RCP is responsible for the content of all referenced policies as they pertain to the delivery of medications utilized in respiratory care ... 3. Refer to the policy Medications - Orders, Administration, Storage, Documentation ... a. Routine medications b. Scheduled respiratory administration times ... i. Patient education regarding medications and medication delivery device ...VI. PROCEDURE: ... D. Correctly identify patient per corporate policy ... introduce yourself to the patient. E. Educate patient/reinforce education as needed ... J. Administer medication per American Association of Respiratory Care (AARC) guidelines ... VIII. EDUCATION: ... B. Inform and educate the patient and/or family on the name of the medication, reason for its administration, possible side effects and benefits of the medication being delivered and document in the EHR ...”. During a review of the facility’s Policy and Procedure (P&P) titled, (P&P) titled, “Medications - Orders, Administration, Storage, Documentation”, dated 12/19/23, the P&P indicated, “PURPOSE: To provide guidelines for the same and accurate ordering, transcribing, labeling, administration, storage and documentation of medications ... B. Medication Administration ... 2. The following staff may administer certain medications within their scope of practice and as defined by unit/department ... b. Respiratory Care Practitioner ... 10. Respiratory Therapy Medications a. The respiratory medications will be administered per prescriber orders with the schedule of administration times ... 16. ... Routine respiratory inhaled medications are to be administered within 60 minutes of the scheduled time unless otherwise ordered by the prescriber ...VI. DOCUMENTATION: ... B. Document on MAR if medication was not given and notify provider ... E. Document the patient education was completed ...VII. PATIENT EDUCATION: A. Inform the patient and/or family of the name of the medication, reasons for its administration, potential side effects and any other pertinent (important) information ...”. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders”, dated 8/25/23, the P&P indicated, “ ...I. PURPOSE...C. To provide guidelines for the receipt, documentation, authentication and use of verbal or telephone orders ...III. POLICY ...M. ... acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order within the prescribed period ...”. 6. During a review of Patient 53’s “Electronic Health Record (EHR)” dated 3/8/24 to 3/14/24, the EHR indicated, Patient 53 arrived at the Emergency Department (ED) on 3/8/24 at 3:02 p.m. and was admitted to the hospital on 3/8/24 at 11:11 p.m., for Altered Mental Status (a change in the mental function that stems from illness, disorders and injuries that have affected the brain) and a Urinary Tract Infection (bladder infection that can cause mental changes or confusion). The EHR indicated that even though the patient was admitted, she remained in the Emergency Department (ED) and was never moved into an inpatient bed on a hospital unit. Patient 53 was in ED yellow-hallway bed 11 and ED north-hallway bed 11 during her stay. The EHR had a left banner (part of the screen that was always visible no matter where a staff navigated in the EHR) that never changed which indicated Patient 53 needed an interpreter in Mon Khmer (Cambodian Language) for written and spoken language. During a review of Patient 53’s “ED Timeline (EDT)”, dated 3/9/24, the EDT indicated, “ ...Acute Speech Language Pathology Swallow Assessment- Speech and Language Pathologist (SLP) 1 ... COGNITION/BASELINE SWALLOW: Patient Alert and cooperative, not able to answer orientation question ... Patient does not speak often, but can speak in her own language when she wants to ... Patient with a history of dementia (the loss of thinking, remembering, and reasoning, to such an extent that it interferes with a person’s daily life and activities) ... SPEECH/LANGUAGE/VOICE: Unable to fully assess, patient did not vocalize except on two instances when suspected to be expressing pain as Physical Therapy was extending her left leg. No dysarthria (when the muscles you use for speech are weak or you have difficulty controlling them) suspected, however not able to confirm with such limited utterances ... vocal quality clear. Is interpreter needed: Yes. ...What type: Phone ... Name: Phone Malfunctioning ...”. During a review of Patient 53’s “Nurses Note (NN)”, dated 3/11/24 at 10:44 p.m., the NN indicated, “ ...Assumed care of patient ... patient is Mon Khmer speaking. Family [family member name] at bedside to help with initial assessment. Patient has a Glasgow Coma Scale of 15. Alert and Oriented x1. Patient has no current complaints ... Patient reports no pain ... Patient verbalizes no needs at this time ...”. During a review of Patient 53’s “EDT”, dated 3/12/24, the EDT indicated, “ ...Bladder Scan (non-invasive ultrasound of the bladder)[greater than 583]. Medical Doctor called with telephone order to do in and out catheterization (Intermittent, or in and out, catheterization is a medical technique used to help empty the bladder. A catheter can be passed through the urethra, after which the bladder is emptied) ... Orders acknowledged: In and Out Catheterization ... In and Out Catheterization Volume: 600 mL (milliliters- unit of measurement) ...”. During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated Patient 53 was her patient during her day shift. RN 9 stated Patient 53 was non-verbal and would nod yes or no when she spoke to her in English. RN 9 stated she never used an interpreter because Patient 53 answered “yes or no to English”. RN 9 stated the Emergency Department (ED) hallway the patient was in was not safe for her due to her communication needs. RN 9 stated “she doesn’t even speak English like that, just yes or no”. RN 9 stated Patient 53 could not yell “help” if needed. RN 9 stated she never used a Cambodian Mon Khmer interpreter to communicate with the patient. During a concurrent observation on 3/14/24 at 3:15 p.m., with Patient 53 in the ED North Hall, hospital staff retrieved a portable iPad interpreter (portable electronic device where the interpreter was called from) per the request of Surveyor. Patient 53 smiled and waved. Patient 53 appeared to respond to the questions of the interpreter appropriately but spoke very softly. Patient 53 waited for the interpreter to stop talking and then she would answer. The hallway was noisy and the interpreter could not hear Patient 53 and the call was terminated due to the interpreter not able to hear. During an interview on 3/14/24 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the EHR banner indicated Patient 53 needed a Mon Khmer interpreter. LVN 3 stated she did not speak Mon Khmer and never used an interpreter for any of Patient 53’s care. LVN 3 stated Patient 53 could understand “a little English I think”. LVN 3 stated that was what she was told in nurse-to-nurse report. LVN 3 stated she had given Patient 53 medications, changed her brief and repositioned her and never used a Mon Khmer interpreter to communicate with her over the course of her shift. During an interview on 3/14/24 at 7 p.m., with Patient 53’s Family Member (FM) 1, FM 1 stated Patient 53 spoke Cambodian (Mon Khmer) only and did not speak or understand English. During a concurrent interview and record review on 3/21/24 at 3 p.m., with the Emergency Department Director (EDD), Resident 53’s “EHR”, dated 3/8/24 to 3/14/24 was reviewed. EDD stated the EHR indicated nursing staff never used an interpreter when communicating with Patient 53. EDD stated interpreters, when used with a patient, need to be charted. EDD stated per the EHR an in-person, video and/or audio interpreter was never used for Patient 53. EDD stated that if an interpreter were used it would have been charted in the “Interpretation Flowsheet” and there was nothing there. EDD stated not communicating with Patient 53 in Mon Khmer was unsafe for the patient and violated her rights as a patient. The EDD stated she had the right to be informed of every aspect of her care and she was not. During a review of Patient 53’s “Interpretation Flowsheet (IF)” dated 3/14/24 (after discharge), the IF indicated, “ ....Interpretation: Interpretation Type- [Blank] ....” During an interview on 3/25/24 at 11:35 a.m., with RN 21, RN 21 stated she was Patient 53’s nurse on 3/12/24 RN 21 stated she knew Patient 53 spoke Cambodian but she did not use a Cambodian interpreter because Patient 53 was “kind of” responding to English. RN 21 stated she performed the bladder scan and the in and out catheterization on Patient 53. RN 21 stated she explained the procedure to Patient 53 in “basic words for her to understand” in English. RN 21 stated she “felt like” Patient 53 knew what she was going to do. RN 21 stated Patient 53 said yes and smiled. RN 21 stated she was not a certified Cambodian interpreter and she never used a Cambodian interpreter to communicate with the patient for the bladder scan nor in and out catheterization. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated interpreters are vital to communication and meeting patients’ needs. The CNO stated if communication occurred without an interpreter in the language needed this would result in inadequate care given to the patient. The CNO stated with patient needs not met, this could result in harm to the patient and is a patient safety concern. The CNO stated that policy and procedure on interpreters was not followed by staff. During a review of the facility’s Policy and Procedure (P&P) titled, “Interpreters/Translation: Non-English/Limited English Proficient & Deaf/Hearing Impaired “, dated 8/10/23, the P&P indicated, “PURPOSE: A. To define the communication system that is used for patients who have Limited English Proficiency (LEP) ... B. To provide guidelines for coordinating timely response in meeting the assessed special language needs of individual patients ... C. To comply with Americans with Disabilities (ADA), Title VI of the Civil Rights Act of 1964 and Health and Safety Code of California ... 1. Health and Safety Code of California requires licensed general acute care hospitals to provide language assistance services to patients with language or communication barriers ... II. DEFINITIONS: A. Communication Barrier: Applies to a person who ... speaks another language that hinders communication ... F. Language Service Line: Language services are available via phone 24 hours a day, 7 days a week ... G. Non-English or LEP: Those individuals whose native language is other than English and who cannot speak, read, write or understand the English language at a level that permits them to interact effectively with health care providers ... III. POLICY: It is the policy of Community Medical Centers (CMC) to provide equal access to and equal participation in health care interactions for persons ... with LEP ... B. CMC recognizes that individuals must be able to communicate effectively with their health care providers in order to importation the quality of the information, the outcome of the patient encounter and to increase patient compliance and patient satisfaction of care and services ... C. It is the policy of CMC to use competent medical interpreters during ... treatment situations ... following modalities (methods): in-person, video and/or audio ... E. Staff shall verbally notify patients of their right to interpretation services available at no cost to them. F ... situations in which the presence of an interpreter ... is necessary to ensure thorough and accurate communication including “critical medical information” listed ... 1. Explaining a medical procedure or intervention ... 3. When explaining and describing medical conditions, tests, treatment options, medications ... 4. When providing a diagnosis, prognosis and recommendation for treatment ... 5. When providing instructions for medications ...follow-up treatments ... H. The patients primary language is to be noted in the patients EHR ... VI. DOCUMENTATION: ... E. The staff member documents the following information in the EHR upon concluding the interpreter session including when interpretation was provided by a family member: 1. Start date 2. Start time 3. End time 4. Language spoken 5. Interpreter session type 6. Interpretation provided ... F. Staff member documents the use of communication devices and adaptive equipment used ...”. During a review of the facility’s Policy and Procedure (P&P) titled, “Urinary Catheters, Indwelling and Intermittent- Adult & Adolescent “, dated 2/9/23, the P&P indicated, “PURPOSE: ... B. To implement the current evidence-based guidelines for the insertion, maintenance, removal and reinsertion of urinary catheters ... D. To define the roles and responsibilities of licensed personnel such as Registered Nurses (RN), Licensed Vocational Nurses (LVN) ... in regard to the maintenance of ... catheters ... E. To provide guidelines for monitoring a patient post urinary catheter removal, including direction on when catheter reinsertion should be considered ...II. DEFINITIONS: ...B. Intermittent (straight) Urinary Catheter: A drainage tube that is inserted in the bladder and removed as soon as urine is drained ... E. Bladder Scan Volume: A bladder scan volume measurement that is not linked to the timing of a patient’s void ... IV. POLICY: Alternatives to catheterization should be the first choice for all patients requiring bladder management. Examples of alternatives include: 1. Intermittent (straight) catheterization ... E. Bladder scans may be performed as indicated or needed (PRN) ... V. PROCEDURE: ... 4. ... b. Interpretation of bladder scan results, unless otherwise ordered by the provider: ... iii. If the scanned bladder volume is greater than 500 mL, the RN should contact provider and obtain an order for insertion of an indwelling urinary catheter. Leave the indwelling catheter in place if the output is confirmed to be greater than 500 mLs ... VII. PATIENT TEACHING: A. Provide [Hospital] approved on-line patient education materials ... refer to Frequently Asked Questions (FAQs) on the Patient/Family Education Forum for English and Spanish. 2. Provide patient education regarding the need for bladder scanning and what to expect ...”. Review of professional reference, “American Journal of Medicine- Interpreters in Health Care: A Concise Review for Clinicians”, dated April 2020, (found at https://www.sciencedirect.com/science/article/pii/S0002934320300127 ) indicated, “ ...Conclusion: It is our duty, both ethically and legally, to provide an environment where our patients can feel comfortable knowing they will be listened to and offered information in a language they can understand. The use of a well-trained health care interpreter is often the most important step in fulfilling this duty ...”. 7. During a review of Patient 5’s “EHR”, dated 2/15/24 to 2/29/24, the EHR indicated Patient 5 was admitted on 2/15/24 for septic shock (a life-threatening medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure). Patient 5 was eventually diagnosed with acute kidney injury (AKI- a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days. AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your body), uremia (occurs when urea and other waste products build up in the body because the kidneys are unable to eliminate them.), low urine output and was ordered hemodialysis ((a treatment for people whose kidneys are failing. Dialysis does the work of your kidneys, removing waste products and excess fluid from the blood). Patient 5 was not eating well during her hospital stay and Medical Doctor (MD) 2 decided to order enteral feeding (tube feed- a method of feeding that uses the gastrointestinal (GI- stomach) tract to deliver nutrition and calories) pump for her. Patient 5’s had a nasogastric tube (NG- a thin, soft tube that goes in through the nose, down the throat, and into the stomach) placed and the tube feed was started on 2/29/24 at 12 p.m. The patient had the tube feeding going when she went to hemodialysis. Shortly after the hemodialysis treatment ended, the patient had a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) and died. During a review of Patient 5’s “Tube Feed Flowsheet (TFF)” dated 2/29/24, the TFF indicated, “ ...Time: 12 p.m. ...Type of feeding: Continuous ... Continuous feeding rate: 20 mL ... Time: 2 p.m. ... Continuous feeding rate: 30 mL ...Time: 5:13 p.m. ...Other comment: Stopped due to low blood pressure during dialysis ...”. During a review of Patient 5’s “[Brand Name- Tube Feed] Pump Photos (KPP)”, with no date, the KPP indicated, pictures of the pump that was used for Patient 5’s tube feed. Pictures show the pump screen was damaged with pixelation missing in the middle of the pump. During a review of Hospital “IRIS Work Order”, dated 3/1/24, the IRIS indicated, “ ...[Brand Name] feeding pump ...Problem code: Equipment Failure ... Comments: Unit was sequestered (to remove or withdraw) this morning and investigated. Findings were a pixelated screen. Cannot see or determine the third hundreds number or middle of screen. The unit does not have any cracks and outer shell looks fine. During a review of instruction for use of “[Brand Name] Enteral Feed and Flush Pump (TFP)”, with no date, the TFP indicated, “ ...Selecting Continuous or Intermittent Feed Mode ... The continuous feeding mode will deliver the enteral nutrition at a steady rate, either until the programmed volume has been delivered or until the supply has been exhausted ...”. During an interview on 3/18/24 at 12 p.m., with the Intensive Care Unit Nurse Manager (NM), the NM stated she had investigated the tube feed “incident”. NM stated that when RN 25 programmed the pump to feed at 30 mL an hour, she programmed it as 300 mL an hour. NM stated she found that the pump used for the tube feed had a broken screen display and should not have been used. NM stated RN 25 should have replaced that pump with another one that was not broken. NM stated the use of the broken pump was “not appropriate”. During an interview on 3/22/24 at 1:45 p.m., with RN 26, RN 26 stated that she was Patient 5’s nurse when the patient came to her unit for a dialysis treatment. RN 26 stated she took report from RN 25 and Patient 5 came to dialysis with the tube feed still running. RN 26 stated she saw the tube feed was running “from afar”. RN 26 stated she never went to the pump and “actually looked at it”. During an interview on 3/22/24 at 3 p.m., with RN 25, RN 25 stated she received the order to start Patient 5’s tube feed and carried out that order at noon on 2/29/24. RN 25 stated she increased the tube feed to 30 ml at 2 p.m. RN 25 stated that when she programmed the pump to run at 30 mL the screen “was messed up” but felt she could still see the numbers well enough to go through with the programming. RN 25 stated she handed off Patient 5 to RN 26 for her hemodialysis treatment and the tube feed was still going. RN 25 stated she did not know the tube feed was running at 300 mL until another RN at the end of the code blue noticed a majority of the tube feed was gone and checked the pump settings. During an interview on 3/26/24 at 11 a.m., with MD 2, MD 2 stated he was told by Hospital Risk Management that a nurse used a defective pump for the tube feed for Patient 5. MD 2 stated it was “not easy to make a mistake on that pump, you need to press several times”. MD 2 stated he was aware of the mistake when he made the determination of Patient 5’s death and felt the mistake did not contribute to the death. MD 2 stated Patient 5 received 900 mL (milliliters- unit of measurement) over a three-hour span. MD 2 stated Patient 5 was supposed to receive 60 mL during that timeframe per his order. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated the defective pump should have never been used for patient care. CNO stated that pump should have been sequestered and not used. CNO stated the use of that broken pump put Patient 5’s safety at risk and could have caused patient harm. 8. During a concurrent observation and interview on 3/13/24 at 10:35 a.m., with Pt 35 in the Emergency Department (ED- a department in the hospital where people who have severe injuries or sudden illness are taken for emergency treatment) lobby, Pt 35 was observed sitting in a chair in the ED lobby without a cardiac monitor. Pt 35 stated on 3/12/24 he was having chest pain and discomfort in his chest and decided to come to the ED on 3/12/24. Pt 35 stated he continued to have chest pain and discomfort while he sat in the ED lobby. Pt 35 stated staff notified him his heart would be “monitored” but was unsure what monitored meant. Pt 35 stated he was not placed a cardiac monitor. Pt 35 stated, “ ... you would think they would keep a closer eye on me since I am here for chest pain ...” During a review of Pt 35’s “History and Physical (H&P)”, dated 3/13/24, the H&P indicated, Pt 35 came to the Emergency Department due to “ ...complaining of chest pain with shortness of breath and dizziness/lightheadedness for 3 days ...” During a concurrent interview and record review on 3/13/24 at 10:41 a.m. with the Emergency Department Manager (EDM), Pt 35’s “Cardiac Monitoring Order (CMO)”, dated 3/13/24 was reviewed. CMO indicated, “ ...Frequency: Continuous ...” EDM validated Pt 35 did not have cardiac monitoring while in the Emergency Department lobby. EDM stated Pt 35 should have been placed on a cardiac monitor to ensure Pt 35’s heart was monitored for cardiac arrhythmia. EDM stated the expectations was for the license nurses to follow physician’s order and hospital policies and procedures. During a concurrent interview and record review on 3/13/24 at 11:15 a.m. with RN 11 and the EDM, Pt 39’s CMO, dated 3/11/24 was reviewed. The CMO indicated, “ ...Indications for monitoring: New and/or potential for cardiac arrhythmia ...” RN 11 stated she was the licensed nurse assigned to Pt 39. RN 11 stated she did not review and document Pt 39’s cardiac monitoring strip and should have. EDM stated the expectation was for RN 11 to review and document Pt 39’s cardiac monitoring strip. EDM stated RN 11 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a concurrent interview and record review on 3/13/24 at 11:24 a.m. with RN 14 and the EDM, Pt 36’s CMO, dated 3/13/24, was reviewed. CMO indicated, “ ...Indications for monitoring: Critical illness [a state of health with vital organ dysfunction or high risk of death] or procedure standard of care for level of care ...” RN 14 stated she was responsible to review and document Pt 36’s cardiac monitoring strip but did not. EDM stated RN 14 should have reviewed and documented Pt 36’s cardiac monitor strip. EDM stated RN 14 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a concurrent interview and record review on 3/13/24 at 11:33 a.m. with RN 13 and the EDM, Pt 37’s CMO, dated 3/11/24, was reviewed. CMO indicated, “ ...Indications for monitoring: Significant risk of cardiac arrest [when the heart stop breathing] or respiratory arrest [absence of breathing] ...” RN 13 stated she was responsible to reviewed and documented Pt 37’s cardiac monitoring strip but did not. EDM stated RN 13 should have reviewed and documented Pt 37’s cardiac monitor reading. EDM stated RN 13 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a concurrent interview and record review on 3/13/24 at 11:43 a.m. with RN 12 and the EDM, Pt 38’s CMO, dated 3/12/24, was reviewed. The CMO indicated, “ ...Indications for monitoring: New and/or potential for cardiac arrhythmia ...” RN 12 stated she was responsible to review and document Pt 38’s cardiac monitoring strip but did not. The EDM stated RN 12 should have reviewed and documented Pt 38’s cardiac monitor strip. The EDM stated RN 12 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During an interview on 3/13/24 at 3:59 p.m. with RN 15 and the EDM, RN 15 stated Pt 46 had physician’s order for cardiac monitoring. RN 15 stated she was responsible to review and document Pt 46’s cardiac monitoring strip but did not. RN 15 stated she did not document because of short staffing. EDM stated RN 15 should have reviewed and documented Pt 46’s cardiac monitor strip. EDM stated RN 15 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders,” dated 08/25/23, the P&P indicated, “ ...The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ...”. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac and Remote Monitoring-Inpatients 14 and Older,” dated 04/14/2022, the P&P indicated, “ ...The assigned RN/designee is responsible for validating and documenting the patient’s rhythm ...The RN will date and sign the cardiac monitoring strip ... every 4 hours ...Routine Cardiac monitoring documentation includes the patient’s rate, rhythm ...This documentation will be a minimum of every 8 hours or by unit standard (4 hours in Emergency Department) in the Electronic Health Record ...”.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 47888 Based on observation, interview and record review the facility failed to ensure the patient rights for one of one patients (Patient 3), when Patient 3 was observed to have two different types of restraints on but not fastened to bed frame on his right side in accordance with hospital policy and procedure. This failure resulted in Patient 3’s rights being violated and his safety was put at risk with the potential for the patient to harm himself. Findings: During a review of Patient 3’s “Electronic Health Record (EHR)” dated 3/8/24 to 3/13/24, the EHR indicated, Patient 3 came to the Emergency Department (ED) via ambulance on 3/8/24 at 5:15 p.m. and was admitted on 3/9/24 to inpatient status at 2:05 a.m. for Altered Mental Status (AMS- a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted to inpatient status, he remained in an Emergency Department (ED) Green Zone Hallway bed for four days. Patient 3 got moved from that ED hallway bed to a medical floor on 3/13/24 at 3:55 p.m. The EHR indicated due to the patients AMS and interference with his medical treatment, his safety was at-risk and therefore placed in non-violent restraints (restraints that are used when a patient pulls at Intravenous [IV- in the vein] lines or tubes, removes equipment or dressings, and cannot respond to direct requests or follow instructions from staff) that started on 3/8/24. During a review of Patient 3’s “Restraints Non-Violent or Non-Self-Destructive Order (RNV)”, dated 3/13/24 at 7:42 a.m., the RNV indicated, “ ...Start date/time: 3/13/24 at 7:42 a.m. ... Frequency: continuous ... Restraint type: Vest/Jacket, Soft Restraint: Left Wrist, Right Wrist ... Restraint Reason: Interference with medical treatment ... Discontinued Order: 3/13/24 at 12:22 p.m. ...”. During an observation on 3/13/24 at 11:50 a.m., in the Emergency Department (ED) Green Zone bay Green Hallway room (GH)-04, Patient 3 was lying on a gurney with his eyes closed and right hand loose on his chest with left hand tied down to the frame of the gurney by restraints. Patient 3 had a Posey Vest (type of medical restraint that is on a patients torso, used to restrain a patient to a bed) and soft-wrist restraints (type of medical restraint used to restrain a patient to a bed) on that were laying loose and not tied to the gurney frame on his right side. Patient 3 appeared to be non-interviewable. During a concurrent observation and interview on 3/13/24 at 12 p.m., with the Emergency Department Director (EDD) in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. The EDD stated the restraints needed to be fastened to the bed frame and they were not on the patient’s right side. The EDD stated it was “dangerous” for the patient to not be restrained as Physician ordered, as he would be able to pull at his foley catheter (a tube that is inserted into your bladder, allowing your urine to drain freely) or IV line. During a concurrent observation and interview on 3/13/24 at 12:05 p.m., with the RN 22 in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. RN 22 stated Patient 3 still needed to be in restraints due to confusion, an attempt to get out of bed and was “pulling stuff off” (Patient 3 had IV and foley catheter). RN 22 stated she was unaware that the restraint was not fastened to the gurney until it was pointed out to her “just now”. RN 22 stated this was not safe for Patient 3 and he could have hurt himself. RN 22 stated it was “impossible” to assess all of her assigned patients on time because she had five other patients to care for. RN 22 said it was not safe for patients when she was responsible for 6 patients at a time because she could not get to her assessments on time. RN 22 stated the last time she assessed Patient 3 was 10 a.m. RN 22 stated she was supposed to do monitoring on Patient 3 every two hours. During an interview on 3/14/24 with the EDD, the EDD stated Patient 3 could harm himself with the restraint not being fastened to the bed frame on the right side. The EDD stated “we” did not follow the restraint policy. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated non-violent restraints are for the patient and staff to remain safe. CNO stated Patient 3 could have harmed himself because his right arm was free and the restraint was not fastened to the bed. CNO stated Patient 3’s safety was put at-risk and staff did not follow the policy and procedure (P&P) “Restraint and Seclusion”. During a review of the instruction for use “Posey Limb Holders- Application Instructions for Wrist and Ankle (PLH)”, dated 2023, the PLH indicated, “ ...Limb holder for limiting limb movement. For bed and stretcher use only. INDICATIONS FOR USE: Patients assessed to be at risk of disrupting life-saving treatments (e.g., pulling lines/tubes) or in danger to injury to themselves or to others. Follow your hospitals restraint policies and procedures which are in compliance with CMS (Centers for Medicare & Medicaid Services- federal agency that enforces rules in relation to high quality health care) guidelines and state laws ... APPLICATION INSTRUCTIONS: ...attach straps to frame ... to restrict patients range of motion ... attach at different points along the frame ... using quick-release ties ... ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...”. During a review of the instruction for use “Posey Criss-Cross Vests (PCCV)” dated 2009, the PCCV indicated, “ ...DESCRIPTION OF PRODUCT: A versatile vest with tie ends. For bed ...application ... INDICATIONS FOR USE: .... Patients requiring a positioning device to assist medical treatment ...APPLICATION INSTRUCTIONS: ... 3. Secure straps to the ... bed frame, out of the patients reach ... WARNING: Make sure straps cannot slide, loosen, or tighten if the patient pulls on them or if the patient bed ...is adjusted ...The patient may suffocate if the straps tighten. If the straps loosen, serious injury or death may occur from ... patient escape ... or suffocation if the patient becomes suspended in the restraint ...ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...”. During a review of the facility’s P&P titled, “Restraint and Seclusion”, dated 6/8/23, the P&P indicated, “I. PURPOSE: A. To provide a standardized process in the use of restraints ... while protecting and preserving patient rights, dignity, safety and well-being ... B. To meet and comply with regulatory requirement ... E. Non-Violent Restraint: Restraints applied to support the management of care when the patient is interfering with medical treatment and safety (not aggressive but attempting to remove essential lines or equipment that would put the patient at risk of harm) ... IV. PROCEDURE: A. Restraint Application 1. Restraint shall be applied/removed in accordance with the following: ... B. Restraints will be applied with safe and appropriate techniques. C. Restraint devices are to be applied/removed in accordance with manufacturer’s instructions and used in a manner consistent with their intended purpose. D. Restraints will be secured to the frame if being used while the patient is in bed ... E. Restraints shall be secured so that they may be released quickly in the event of an emergency. F. Restraint devices are to be applied/removed in a manner that preserves the dignity, comfort and well-being of the patient ... 6. ... D. NON-VIOLENT RESTRAINTS: 1. Restraints are utilized for the non-violent patient. Must have clinical justification to protect patient from unsafe situation (e.g. pulling at tubes/lines) ... 4. Non-violent restraints available ... a. soft restraints b. Posey vest ...”. During a review of Professional Reference, “American Nurses Association- The Ethical Use of Restraints: Balancing Dual Nursing Duties of Patient Safety and Personal Safety (ANA)”, dated 2020, (found at https://www.nursingworld.org/~48f80d/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/nursing-practice/restraints-position-statement.pdf) indicated, “ ...PURPOSE: ... Registered nurses are expected to balance dual nursing duties of patient safety and personal safety when using restraints ... Nurses promote and advocate for the protection of patients from harm and from the potential for harm that could result from the use of physical restraints. While patients may be restrained to prevent them from harming themselves or others, this practice could result in patient harm ... Therefore, nurses have an important role in creating a safe environment for patients ... When patients are at risk of harming themselves through interference with their treatment or through impaired mobility or cognitive function, nurses have a duty to act to promote patient safety when critical safety issues that cannot be resolved with other methods place patients at risk of harming themselves. Accountability and responsibility for making nursing judgments, decisions, and taking action to provide a safe patient care environment is expressed ... Patient Safety: ... Monitor the appropriate use of restraints through mechanisms such as a multidisciplinary restraints committee and restraints rounds ... nurses should respect and uphold the autonomy and inherent dignity, and human rights of all individuals involved. Nurses must be aware of and balance a patient’s right to self-determination with the health and welfare rights of those in the clinical setting ...”.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 45977 Based on interview and record review, the hospital’s Quality Assurance Performance Improvement (QAPI) program failed to use data in high-risk, high-volume and problem-prone areas such as the Emergency Department (ED) and Medical-Surgical units to identify opportunities for improvement and implement changes that will lead to improvement. These failures resulted in a delay in implementing improvement measures that could affect health outcomes and patient safety. Findings: During a concurrent interview and record review on 3/25/24 at 3:10 p.m., with Director of Quality Outcomes (QD) and Risk Manager Director, (RM), the hospital’s policy and procedure (P&P) “Adverse Event Reporting to the California Department of Health Services”, dated 1/3/22, “Sentinel Event & Unusual Occurrence,” dated 12/17/21, and “CCMC Performance Excellence Plan - Fiscal Year 2024”, undated, were reviewed. The RM and QD discussed during the interview the process of determining what patient events qualify for a Root Cause Analysis (RCA). The RM and QD stated, the hospital currently does not an active performance improvement plan from any active RCAs. The RM stated, she follows the policy, “Sentinel Event and Unusual Occurrence” for determining Root Cause Analysis (RCA) recommendations and if a reported event fits the list of sentinel events, then the information is forwarded to leadership and they determine if a RCA is required. The RM stated, she firsts investigates a reported event after reviewing the electronic reports, or phone calls from staff and then discusses the event with the managers and directors of the unit involved. Then she fills out a form and submits it to it to leadership. The RM stated, if leadership decides no RCA is needed, then the directors and managers will follow up with investigating the event. The RM stated, no RCA’s have been done since September of 2023. The RM stated, a RCA will be initiated for Patient 5 (PT 5) (Patient was admitted on 3/13/24 and expired on 3/13/13 due to the malfunctioning equipment.). The QD stated, the quality management staff meet with different departments every week to review metrics, electronic reports, and complaints/grievances to determine projects for performance improvement. The QD stated, if unusual occurrences or deaths would come in these discussions, then the information could be forwarded to leadership for a possible RCA. The QD stated, she could not recall any RCA’s being initiated as result of meeting with the different departments. The RM and QD stated, deaths are not reviewed routinely and RCAs are not done about routine deaths, only those involved in a sentinel event. During concurrent interviews and record review, on 3/26/24, at 11:00 a.m., with members of CCMC (Clovis Community Medical Center) Practice & Compliance Committee (PCC) including the Chief Executive Officer (CEO), the Senior VP/Chief Clinical & Operations Officer (SCNO), the Chief Medical Officer (CMO), the Chief Nursing Officer (CNO), the Director of Inpatient Services (DIS), the Emergency Department Director (EDD), the ED MD Medical Director (EDDIR), the RM, and the QD, the Quality Assessment and Performance Improvement (QAPI) plan for the year, “CCMC Performance Excellence Plan - Fiscal Year 2024,” not dated, was reviewed. a. The RM stated: 1) PT 5 (admitted on 2/15/24 and patient expired on 2/29/24 in the dialysis unit, related to an equipment malfunction) was reported on 2/29/24 to California Department of Public Health (CDPH) and RCA will be done for that case. 2) The RM stated, PT 6 (admitted with preeclampsia (condition during pregnancy marked by high blood pressure, fluid retention and protein in urine) on 2/9/24, with a history of diabetes mellitus (body unable to produce or respond to insulin resulting in elevated blood sugars) who’s hospital course was complicated by a medication error resulting in a large dose of insulin administered) was reported to CDPH and RCA is in progress. 3) PT 1 (admitted to inpatient on 12/13/23, remained in ED for 3 days prior to obtaining an inpatient bed and developed a pressure ulcer (skin breakdown)) and PT 2 (admitted to inpatient on 2/29/24, remained in ED for three days prior to obtaining an inpatient and deep tissue injury (form of pressure injury) were discovered during survey and no RCAs have been decided yet. 4) PT 33 (presented to ED on 3/13/24 and who expired on 3/13/24 in the ED) was discovered during survey and are reviewing at this time. 5) The hospital is aware of the events related to PT 1, PT 2, PT 33, PT 5 and PT 6. RM stated, no RCAs have been completed on any of these patients and the factors that lead to injuries for each patient has not been determined. The RM stated, no performance improvement activities have been started related to the factors that lead to the harm of these patients. b. The EDD stated, the volume of patients in the ED and the complexity of the patients has resulted in a high risk and a high volume situation. The EDD stated, no performance project to the determine factors for high risk and high volume of patients in the EDD has been conducted and no analysis of the data to improve the situation has been done. The EDD stated, the hospital has been beyond capacity with 60 “admits holds” (patients admitted to inpatient status but remaining in the ED due to lack of beds) today but we have had over 100 admit holds over the last six months several times. The EDD stated, for the month of December, we averaged above 100 admit holds every day. c. The DIS stated, the organization has a huddle every morning, Monday through Friday, with over 240 supervisors/staff that includes all departments of the organization and the meeting is conducted virtually. The DIS stated, the purpose of the huddle is to review incidents and issues for the last 24 hours and there is a discussion about safety issues and what needs further investigation. The DIS stated, the event that occurred with PT 5 was brought up at the meeting, which lead to a RCA being decided. The DIS stated, for the recent decision about starting a RCA this month, the organization leadership spent many hours investigating what occurred before deciding on starting a RCA. The DIS stated, deaths are not usually reviewed routinely unless a sentinel event or unusual occurrence is suspected and then a decision about a RCA would occur. d. The EDDIR stated, deaths related to sepsis (a serious condition in which the body responds improperly to an infection) is a core measure for the hospital and much work has been done in the Emergency Medicine Committee but other deaths are not reviewed. When asked about other deaths that occur, the EDDIR stated, there are missed opportunities to investigate and review routine deaths related to patient safety and quality of care. e. The CNO stated, currently the second tower, 5th floor (30 inpatient beds) is not staffed for inpatient use, The CNO stated, in order to open the new unit, we decided to keep patients in the ED on admit hold until we have a enough “core” (meaning staff employed by the hospital and not contracted staff) staff on the new unit hired. The CNO stated, previously when we had opened the new units in the new tower to alleviate the ED census, the unit was full of patients and the community discovered we had capacity in the ED and our ED was beyond capacity again. The CNO stated, for the last unit that is empty now, we have a new manager that is hiring “core” staff before we open the unit and admit patients. The CNO stated, this decision should have been made to handle capacity and the increased volume of patients. The CNO stated, the minutes of the CCMC PCC meetings may have reflected the issue of growth and capacity. The CNO stated, the decisions and analysis about recruiting new staffing and opening the new units were not in the minutes. During concurrent record review and interviews, on 3/26/23, at 3:00 p.m., with the Board of Trustees, including the Chari of the Board, 2 Board Members (BM 1 and BM 2), the Chief Operating Officer (COO), the VP of Operations, the CNO, the SCNO, CMO, the Director of Quality, the Vice President of Quality, the system CMO, the System Chief of Human Resources, and the System Executive Vice President/Chief Operating Officer, the minutes of the Board of Trustees was reviewed. a. The BM 2 stated. “We are embarrassed that we have a wing closed and have patients admitted downstairs.” The BM 2 stated, we are feeling overwhelmed and realizing that this is an issue that we have to take care of. The BM 2 stated, with the closure of [Name] in the community, we had to absorb patients and we are trying to adapt to it. b. The SCNO stated, we did not anticipate the increase in traveler nurses (contracted nurses, usually from other states) rates and it is too expensive. The SCNO stated, we have decided to increase nurse staff by hiring from schools and new students and this strategy will decrease the turnover rate with increased vesting in the organization over 2 to 3 years. During a review of the hospital document titled, “CCMC Practice & Compliance Committee - Minutes,” dated 9/7/2023, 10/2/2023, 11/2/2023, 1/4/24 and 2/1/24, the meeting minutes did not identify any Root Cause Analysis’s (RCA) or other Performance Improvement (PI) projects for addressing ongoing problems related to increased census, capacity and/or increase in admit holds in the ED. During a review of the hospital document titled ,”CCMC Emergency Medicine Committee Minutes,” dated 9/13/2023, and 12/13/23, the meeting minutes did not identify any Root Cause Analysis’s (RCA) or other Performance Improvement (PI) projects for addressing ongoing problems related to increased census, capacity and/or increase in admit holds in the ED. During a review of the hospital document titled, “CCMC Medical Executive Committee Minutes,” dated 9/14/2023, and 10/12/23, 11/9/23, and 12/14/23. the meeting minutes did not identify any Root Cause Analysis’s (RCA) or other Performance Improvement (PI) projects for addressing ongoing problems related to increased census, capacity and/or increase in admit holds in the ED. During a record review of the hospital document titled, “CCMC Performance Excellence Plan - Fiscal Year 2024”, undated, the plan indicated, “ ...[Name] aims to deliver exceptional healthcare to our patients through staff engagement, a commitment to continuous improvement, and performance excellence. ... A. Commitment to achieving zero preventable harm, fostering the culture of safety, and incorporating highly effective process improvement methodologies that advance [Name] towards a high reliability organization. ... E. Reliance on validated analytical metrics to monitor and direct quality and patient safety performance improvement endeavors. ... Professional Affairs and Quality Committee PAQC ... Ultimate responsibility for Hospital and Medical Staff quality and safety. ... Provides oversight of all quality and safety related functions and activities. ... Medical Executive Committee MEC ... Oversight of Credentialing, Peer Review and ultimately all other patient care quality and safety functions as delegated by the BOT [Board of Trustees]. ... Practice and Compliance Committees ... Regulatory Compliance monitoring and reporting, Tracer report monitoring. QAPI monitoring. Focused forum to collaborate with CCMC leaders on quality review and performance improvement. ... An RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process gives you a way to identify system vulnerabilities so that they can be eliminated or mitigated. The purpose is to find out what happened, why it happened, and determine what changes need to be made. ... The process is not to be used to focus on or address individual performance, since individual performance is a symptom of larger systems-based issues. Identify adjacency for system-wide impact. ... The most important step is the identification of actions to eliminate or control system hazards or vulnerabilities identified in the causal statements. ... Identification and implementation of sustainable systems-based improvements that make patient care safer in settings across the continuum of care. ... Teams should strive to identify stronger actions that prevent the event from recurring and, if that is not possible, reduce the likelihood that it will occur or that the severity or consequences are reduced if it should recur. ... “ During a review of the facility’s policy and procedure (P&P) titled, “Sentinel Event & Unusual Occurrence,” dated 12/17/21, the P&P indicated, “...A. Identifying and Reporting of Events Procedure ... 1. All events which are considered reportable as defined by this policy are reported to the supervisor/manager immediately by involved staff. ... 2. The supervisor/manager investigates the event and contacts the Patient Safety/Risk Manager on-call at (559) 779-6634 when a sentinel event/unusual occurrence is suspected. The supervisor/manager also contacts the department director, administrative officer on-call after 5:00 p.m., and the facility Assistant Chief Nursing Officer (ACNO). ... 3. An Incident Reporting Intranet System (IRIS) form is completed within 24 hours. (Refer to Incident Reporting Intranet System (IRIS) policy). ... 4. The Patient Safety/Risk Manager initiates a formal investigation of the reported event ... a. The Patient Safety/ Risk Manager notifies Legal Services, the Corporate Risk Management Officer, Facility ACNO, and other support staff as appropriate within 24 hours of awareness of the event and prior to reporting to CDPH [California Department of Public Health]. ... b. Upon completion of the investigation, the Patient Safety/Risk Manager contacts Legal Services, System Chief Medical Officer, Facility Leadership, and the Director of Risk Management for final review and determination of notification requirements. ... c. If the event is deemed reportable, Risk Management personnel follow defined time lines for notification to the appropriate agency. As appropriate, Risk Management also informs the following of the sentinel event/unusual occurrence: i. Quality Council ... ii. Medical Staff departments ... iii. Professional Affairs and Quality Committee (PAQC) of the Board ... 5. If the event does not fit the definition of a sentinel event, adverse event or an unusual occurrence, the notification form is routed in the standard process described in the Incident Reporting Intranet System (IRIS) policy within 24 hours. ... B. Investigation of Events ... 1. It is the responsibility of Risk Management to coordinate the initial investigation and support the root cause analysis or other approved investigative process within the framework of Quality Council and facility Quality Patient Safety Committees (QPSC). The investigation is conducted for the purpose of evaluation for reporting purposes under this policy and improvement of the quality of care in the hospital and as such is afforded the protections of California Evidence Code §1157. ... 2. A thorough and credible Root Cause analysis is completed on all sentinel events and unusual occurrences. ... 3. Risk Management identifies a team and directs and facilitates the process of conducting a root cause analysis. ... 4. The root cause analysis must be completed within 45 business days of the known occurrence of the event. ...” A Review of the U.S. Department of Veteran Affairs, VHA National Center for Patient Safety, “Root Cause Analysis,” located at https://www.patientsafety.va.gov/professionals/onthejob/rca.asp , indicated “ ... a multi-disciplinary team approach, known as Root Cause Analysis - RCA - to study health care-related adverse events and close calls. The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. ... RCA teams investigate how well patient care systems function. We focus on the “how” and the “why” ? not on the “who”. Through the application of Human Factors Engineering (HFE) approaches, we aim to support human performance. ... The goal of an RCA is to find out: ...What happened ...Why did it happen ... How to prevent it from happening again. ... The RCA process is: ... Inter-disciplinary, involving experts from the frontline services ... Involving of those who are the most familiar with the situation ... Continually digging deeper by asking why, why, why at each level of cause and effect. ... A process that identifies changes that need to be made to systems ... A process that is as impartial as possible ...” A Review of the Agency for Healthcare Research and Quality -Patient Safety Network, “Patient Safety 101 - Root Cause Analysis”, located https://psnet.ahrq.gov/primer/root-cause-analysis indicated, “ ... Root cause analysis (RCA) is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify both active errors (errors occurring at the point of interface between humans and a complex system) and latent errors (the hidden problems within health care systems that contribute to adverse events). It is one of the most widely used retrospective methods for detecting safety hazards. ... RCAs should generally follow a prespecified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors). ... The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events. ... “”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 45977 Based on interview and record review, the facility failed to follow the hospital policy and procedure titled “Employee License/Certificate” when one of seven sampled staff (Registered Nurse [RN] 17) who worked in the facility’s float pool (staff who move around between different units and departments to meet staffing needs) did not complete the required biannual skills validation training (process of assessing, verifying, and documenting an individual’s competencies in a specific area) for Advanced cardiac life support (ACLS - a course designed to equip healthcare providers with the skills and knowledge needed to respond effectively to medical emergencies). This failure had the potential for RN 17 to be unprepared to handle emergency situations and had the potential to result in patient harm due to lack of staff training in the management of patients with medical emergencies. Findings: During a concurrent interview and record review on 3/20/2024 at 3:20 p.m. with Nurse Manager of Centralized Float Pool (NM 1), Registered Nurse (RN) 17’s personnel file was reviewed. RN 17 was hired on March 9, 2021 and had been oriented to his current position in the float pool on April 2023. A document titled, “Advanced Cardiac Life Support”, no date, indicated RN 17’s ACLS certification was expired as of July 2023 and was not current. NM 1 stated, RN 17 had worked earlier this week in the Emergency Department (ED) and per the policy, RN 17 should have a current ACLS training. NM 1 stated, RN 17 has been suspended until he has obtained the training. During a review of RN 17’s personnel file, a document titled, “Clinical Nurse 1 - Job Description”, dated November 8, 2023, indicated, “ ... Additional Certification Requirements ... Adult Cardiac Life Support {ACLS} certification must be obtained within 6 months of hire or transfer into job for the following departments: ... 04-87301 Centralized Flex Staffing, 04-87302 Centralized Float ... 01-87300 Nurse Float-PR Only. “”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49884 Based on interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital’s policies and procedures (P&P), when: 1. Two of four sampled hospital patients on restraints (Patient (Pt) 24 and Pt 3), Pt 24 did not have restraint monitoring documentation by nursing staff and Pt 3’s restraints was not fastened to the bed per policy and procedure. These failures had the potential for Pt 24 and Pt 3 to receive injuries and not have their needs met. 2. Six of 25 hospital patients (Pt 35, Pt 39, Pt 36, Pt 37, Pt 38, and Pt 46) sampled from the emergency department (ED) had orders for Cardiac Monitoring (a device used to monitor the electrical activity of the heart to ensure it is working normally) and one of the six Pt 35 had no cardiac monitor on and the other five patients did not have cardiac monitoring strips (the record of the electrical activity of the heart) reviewed and documented in there electronic health records (EHR). These failures put Pt 35 at risk of having a cardiac event that could cause injury if not death without monitoring and placed the other five patients at risk of having an irregular rhythm that would be missing and cause injury or death to the patient. 3. Four of 25 hospital patients (Pt 4, Pt 36, Pt 37, and Pt 56) sampled from the ED, when Pt 4, Pt 36, Pt 37, and Pt 56 were not administered nebulizer treatments (a drug used to relax breathing muscles and permits air to flow more easily in and out of the lungs) as ordered by the physician. These failures resulted in Pt 4, Pt 36, Pt 37, and Pt 56 not receiving nebulizer treatments which could potentially place Pt 4, Pt 36, Pt 37, and Pt 56 at risk for respiratory failure (a life-threatening medical condition that occurs when a person stops breathing). 4. Two of four hospital patients (Pt 5 and Pt 8) were not properly assessed and vital signs (SpO2- oxygen levels) were not monitored per policy and procedure. This failure resulted in delay in care where Pt 5 ultimately coded and died. 5. Four of four hospital patients (Pt 1, Pt 8, Pt 4, and Pt 55) sampled were given pain medication and the hospital failed to follow pain management services consistent with professional standards of practice and hospital policies and procedures when: Pt 1 numeric pain scale (a pain screening tool used to assess pain severity 0 no pain, one-three mild pain, four-six moderate pain, seven-nine severe pain, 10 worst pain) was assessed at eight out of 10 and Licensed Vocational Nurse (LVN) 2 administered Oxycodone 24 milligrams (mg-a unit of measurement) ordered for moderate pain and did not notify the physician to obtain pain medication appropriate for Pt 1’s assessed level of pain; Pt 4, Pt 8, and Pt 55 were given pain medication and pain reassessments were not completed by nursing staff. These failures resulted in Pt 1 having experienced severe pain from 3/9/24 to 3/23/24 which could have negatively affected Pt 1’s physical, emotional, and psychosocial well-being and placed Pt 8, Pt 4, and Pt 55 at risk of not having their pain addressed appropriately and having negative side effects from pain medication i.e., low oxygen levels, low blood pressure since after the first dose of narcotics Pt 8’s oxygen saturations dropped. Findings: 1. During a concurrent interview and record review on 3/14/24 at 11:55 a.m., with Medical Surgical Manager (MSM). Patient 24’s (Pt 24’s) “Hospitalist History and Physical (H&P)”, dated 3/14/24 was reviewed. The “H&P” indicated Pt 24 was brought in by ambulance from long term care facility. H&P indicated, Pt 24 had past medical history of basal ganglia hemorrhage stroke (blood leaked from a burst, torn or unstable blood vessel into brain tissue, The blood increased pressure on brain cells and damaged them.) with left sided residual defects. (partial weakness on left side of body) H&P indicated present history of agitation. During an interview on 3/19/24 at 9:40 a.m. with Emergency Department Manager (EDM), EDM stated monitoring patients on restraints is important to ensure patient safety. EDM stated, nurses should check skin under restraints for breakdown. EDM stated, nurses should monitor restraints to determine if they are still necessary for the safety of the patient. EDM stated it was her expectation that nurses were monitoring patients and documenting the monitoring for patients on restraints. EDM stated, it was her expectation for nurses to follow policy. During a concurrent interview and record review on 3/19/24 at 2:19 p.m. with Clinical Supervisor Emergency Department (CS 1), Pt 24’s “Restraint Documentation Flowsheet (RDF)” dated 3/14/24 from 2:00 p.m. to 3/15/24 at 12:00 p.m. was reviewed. The “RDF” indicated, non-violent restrains: Q 2 (every two hours) monitoring was not completed by nursing staff from 5:00 a.m. to 8:00 a.m. CNS stated, no monitoring was documented from 6:00 a.m. to 7:00 a.m. CN 1 stated his expectation was restraint monitoring was completed every two hours per policy. CN 1 stated restraint monitoring was important for the safety of patients and should be completed every two hours per policy. During an interview on 3/20/24 at 11:35 a.m. with Registered Nurse 6 (RN 6), RN 6 stated, nurses are required to do visual check on patients in restraints. RN 6 stated nurses supposed to assess the skin under the restraint area, check circulation, offer water, and food for restrained patients. RN stated monitoring for nonviolent restraints is every two hours. RN 6 stated monitoring the patient on restraints is importing for their safety. RN 6 stated, nurses must document the information when completed. During a During a concurrent interview and record review on 3/22/24 at 9:45 a.m. with CS 1, Pt 24’s “Non-Violent Restraint Order 403094748 (NVRO)” dated 3/9/24 at 7:07 p.m. was reviewed. The “NVRO” indicated, Pt 24 had right, and left soft wrist restraints applied due to interference with medical treatment. CS 1 stated, interference with medical treatment is indicated when patients were pulling at intravenous lines (through a needle or tube inserted into a vein). During a During a concurrent interview and record review on 3/19/24 at 9:51 a.m. with CS 1, Patient 24’s “NVRO number 403084758 (NVRO)” dated 3/10/24 at 12:45 a.m. was reviewed. The “NVRO indicated, Pt 24 had right, and left soft wrist restraints, and right and left ankle soft restraints, applied due to interference with medical treatment. CS 1 stated, “NVRO” was a modification of previous order to add ankle restraints. CS 1 stated, “NVRO” reason was interference with medical treatment. CS 1 stated, patient need for ankle restraints could be that patients could move legs and feet up to area where medical equipment is and hurt themselves. During a During a concurrent interview and record review on 3/19/24 at 9:55 a.m. with CS 1, Pt 24’s “NVRO Number 403636987 (NVRO)” dated 3/16/24 at 9:02 a.m. was reviewed. The “NVRO” indicated, restraint order, of right, and left soft wrist restraints, applied due to interference with medical treatment. The CS 1 stated “NVRO” indicated, Pt 24’s order was a modification from previous restraint order, ankle restraints were removed. CS 1 stated order was discontinued 3/17/24 at 11:22 a.m. During a concurrent interview and record review on 3/26/24 at 8:35 a.m. with Medical Surgical Manager (MSM), Pt 24’s “RDF” dated 3/14/24 from 2:00 p.m. to 3/15/24 at 12:00 p.m. was reviewed. The “RDF” indicated, non-violent restrains: Q 2 (every two hours) monitoring was not completed by nursing staff from 5:00 a.m. to 8:00 a.m. MSM stated there was an 6:00a.m. to 7:00 documentation missing for this patient. MSM stated when nurses were not monitoring patient in restraints, they may get an injury to the restraint area. MSM stated, if a patient was not being assessed and monitored every two hours patients would not be able to eat, drink or use the bathroom. MSM stated it was her expectation that nurses monitor patients in restraints. MSM stated, it was her expectation that nurses document all their restraint monitor checks. MSM stated, it was her expectation that nurses follow policy regarding restraints. During a concurrent interview and record review on 3/26/24 at 8:45 a.m. with MSM, The facility’s policy and procedure (P&P) titled “Restraint and Seclusion” dated 6/8/23 was reviewed. The P&P indicated, ... “E. Non-Violent Restraint: ...when the patient is interfering with medical treatment and safety ... (but attempting to remove essential lines or equipment would put the patient at risk of harm) .... IV. Procedure ... D. ... 5. Initial Assessment Requirements: a. RN to document clinical indication for restraint ... 6. Ongoing Assessment Requirements: ... b. Assessment ... i. Frequency - at least every two hours ... I. Visual check II. Patient’s circulation. III. Patient’s level of agitation. IV. Skin assessment for injury at site of restraint. V. Patient’s general care ... eating, hydration/fluids, toileting ... VI. Less restrictive restraint alternatives attempted ... 7. Discontinuation Requirements ... a. Restraint must be discontinued at the earliest possible time ... V. Documentation ...A. 5. Individual patient monitoring, assessments, and reassessments.” During a review of Patient 3’s “Electronic Health Record (EHR)” dated 3/8/24 to 3/13/24, the EHR indicated, Patient 3 was admitted on 3/9/24 for Altered Mental Status (AMS- a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted, he remained in the Emergency Department (ED) Green Zone Hallway bed. The EHR indicated due to the patients AMS and interference with his medical treatment, his safety was at-risk and therefore placed in non-violent restraints that started on 3/8/24. During an observation on 3/13/24 at 11:50 a.m., in the Emergency Department (ED) Green Zone bay Green Hall (GH)-04 (room number), Patient 3 was lying on a gurney with his right hand loose on his chest and left hand tied down to the frame of the gurney by restraints. Patient 3 had a Posey Vest (type of medical restraint that is on a patient’s torso, used to restrain a patient to a bed) and soft-wrist restraints (type of medical restraint used to restrain a patient to a bed) on that were not secured to the gurney frame on his right side. During a concurrent observation and interview on 3/13/24 at 12 p.m., with the Emergency Department Director (EDD) in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. The EDD stated the restraints needed to be fastened to the bed frame and they were not on the patient’s right side. The EDD stated it was dangerous for the patient to not be restrained as Physician ordered. During a concurrent observation and interview on 3/13/24 at 12:05 p.m., with the Registered Nurse (RN) 22 in the ED Green Zone at Patient 3 Hall bed GH-04, Patient 3 restraints were not secured to the gurney frame. RN 22 stated Patient 3 still needed to be in restraints due to confusion, an attempt to get out of bed and was “pulling stuff off”. RN 22 stated she was unaware that the restraint was not fastened to the gurney until it was pointed out to her “just now”. RN 22 stated this was not safe for Patient 3 and he could have hurt himself. RN 22 stated it was “impossible” to assess all of her patients on time because she was out of ratio with 6 patients for the day. RN 22 said it was not safe for patients when she was responsible for 6 patients at a time. During an interview on 3/14/24 with the EDD, the EDD stated Patient 3 could harm himself with the restraint not being fastened to the bed frame on the right side. The EDD stated “we” did not follow the restraint policy. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated non-violent restraints are for the patient and staff to remain safe. CNO stated Patient 3 could have harmed himself because his right arm was free, and the restraint was not fastened to the bed. CNO stated Patient 3’s safety was put at-risk, and staff did not follow the policy and procedure (P&P) “Restraint and Seclusion”. During a review of the instruction for use “Posey Limb Holders- Application Instructions for Wrist and Ankle (PLH)”, dated 2023, the PLH indicated, “ ...Limb holder for limiting limb movement. For bed and stretcher use only. INDICATIONS FOR USE: Patients assessed to be at risk of disrupting life-saving treatments (e.g., pulling lines/tubes) or in danger to injury to themselves or to others. Follow your hospitals restraint policies and procedures which are in compliance with CMS (Centers for Medicare & Medicaid Services- federal agency that enforces rules in relation to high quality health care) guidelines and state laws ... APPLICATION INSTRUCTIONS: ...attach straps to frame ... to restrict patients range of motion ... attach at different points along the frame ... using quick-release ties ... ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...”. During a review of the instruction for use “Posey Criss-Cross Vests (PCCV)” dated 2009, the PCCV indicated, “ ...DESCRIPTION OF PRODUCT: A versatile vest with tie ends. For bed ...application ... INDICATIONS FOR USE: .... Patients requiring a positioning device to assist medical treatment ...APPLICATION INSTRUCTIONS: ... 3. Secure straps to the ... bed frame, out of the patients reach ... WARNING: Make sure straps cannot slide, loosen, or tighten if the patient pulls on them or if the patient bed ...is adjusted ...The patient may suffocate if the straps tighten. If the straps loosen, serious injury or death may occur from ... patient escape ... or suffocation if the patient becomes suspended in the restraint ...ADDITIONAL WARNINGS: 1. Improper application or use of any restraint may result in serious injury or death ... Be aware that constant monitoring may be required ...ALWAYS secure straps to a part of the frame that moves with the patient, out of the patients reach ...”. During a review of the facility’s P&P titled, “Restraint and Seclusion”, dated 6/8/23, the P&P indicated, “I. PURPOSE: A. To provide a standardized process in the use of restraints ... while protecting and preserving patient rights, dignity, safety, and well-being ... B. To meet and comply with regulatory requirement ... E. Non-Violent Restraint: Restraints applied to support the management of care when the patient is interfering with medical treatment and safety (not aggressive but attempting to remove essential lines or equipment that would put the patient at risk of harm) ... IV. PROCEDURE: A. Restraint Application 1. Restraint shall be applied/removed in accordance with the following: ... B. Restraints will be applied with safe and appropriate techniques. C. Restraint devices are to be applied/removed in accordance with manufacturer’s instructions and used in a manner consistent with their intended purpose. D. Restraints will be secured to the frame if being used while the patient is in bed ... E. Restraints shall be secured so that they may be released quickly in the event of an emergency. F. Restraint devices are to be applied/removed in a manner that preserves the dignity, comfort, and well-being of the patient ... 6. ... D. NON-VIOLENT RESTRAINTS: 1. Restraints are utilized for the non-violent patient. Must have clinical justification to protect patient from unsafe situation (e.g., pulling at tubes/lines) ... 4. Non-violent restraints available ... a. soft restraints b. Posey vest ...”. 2. During a concurrent observation and interview on 3/13/2024 at 10:35 a.m., with Pt 35 in the Emergency Department (ED- a department in the hospital where people who have severe injuries or sudden illness are taken for emergency treatment) lobby, Pt 35 was observed sitting in a chair in the ED lobby without a cardiac monitor. Pt 35 stated on 3/12/24 he was having chest pain and discomfort in his chest and decided to come to the ED on 3/12/24. Pt 35 stated he continued to have chest pain and discomfort while he sat in the ED lobby. Pt 35 stated staff notified him his heart would be “monitored” but was unsure what monitored meant. Pt 35 stated he was not placed a cardiac monitor. Pt 35 stated “ ... you would think they would keep a close on eye on me since I am here for chest pain ...” During a review of Pt 35’s “History and Physical (H&P)”, dated 3/13/2024, the H&P indicated, Pt 35 came to the Emergency Department due to “ ...complaining of chest pain with shortness of breath and dizziness/lightheadedness for 3 days ...” During a concurrent interview and record review on 3/13/24 at 10:41 a.m. with the Emergency Department Manager (EDM), Pt 35’s “Cardiac Monitoring Order (CMO)”, dated 3/13/24 was reviewed. The CMO indicated, “ ...Frequency: Continuous ...” The EDM validated Pt 35 did not have cardiac monitoring while in the Emergency Department lobby. The EDM stated Pt 35 should have been placed in a cardiac monitor to ensure Pt 35’s heart was monitored for cardiac arrhythmia. The EDM stated the expectations was for the license nurses to follow physician’s order and hospital policies and procedures. During a concurrent interview and record review on 3/13/24 at 11:15 a.m. with RN 11 and the EDM, Pt 39’s CMO, dated 3/11/24 was reviewed. The CMO indicated, “ ...Indications for monitoring: New and/or potential for cardiac arrhythmia ...” RN 11 stated she was the licensed nurse assigned to Pt 39. RN 11 stated she did not review and document Pt 39’s cardiac monitoring strip and should have. The EDM stated the expectation was for RN 11 to review and document Pt 39’s cardiac monitoring strip. The EDM stated RN 11 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a concurrent interview and record review on 3/13/24 at 11:24 a.m. with RN 14 and the EDM, Pt 36’s CMO, dated 3/13/24, was reviewed. The CMO indicated, “ ...Indications for monitoring: Critical illness [a state of health with vital organ dysfunction or high risk of death] or procedure standard of care for level of care ...” RN 14 stated she was responsible to review and document Pt 36’s cardiac monitoring strip but did not. The EDM stated RN 14 should have reviewed and documented Pt 36’s cardiac monitor strip. The EDM stated RN 14 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a concurrent interview and record review on 3/13/24 at 11:33 a.m. with RN 13 and the EDM, Pt 37’s CMO, dated 3/11/24, was reviewed. The CMO indicated, “ ...Indications for monitoring: Significant risk of cardiac arrest [when the heart stop breathing] or respiratory arrest [absence of breathing] ...” RN 13 stated she was responsible to reviewed and documented Pt 37’s cardiac monitoring strip but did not. The EDM stated RN 13 should have reviewed and document Pt 37’s cardiac monitor reading. The EDM stated RN 13 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a concurrent interview and record review on 3/13/24 at 11:43 a.m. with RN 12 and the EDM, Pt 38’s CMO, dated 3/12/24, was reviewed. The CMO indicated, “ ...Indications for monitoring: New and/or potential for cardiac arrhythmia ...” RN 12 stated she was responsible to review and document Pt 38’s cardiac monitoring strip but did not. The EDM stated RN 12 should have reviewed and documented Pt 38’s cardiac monitor strip. The EDM stated RN 12 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During an interview on 3/13/24 at 3:59 p.m. with RN 15 and the EDM, RN 15 stated Pt 46 had physician’s order for cardiac monitoring. RN 15 stated she was responsible to review and document Pt 46’s cardiac monitoring strip but did not. RN 15 stated she did not document because of short staffing. The EDM stated RN 15 should have reviewed and documented Pt 46’s cardiac monitor strip. The EDM stated RN 15 did not follow the hospital’s policy and procedure for cardiac and remote monitoring. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders,” dated 08/25/23, the P&P indicated, “ ...The RN acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order ...” During a review of the facility’s policy and procedure (P&P) titled, “Cardiac and Remote Monitoring-Inpatients 14 and Older,” dated 04/14/2022, the P&P indicated, “ ...The assigned RN/designee is responsible for validating and documenting the patient’s rhythm ...The RN will date and sign the cardiac monitoring strip ... every 4 hours ...Routine Cardiac monitoring documentation includes the patient’s rate, rhythm ...This documentation will be a minimum of every 8 hours or by unit standard (4 hours in Emergency Department) in the Electronic Health Record ...” 3. During a review of Patient 4’s “History and Physical Examination (H&P- initial exam)”, dated 3/10/24, the H&P indicated, “ ...Chief Complaint pain in the abdomen ... Plan: Admit to medicine and start IV (intravenous- in the vein) fluid, IV [antibiotics], oxygen and bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), pain medication as needed ...”. During a review of Patient 4’s “Medication Administration Report (MAR)”, dated 3/9/24 to 3/15/24, the MAR indicated, “ ...Albuterol [Brand Name] 2.5 mg [milligrams- unit of measurement]/3 mL [milliliters- unit of measurement] nebulizer solution [liquid medication that could be inhaled and exhaled directly into the lungs] ... Frequency: every 6 hours ... Route: Nebulization [electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece] ... Start: 3/10/24 ... End: 3/14/24 at 4:28 p.m. ....Medication Not Given 17 separate times: 3/10/24- 4:42 p.m., 9:24 p.m., 3/11/24- 5:03 a.m., 9:48 a.m., 4:54 p.m., 9:44 a.m., 3/12/24- 4:25 a.m., 10 a.m., 4 p.m., 3/13/24- 1:04 a.m., 4:47 a.m., 10 a.m., 6:55 p.m., 10 p.m., 3/14/24- 3:53 a.m., 11:38 a.m., 4:56 p.m. ...”. During a review of Patient 4’s “MAR Flowsheet #1- #7 (MF)”, dated 3/11/24 to 3/13/24, the MF indicated,... “MF 1- 3/11/24 at 9:44 p.m., route: nebulization ... user: [Respiratory Care Provider (RCP) 2] Delivery: Not Given- Hall... MF 2- 3/12/24 at 4:25 a.m., route: nebulization ... user: [RCP 2] Delivery: Not Given- Hall... MF 3- 3/12/24 at 10 a.m., route: nebulization ... user: [ RCP 3] Delivery: Not Given Comment: Hall... MF 4- 3/12/24 at 4 p.m., route: nebulization ... user: [RCP 3] Delivery: Not Given- Comment: Hall... MF 5- 3/13/24 at 1:04 a.m., route: nebulization ... user: [Registered Nurse (RN) 21] Comment: patient in the hallway, no available room for breathing treatment... MF 6- 3/13/24 at 4:47 a.m., route: nebulization ... user: [RCP 4] Delivery: Not Given- Hall Bed... MF 7- 3/13/24 at 10 p.m., route: nebulization ... user: [RCP 5] Delivery: Not Given- Comment: Patient in hall bed.” During an interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9, RN 9 stated she was responsible for multiple patients in the ED North Hall and patient 4. RN 9 stated patients that are in the hallway with nebulizer treatments ordered do not receive them. RN 9 stated “it’s a rule” that the RCP’s do not administer them. RN 9 stated those nebulizer treatments “just get skipped”. RN 9 stated that she did not notify the Physician when Patient 4 did not get her nebulizer treatment and thought the RCP was supposed to. During an interview on 3/14/24 at 4 p.m., with Patient 4, Patient 4 stated she found out she had nebulizer treatment (electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) ordered by a Doctor in the Emergency Department through her patient online portal. Patient 4 stated staff never told her those treatments were ordered for her and why. Patient 4 stated she never received any nebulizer treatments while admitted in the ED. During an interview on 3/22/24 at 9:15 p.m., with the Director of Respiratory Therapy (DRT), the DRT stated RCP staff had guidance that was outdated and would not administer patient’s nebulizer treatments in hallway ED beds. The DRT stated that guidance has changed and now will complete nebulizers in the halls. The DRT stated RCP staff should have educated patients and told them about their nebulizer treatments and they did not. The DRT stated staff should have notified the ordering Physician of the nebulizer treatment not given and they did not. The DRT stated RCP staff did not follow facility policy and procedures (P&P) “Respiratory Care Orders/Administration/Documentation, Provider Orders and Medications, Orders, Administration, Storage, Documentation”. During an interview on 3/22/24 at 10 a.m., with RCP 3, RCP 3 stated Patient 4 was in the hallway, and she refused the nebulizer treatment for her due to her being admitted to the ED hallway. RCP 3 stated RCPs did not do nebulizer treatments in the ED hallways for any patients. RCP 3 stated “we were told not too”. RCP 3 stated she did not tell Patient 4 she was ordered a nebulizer treatment and did not educate her. RCP 3 stated she did not notify the ordering Physician that she refused Patient’s 4 treatment. RCP 3 stated patient’s medical condition could get worse by not giving the treatments and not notifying the Physician. RCP 3 stated a patient’s safety would be put at-risk. RCP 3 stated she did not follow hospital policy and procedure. During an interview on 3/22/24 at 11:30 a.m., with the RCP Manager (RCPM), the RCPM stated it was normal practice for RCP’s to not complete any nebulizer treatment for any patient in a hallway bed. The RCPM stated that practice put patient safety at risk and a patient could deteriorate. The RCPM stated patients have a right to be a part of their care and RCPs should have been notifying them of their treatments. The RCPM stated staff did not follow the hospital policies and procedures RCPs are supposed to follow. During a review of Pt 36’s “Hospitalist History and Physical (HH&P)”, dated 3/13/24, the HH&P indicated, “ ...Chief Complaint ...Respiratory short of breath ...Pt c/o (complaint of) shortness of breath ...With a SpO2 [is a measurement of the percentage of oxygen in the blood, relative to the maximum it could carry]. 88% on room air [A normal SpO2 level for a healthy person is between 96% and 99%] ... Plan Methylprednisolone [a drug used to treat various medical conditions including lung or breathing problems] 20mg [milligrams-unit of measurement] IV (intravenous- administered into the vein) TID (three times a day) ... ipratropium/albuterol [a drug used to help control symptoms of lung disease by opening the lung airways] as needed ...” During a review of Patient 36’s “Medication Administration Report (MAR)”, dated 3/21/24 , the MAR indicated, “ ...Ipratropium-albuterol 2.5 mg /3 mL [milliliters- unit of measurement] nebulizer solution [liquid medication that is turned into a mist that can be inhaled and exhaled directly into the lungs] ... Frequency: every 6 hours ... Route: Nebulization [a device that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece] ... Start: 3/14/24 at 12:01 a.m. ...End: 3/16/24 at 10:05 p.m. ...” The Ipratropium-albuterol was not given on 3/14/24 at 12:05 a.m., 5:18 p.m., 9:40 p.m., and on 3/15/24 at 4:00 a.m. During a review of Pt 36’s “MAR Flowsheet #1- #4 (MF)”, dated 3/21/24, the “MF” indicated, “ ...MF 1- 3/14/24 at 1205 a.m., route: nebulization ... user: [Respiratory Care Provider (RCP) 2] Delivery: Not Given ...Comment: In Hallway ... MF 2- 3/14/24 at 5:18 p.m., route: nebulization ... user: [RCP 2] Delivery: Not Given ...Comment: In Hallway ... MF 3- 3/14/24 at 9:40 p.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed ... MF 4- 3/15/24 at 4:00 a.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed ...” During a review of Pt 37’s “HH&P”, dated 3/11/24, the “HH&P” indicated, “ ...Chief Complaint ...Difficulty breathing ...cough ...pleurisy [inflammation of the pleura, the two thin layers of tissue that separate the lungs from the chest wall. This can cause a sharp chest pain while breathing] ...ESRD [End Stage Renal Disease- a medical condition when the kidney’s stop to function] ... Who is here for acute hypoxic respiratory failure [AHRF-a severe form of low oxygen in the body] ... Plan ...As needed cough and expectorant [a type of cough medicine used to help clear mucus [phlegm] from your airway] ...” During a review of Pt 37’s “MAR”, dated 3/21/24, the MAR indicated, “ ...Acetylcysteine [a drug used to relieve chest congestion due to thick mucus secretions in the lungs] 200 mg /3 ml nebulizer solution ... Frequency: every 6 hours ... Route: Nebulization ... Start: 3/12/24 at 4:00 a.m. ...End: 3/18/24 at 12:55 a.m. ...” The Acetylcysteine was not given on 3/13/24 at 12:31 a.m., 4:41 a.m., 10:00 a.m., 7:37 p.m., 11:03 p.m., and on 3/14/24 at 3:58 a.m., and 10:00 a.m. During a review of Pt 37’s “MAR Flowsheet #1- #3 (MF)”, dated 3/21/24, the MF indicated, “ ...MF 1- 3/13/24 at 7:37 p.m., route: nebulization ... user: [(RCP) 4] Delivery: Not Given ...Comment: not given by day shift, next dose close, MF 2- 3/13/24 at 11:03 p.m., route: nebulization ... user: [RCP 4] Delivery: Not Given ...Comment: Patient in dialysis, patient in hallway bed, MF 3- 3/14/24 at 3:48 a.m., route: nebulization ... user: [RCP 3] Delivery: Not Given ...Comment: Pt in hall bed..” No documentation was provided for date 3/13/24 at times of 12:31 a.m., 4:41 a.m., 10:00 a.m. or date 3/14/24 at 10:00 a.m. the reason why nebulization medication was not administered. During a review of Pt 56’s “Hospitalist History and Physical (HH&P)”, dated 3/12/24, the H&P indicated, “ ... Chief complaint ...difficulty breathing ...Pt c/o shortness of breath ...history of Idiopathic Pulmonary Fibrosis (IPF-a rare, chronic lung disease that causes lung tissue to thicken and stiffen and makes breathing more difficult) ...Plan ... [brand name] [Levalbuterol- a drug used to treat shortness of breath that commonly occur with lung problems] neb x1 (1 time) ...” During a review of Pt 56’s MAR, dated 3/13/24, the MAR indicated, “ ...Levalbuterol [Brand name] ...1.25 mg nebulizer solution ...Frequency: Once ...Route: Nebulization ...Start: 3/12/24 3:37 a.m. ...End: 3/13/24 3:37 a.m. ...” The Levalbuterol was not given on 3/12/24- 5:26a.m. During a review of Pt 56’s MF#1, dated 3/21/24, the MF indicated, “ ...MF 1- 3/12/24 at 5:26 a.m., route: nebulization ... Delivery: Not Given ...Comment: Hallway. During an interview on 3/15/24 at 10:49 a.m., with Respiratory Care Provider (RCP) 1, RCP 1 stated nebulizer treatments were not administered in the hospital’s hallways. RCP 1 stated he did not administer nebulizer treatments to patients in the hospital’s hallways. RCP 1 stated it was not a common practice to administer nebulizer treatments in the hospital’s hallways. RCP 1 did not know the reason not to administer nebulizer treatments in the hospital hallways. During a review of the facility’s Policy and Procedure (P&P) titled, “ Respiratory Care Orders/Administration/Documentation “, dated 10/13/17, the P&P indicated, “PURPOSE: To ensure safe preparation, administration and documentation of medication with appropriate modality used by Respiratory Care Practitioners (RCP). II. POLICY: A. The RCP is responsible for the content of all referenced policies as they pertain to the delivery of medications utilized in respiratory care ... 3. Refer to the policy Medications - Orders, Administration, Storage, Documentation ... a. Routine medications b. Scheduled respiratory administration times ... i. Patient education regarding medications and medication delivery device ...VI. PROCEDURE: ... D. Correctly identify patient per corporate policy ... introduce yourself to the patient. E. Educate patient/reinforce education as needed ... J. Administer medication per American Association of Respiratory Care (AARC) guidelines ... VIII. EDUCATION: ... B. Inform and educate the patient and/or family on the name of the medication, reason for its administration, possible side effects and benefits of the medication being delivered and document in the EHR ...”. During a review of the facility’s Policy and Procedure (P&P) titled, “ “, dated 10/13/17, the P&P indicated, “PURPOSE: To provide guidelines for the same and accurate ordering, transcribing, labeling, administration, storage and documentation of medications ... B. Medication Administration ... 2. The following staff may administer certain medications within their scope of practice and as defined by unit/department ... b. Respiratory Care Practitioner ... 10. Respiratory Therapy Medications a. The respiratory medications will be administered per prescriber orders with the schedule of administration times ... 16. ... Routine respiratory inhaled medications are to be administered within 60 minutes of the scheduled time unless otherwise ordered by the prescriber ...VI. DOCUMENTATION: ... B. Document on MAR if medication was not given and notify provider ... E. Document the patient education was completed ...VII. PATIENT EDUCATION: A. Inform the patient and/or family of the name of the medication, reasons for its administration, potential side effects and any other pertinent (important) information ...”. During a review of the facility’s policy and procedure (P&P) titled, “Provider Orders”, dated 8/25/23, the P&P indicated, “ ...I. PURPOSE...C. To provide guidelines for the receipt, documentation, authentication and use of verbal or telephone orders ...III. POLICY ...M. ... acknowledgment of orders indicates they assume responsibility for ensuring implementation of the order within the prescribed period ...”. 4. During a review of Patient 5’s “EHR”, dated 2/15/24 to 2/29/24, the EHR indicated Patient 5 was admitted on 2/15/24 for septic shock (a life-threatening medical condition that can occur when an infection in your body causes extremely low blood pressure and organ failure). Patient 5 was diagnosed with acute kidney injury (AKI- a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days. AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your body), uremia (a medical condition when waste products, such as urea, build up in the body because the kidneys are unable to eliminate them.), low urine output and was ordered hemodialysis (the process of treating kidney failure with a machine that removes waste products and excess fluid from the blood) Medical Doctor (MD) 2 decided to order enteral feeding (also called tube feed- a method of feeding that uses the gastrointestinal (GI- stomach) tract to deliver nutrition and calories) pump to support the nutritional needs for Patient 5. Patient 5 had a nasogastric tube (NG- a thin, soft tube that goes in through the nose, down the throat, and into the stomach) placed and the tube feed was started on 2/29/24 at 12 p.m. The patient had the tube feeding going when she went to hemodialysis. Shortly after the hemodialysis treatment ended, the patient had a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) and died. During a review of Patient 5’s “Vital Signs Flowsheet during Hemodialysis (VS)”, dated 2/29/24, the VS indicated, “Vitals: ...O2 device: Nasal Cannula ... O2 flow rate: 4 Liters (unit of measurement) ... Time: 3:06 p.m. (Dialysis treatment begun) ... Temperature: 36.6, Heart Rate: 84, Respirations: 16, Blood Pressure: 102/68, SpO2: [empty] ...”. VS indicated next SpO2 (a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) taken was 5:57 p.m. VS indicated Sp02 was not monitored or recorded for 2 hours and 51 minutes. During a review of Patient 5’s “Expiration Discharge Summary (EDS)”, dated 2/29/24, the EDS indicated, “ ...Diagnosis: *Principal- Acute Respiratory Failure (occurs when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning) with hypoxia (low levels of oxygen in your body tissues) ...Patient had worsening hypoxia during hemodialysis ... initially alert, then unresponsive ... resuscitation (lifesaving technique that’s useful in many emergencies in which someone’s breathing or heartbeat has stopped) was not successful ...”. During a concurrent interview and record review on 3/22/24 at 1:45 p.m., with RN 26, Patient 5’s VS dated 2/29/24 were reviewed. The VS indicated Sp02 was not monitored or recorded for 2 hours and 51 minutes, the entirety of the hemodialysis treatment. RN 26 stated that she was Patient 5’s nurse when the patient came to her unit for a dialysis treatment. RN 26 stated during a hemodialysis treatment, patient vital signs are to be taken every fifteen minutes. RN 26 stated vital signs that should be monitored would be temperature, heart rate, blood pressure, Sp02 and respirations. RN 26 stated Patient 5 had continuous oxygen monitored because she was on 4 Liters nasal cannula during the dialysis treatment. RN 26 stated she did not monitor the Sp02 for the entire hemodialysis treatment and did not follow the hospital policy. RN 26 stated because she did not monitor Patient 5 correctly, the patient could have deteriorated sooner, and she would not have known. During an interview on 3/26/24 at 11 a.m., with MD 2, MD 2 stated if Sp02 was not monitored properly for Patient 5, that could be a patient safety issue. MD 2 stated that Sp02 should be monitored with the other vital for Patient 5. MD 2 stated the cause of death for Patient 5 was acute respiratory failure with hypoxia. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated that Sp02 should have been monitored for Patient 5 during hemodialysis. The CNO stated because Sp02 was not monitored it would be a patient safety issue that could lead to patient harm. The CNO stated staff did not follow the policy and procedure “Monitoring the Patient During Hemodialysis” and nurse standards of practice. During a review of the facility’s Policy and Procedure (P&P) titled, “ Monitoring the Patient During Hemodialysis”, dated 11/18/21, the P&P indicated, “PURPOSE: A. To define the standard of monitoring the patient during dialysis ... POLICY: ... D. Vital signs will be checked every thirty (30) minutes ... DOCUMENTATION: Document vital signs ... in the patient’s electronic health record ...”. Review of Nursing World.org Professional Reference titled, “The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition”, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, “ ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...”. During a review of Pt 8’s Face sheet dated 3/15/24, Pt 8 arrived at the ED on 10/11/23 at 11:43 a.m. with an admit reason of Abdominal Wall Cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area) and was admitted at 12:04 p.m. on the same day (10/11/23). During a concurrent interview and record review on 3/15/24, at 11 a.m. with the Emergency Department Manager (EDM) Pt 8’s electronic health records (EHR) for admission 10/11/23 was reviewed. The EDM stated per the EHR Pt 8 came into the ED on 10/11/23 with a chief complaint of having a cyst (a fluid filled sack) on her hip and abdomen that needed to be drained. Pt 8’s EHR indicated Pt 8 was a 44 year old female who was alert and oriented and had a past medical history of Coronary Artery Disease (CAD- damage or disease to the hearts major blood vessels), had a CABG (Coronary Artery Bypass graft -major heart surgery to treat CAD), Diabetes mellitus (inability to sugar), End stage renal disease (ESRD- kidneys not able to flush out toxins in the blood) with hemodialysis (a treatment to filter wastes and water from your blood) Monday, Wednesday and Friday, hypertension (elevated blood pressure above 120/80), and stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) with left side weakness. During a concurrent interview and record review on 3/18/24, at 10:48 a.m., with the EDM, Pt 8’s Vital signs for Pt 8’s admission on 10/11/23 were reviewed. The EDM stated vital signs (VS) should have been done in the ED every 4 hours for Pt 8. VS flow sheet for Pt 8 indicated oxygen levels were checked on 10/11/23 at 1:10 p.m. 77 percent (%) on room air (RA), 1:15 p.m. 100 % on nonrebreather mask (mask placed on patient to provide 100% oxygen to help get patients oxygen levels up), at 1:21 p.m. 99 % on 3 liters (L) nasal canula (NC- small tubes place in the nose to provide oxygen directly to the patient), on 10/12/23 at 4:36 a.m. 92 % (no mention if patient was on any form of oxygen), at 8:17 a.m. 98%, and at 1:23 p.m. 97%. The EDM stated the oxygen level of a patient is part of the vital signs that are supposed to get done every 4 hours, but it looks like two were missed (the 8 p.m. and the 12 a.m.) from 1:21 p.m. the next done at 4:36 a.m. the next day. The EDM stated it was important to monitor the oxygen saturations of patient because if they drop their saturations and begin to deteriorate then we are able to respond to their needs more quickly. During a review of Pt 8’s Nursing Note dated 10/11/23, at 1:18 p.m., the note indicated Pt 8 had a near syncopial (fainting or passing out) episode lasting less than 2 minutes oxygen saturations 77 % on RA, patient reports on 3 L NC at home but did not bring her oxygen, oxygen placed on patient oxygen saturations back up. During a review of the facility’s policy titled, “Standards of Practice for Emergency Department” effective date 9/14/22, indicated, “I. PURPOSE These Standards of Practice are necessary and realistic levels of nursing process, which assure that quality care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive in the Emergency Department (ED) of [name of hospital] ... IV. Procedure. A. Standard of Practice: Safety, Medications, IV therapy, infection control. The patient will be provided a safe therapeutic environment for the delivery of health care. The licensed nurse will: ... 2. Adhere to all established name of hospital policies and procedures .... B. Standards of Practice: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a licensed nurse. Utilizing the nursing process, the RN will: 1. Collect, document, and communicate data to the interdisciplinary team. The frequency of data collection will vary according to the gravity of the patient’s problem/needs as well as individual standardized procedure and physician order.... F. Vital signs, with pain assessment a minimum every 4 hours. Unless otherwise ordered or warranted....” Review of Nursing World.org Professional Reference titled, “The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition”, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, “ ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...”. 5. During a concurrent interview and record review on 3/15/24 at 10:23 a.m., with the Medical Surgical Manager (MSM), Pt 1’s “History and Physical (H&P)”, dated 12/13/23 was reviewed. The “H&P” indicated, 67-year-old male with avascular necrosis of bones of both hips (a disease that results from the temporary or permanent loss of blood supply to the bone). During a concurrent interview and record review on 3/26/24 at 8:05 a.m. with Licensed Vocational Nurse (LVN) 2, Pt 1’s “Pain Monitoring Accordion (PMA)”, dated 3/9/24 at 4:45 p.m. to 3/11/24 at 5:09 p.m. was reviewed. The “PMA” indicated LVN 2 documented a pain scale of eight out of 10 on 3/9/24 at 9:06 p.m. and 3/10/24 at 4:51 a.m. LVN 2 stated she would administer pain medication according to the patient’s pain level assessment. LVN 2 stated the standards of practice was to follow physician’s order. LVN 2 stated Pt 2’s numeric pain scale was eight out of 10 which indicated severe pain and she administered Oxycodone 24 mg for moderate pain. LVN 2 stated she did not follow physician order when she administered pain medication for moderate pain for a reported pain scale in the severe range. During a concurrent interview and record review on 3/26/24 at 8:30 a.m. with the MSM, Pt 1’s “Physician Medication Order (PMO)” dated 2/18/24 was reviewed. The MSM stated Pt 1’s “PMO” indicated to administer oxycodone immediate release tablet 25 mg PRN (as needed) every 4 hours for moderate pain. The MSM stated Pt 1 did not have pain medication ordered by the physician for severe pain. During a concurrent interview and record review on 3/27/24 at 3:35 p.m. with the MSM, Pt 1’s “Pain Monitoring Flowsheet (PMF)”, dated 3/6/24 to 3/23/24 was reviewed. The MSM stated from 3/9/24 to 3/23/24 Pt 1’s numerical pain scale was eight out of 10 which indicated severe pain and the license nurse administered pain medication for moderate pain. The MSM stated licensed nurses should have call the physician to get an order for pain medication appropriate for Pt 1’s assessed pain level and report pain level outside of the current pain medication order parameters. During a concurrent interview and record review on 3/27/24 at 3:50 p.m. with MSM, the facility’s P&P titled, “Pain Assessment & Management - Patients 14 and Older” dated was reviewed. The P&P indicated, “ ... IV. PROCEDURE ... 6. Pain management scales utilizing the 0-10 descriptors, ... 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain and 7-10 = severe pain. ... C. Implementation 2. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider ...” The MSM stated the hospital policies and procedures was not followed. During a review of the professional reference form https://www.amnhealthcare.com/blog/nursing/contract/what-is-a-nurses-role-in-patient-pain-management/ titled What is a Nurse’s Role in Patient Pain Management? Dated 2019, indicated ...” One of the more difficult scenarios you’ll face as a nurse is patient pain management. The patients you encounter may experience pain in very different ways and to very different degrees. Patients also respond differently to pain management medications and techniques...While it’s ultimately up to the attending physician to prescribe and manage a patient’s pain, it falls within your role to closely monitor your patients, act as a liaison between them and the doctors you work with and ensure that levels are acceptable and well maintained ... Observations you make should include: What the patient’s current pain level is at, How the patient’s pain level has increased or decreased over time, Where the patient’s pain is primarily located and how that location may have changed over time, How the patient has responded to pain medication ... By consistently documenting these observations, reporting them to attend providers, and following up regularly to note changes, you can help ensure the patient is appropriately treated and remains as comfortable as possible while undergoing diagnosis and treatment ... Work As A Patient Advocate To Manage Pain ... You are a trusted advisor and advocate for the patient while they’re under your care, particularly when they are experiencing significant pain ... How pain occurs and how it impacts the patient can sometimes be difficult for them to put into words ... Additionally, patients may not know what questions to ask or what treatments or medications to ask for or accept upon a doctor’s recommendation. This means that one of your most important roles in pain management is as an advocate ... This gives you the tasks of ensuring that doctors and other providers are truly hearing the patient’s pleas for help and working to develop an action plan appropriate for each patient’s needs ... Patients whose pain isn’t adequately treated may end up right back in the emergency department hours or days later or may resort to dangerous self-treatment alternatives. You can work to ensure their needs are heard and met while they are under your care ...” During a review of Patient 4’s “History and Physical Examination (H&P- initial exam)”, dated 3/10/24, the H&P indicated, “ ...Chief Complaint pain in the abdomen ... Plan: Admit to medicine and start IV (intravenous- in the vein) fluid, IV [antibiotics], oxygen and bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), pain medication as needed ...”. During a review of Patient 4’s “Patient Care Timeline (PCT)”, the PCT indicated, Patient 4 received pain medication without a pain reassessment on: 3/10/24: 4:50 p.m., Morphine (pain medication) 2 mg (milligram- unit of measurement), Pain level: 9 severe; no reassessment. 9:06 p.m., Morphine 2 mg, Pain level: no pain assessment; no reassessment completed. 3/11/24: 1:34 a.m., Morphine 4 mg, Pain level: no pain assessment; no reassessment completed. 10:49 a.m., Morphine 4 mg, Pain level: 8 severe; no reassessment completed. 11:34 p.m., Morphine 4 mg, Pain level: 2 mild; no reassessment completed. 3/12/24: 3 p.m., Morphine 4 mg, Pain level: 8 severe; no reassessment completed. 11:21 p.m., Morphine 4 mg, Pain level: 7 severe; no reassessment completed...” During a review of Patient 55’s “H&P”, dated 3/12/24, the H&P indicated, “ ...Chief Complaint: abdominal pain ... Plan: Admit to surgery ...”. During a review of Patient 55’s “Patient Care Timeline (PCT)”, the PCT indicated, Patient 55 received pain medication without a pain reassessment on: 3/12/24: 3:45 a.m., Morphine 4 mg, Pain level: no assessment; no reassessment completed. 5:29 a.m., Morphine 4 mg, Pain level: 7 severe; no reassessment completed. 8:32 a.m., Morphine 4 mg, Pain level: 10 severe; no reassessment completed. 3:32 p.m. Oxycodone (pain medication) 5mg, Pain level: 5 moderate; no reassessment completed. 3/13/24: 8:59 a.m., Oxycodone 5 mg, Pain level: 6 moderate; no reassessment completed. 5:54 p.m., Morphine 2 mg, Pain level: 7 severe; no reassessment completed. 9:03 p.m., Morphine 4 mg, Pain level: 9 severe; no reassessment completed. 3/14/23: 6:12 a.m., Oxycodone 5 mg, Pain level: 6 moderate; no reassessment completed. 8:21 a.m., Morphine 2 mg, Pain level: 5 severe; no reassessment completed.1:19 p.m., Morphine 4 mg, Pain level: 7 severe; no reassessment completed. 4:35 p.m., Morphine 2 mg, Pain level: 7 severe; no reassessment completed...” During an interview on 3/13/24 at 4:10 p.m., with Patient 55, Patient 55 stated he was in “excruciating (unbearable)” amount of pain when he came to the Emergency Department (ED), and he had “to beg” for some medication. Patient 55 stated he “went up to them [staff] multiple times” to address his pain. Patient 55 stated staff gave him some pain medication and then he “wouldn’t see them again for hours”. Patient 55 stated he felt “his pain was not addressed at all”. During a concurrent interview and record review on 3/20/24 at 10:30 a.m., with Emergency Department Clinical Supervisor (EDCS), Patient 55’s “PCT” dated 3/12/24 to 3/15/24 was reviewed. The PCT indicated, Patient 55 had 11 missed pain reassessments after pain medication was given. The EDCS stated these missed reassessments were a patient safety issue. The EDCS stated staff did not follow the policy and procedure for pain assessments. During a concurrent interview and record review on 3/25/24 at 11 a.m., with RN 30, Patient 4’s “PCT” dated 3/10/24 to 3/14/24 was reviewed. The PCT indicated, Patient 4 had 7 missed pain reassessments after pain medication was given. RN 30 stated that he was the nurse for Patient 4 on 3/11/24 and 3/12/24. RN 30 stated he gave Patient 4 pain medication on both days for severe pain but did not complete a reassessment after administration. RN 30 stated pain reassessments are there for the patient’s safety after pain medication administration. RN 30 stated a nurse needs “to gauge” if the pain medication worked or didn’t work. RN 30 stated he did not keep Patient 4 safe, but her safety was put at-risk by him not getting a pain reassessment completed. RN 30 stated he did not follow the policy and procedure for pain assessment. During a review of Pt 8’s Face sheet dated 3/15/24, Pt 8 arrived at the ED on 10/11/23 at 11:43 a.m. with an admit reason of Abdominal Wall Cellulitis and was admitted at 12:04 p.m. on the same day (10/11/23). During a concurrent interview and record review on 3/15/24, at 11 a.m. with the Emergency Department Manager (EDM) Pt 8’s electronic health records (EHR) for admission 10/11/23 was reviewed. The EDM stated per the EHR Pt 8 came into the ED on 10/11/23 at 11:43 a.m. with a chief complaint of having a cyst (a fluid filled sack) on her hip and abdomen that needed to be drained, with a pain score of 10 out of 10. Pt 8’s EHR indicated Pt 8 was a 44 year old female who was alert and oriented and had a past medical history of Coronary Artery Disease (CAD- damage or disease to the hearts major blood vessels), had a CABG (Coronary Artery Bypass graft -major heart surgery to treat CAD), Diabetes mellitus (inability to sugar), End stage renal disease (ESRD- kidneys not able to flush out toxins in the blood) with hemodialysis (a treatment to filter wastes and water from your blood) Monday, Wednesday and Friday, hypertension (elevated blood pressure above 120/80), and stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) with left side weakness. During a concurrent interview and record review on 3/15/24, at 11:15 a.m., with EDM, Pt 8’s “ED Care Timeline” dated 10/11/23 11:43 a.m. to 10/13/23 7:37 a.m. was reviewed. The EDM confirmed that Pt 8 had the following orders for pain: 10/11/23 at 12:17 p.m. Fentanyl (strong pain medication) injection 75 mcg (micrograms-unit of measurement) given at 1 p.m. for pain level 9 out of 10. Pain reassessed at 2:06 p.m. 10/11/23 at 6:52 p.m. Morphine injection 4 mg (milligrams- unit of measurement) given at 6:59 p.m. for a pain level of 10 out of 10. No pain reassessment done confirmed with EDM. 10/11/23 at 7:46 p.m. Oxycodone-acetaminophen (oral pain medication) 5-325 mg tablet and Hydromorphone (strong pain medication) injection 1 mg were ordered. 10/12/23 at 4:36 a.m. Pt 8 reports 8 out of 10 pain. At 5:06 a.m. Pt 8 is given Oxycodone-acetaminophen 1 tablet. No pain reassessment done confirmed with EDM. Oxycodone-acetaminophen 1 tablet given again at 6:22 p.m. for pain level of 6 out of ten. At 7:07 p.m. pain reassessed at 3 out of 10. 10/12/23 at 11:49 p.m. Hydromorphone 1 mg injection given for 8 out of 10 pain to Pt 8. On 10/13/23 at 12:05 a.m. Pain assessment per RN patient is sleeping. 10/13/23 at 4 a.m. Pain assessment per RN patient is sleeping. At 5:29 a.m. Pt 8 is given Hydromorphone 1 mg injection with no pain score documented and at 6:20 a.m. a code blue (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest) was called and a note by the RN indicates at 6:10 a.m. Pt 8 was found unresponsive all confirmed with the EDM. The EDM stated pain reassessment were not done per policy, it is important to reassess pain after pain medication is given to confirm the effectiveness of the pain medication and to make sure it was not too much for the patient. During an interview on 3/20/24 at 2 p.m., with the Emergency Department Director (EDD), the EDD stated pain reassessments are there to validate if the pain intervention worked or did not work. The EDD stated without proper pain reassessments patients would have increased length of stays, delayed healing and it was overall poor patient care. The EDD stated a nurse could have given a pain medication and it could have put the patient “over the edge”, potentially resulting in patient harm due to the lack of reassessment. The EDD stated nursing staff did not follow the policy and procedure for pain assessments. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated nursing staff was responsible for all pain reassessments after a pain medication was given. The CNO stated pain needs to be reassessed for effective pain management. The CNO stated if reassessments are not completed than that is a patient safety risk. The CNO stated nursing staff did not follow the Policy and Procedure “Pain Assessment & Management- Patients 14 and Older”. During a review of the facility’s Policy and Procedure (P&P) titled, “Pain Assessment & Management- Patients 14 and Older”, dated 10/12/23, the P&P indicated, “PURPOSE: A. To demonstrate [Hospital Name] commitment to a patient’s right to effective pain management. B. To establish standards of nursing care and practice that defines the role and responsibilities of the RN to provide pain management at all facilities ... III. POLICY: A. It is the policy ... to provide safe and effective pain treatment for all patients ... B. Pain is whatever the person experiencing says it is ... Pain is always subjective ... E. Pain management tool is a reliable and validated tool used to measure clinical pain intensity and approved for use ...IV. PROCEDURE: ... 5. Assess and reassess pain using one of the following scales as appropriate. a. 0-10 pain intensity scale ... The appropriate pain rating scale is used to determine an appropriate pain management modality ... C. Implementation ... 2. Medications will be administered based on the patient’s pain scale level identified and as ordered by the provider ... D. Evaluation/Reassessment of Pain Management ...2. Pain intensity will be reassessed after each pharmacological pain management intervention once a sufficient time has lapsed for the treatment to reach peak effect, but no longer than 90 minutes after intervention. Generally, intravenous (IV- in the vein) medication is effective within 30 minutes and by mouth or intramuscular medication is effective within 60 minutes. This re-assessment will be documented in the patient medical record using the appropriate pain scale ... 5. Evaluate and reassess for side effects of treatment and risk factors for adverse events caused by treatment ... V. DOCUMENTATION: ... 2. Subsequent reassessments should include the following: intensity, location, response to treatment, modalities (the way in which something happens or is experienced) and type of pain assessment scaled used ...VI. PATIENT EDUCATION: ... 2. The patient’s pain and the effective treatment is an important part of the treatment plan ...”. Review of Nursing World.org Professional Reference titled, “The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition”, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, “ ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation ...”.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 41166 Based on interview, and record review, the hospital failed to ensure medications were prepared and administered in accordance with approved policies, procedures, and physician orders when Registered Nurse (RN) 1 administered 200 units of insulin lispro (short acting insulin) intramuscularly (in the muscles) without a physician’s order, which led to Patient (PT) 6 experiencing hypoglycemia and having to be administered Dextrose 5% and 50% solution (medications administered into the vein to treat low blood sugar). This failure had the potential to result in complications including seizures, brain damage, and death. Findings: During a review of PT 6’s “Care Note (CN)”, dated 2/15/24, the “CN” indicated PT 6 was a 30 year old, 28 week 5 day gestational pregnant female who was admitted with preeclampsia (condition during pregnancy marked by high blood pressure, fluid retention and protein in urine) on 2/9/24, with a history of diabetes mellitus (body unable to produce or respond to insulin resulting in elevated blood sugars) and hypothyroidism (body unable to produce enough thyroid hormone). The “CN” indicated, “Antepartum [period before childbirth] course was complicated by medication error resulting in a large dose of insulin administered. This was managed by serial blood glucose and treatment with glucose. On hospital day 3 she was stable for transfer.” During a review of PT 6’s “Medication Administration Record (MAR)”, dated 2/15/24, the “MAR” indicated, insulin NPH (neutral protamine Hagedorn- intermediate acting insulin) injection 14 units subcutaneously (into fatty tissue, under the skin) nightly on 2/9/24 at 10:59 p.m., and 2/11/24 at 9:08 p.m.; for insulin lispro injection subcutaneously 0 to 12 units four times daily with meals and nightly, 10 units at 12:26 p.m., 6 units at 6 p.m., 200 units at 6:29 p.m.; metformin 500 mg[milligrams- unit of measure] twice daily with meals was administered on 2/10/24 at 2:01 p.m., 6:29 p.m., 2/11/24 at 6:13 p.m..; betamethasone (steroid use to help mature fetal organs) injection 12 mg (milligrams- unit of measure) intramuscularly every 24 hours was administered on 2/9/24 at 6:33 p.m. During an interview on 3/13/24 at 4:06 p.m. with RN Risk Manager (RNRM), RNRM stated that on 2/10/24 at approximately 9 p.m., she received a call from the Labor and Delivery (L&D) clinical nurse supervisor, who informed her that PT 6 had been administered 200 units of insulin lispro in error. RNRM stated, “ ...she was given betamethasone 2ml. I was told that they had mixed it up, found out later she had gotten all insulin. Said patient was doing ok, blood sugar dropped a little, got D50 [dextrose 50%- injection to treat low blood sugar], disclosed to patient and husband what happened, patient was on 2:1 [2 nurses to patient], told clinical nurse supervisor to call if anything happened ... Following day, I waited to make sure patient fine throughout night, did chart review of patient and sent summary to leadership regarding incident 2/11/24. They did a leadership huddle on 2/12/24 to talk about event.” During a concurrent interview and record review on 3/14/24 at 9:02 a.m. with Director of Women and Newborn (DWN), Medication Safety Officer (MSO), and L&D Clinical Supervisor (LDCS), PT 6’s medical records were reviewed. DWN stated RN 1 took betamethasone and insulin vials from the medication room pyxis to PT 6’s bedside, where she drew up medications at bedside and administered to PT 6 around 6:30 pm on 2/10/24. RN 1 stated to DWN that she realized she may have erred by giving 2 ml of insulin intramuscularly instead of 2 ml of betamethasone and notified her supervisor immediately. DWN stated a rapid response (team of highly trained nurses and respiratory therapy who respond to patients with medical emergencies) was called, a physician went to PT 6’s bedside, and they began treating PT 6 and monitoring PT 6’s blood sugars.When asked what the expectation was for nursing staff when obtaining doses for different patients using the same multidose insulin vial, DWN stated, “Multidose insulin is to be drawn up in medication room, once they draw it, put it back and go to bedside to administer to patient .... Being a multiuse vial, you want to secure its integrity, want to keep it as clean and safe as possible for infection control.” A review of PT 6’s MAR Audit Trail Report indicated that on 2/10/24, RN 1 scanned the barcode on the betamethasone vial at 6:29 p.m. and 26 seconds, and again at 6:29 p.m. and 38 seconds. MSO acknowledged RN 1 did not scan the barcode of the insulin vial, prior to preparing and administering the insulin medication. MSO stated, “Insulin was not scanned at time of error, betamethasone was scanned twice. When she edited, was when she scanned [insulin].” LDCS stated the correct practice was for nurses to scan insulin and prepare syringe in the medication room, and only administer at bedside to prevent medication error. When asked if the practice was for nurses was to prepare multiple vials for injection prior to administration, LDCS stated, “I would scan one draw it and give, scan the next one and give. To scan two, draw two, and give two, would not be standard of practice. Could cause error because not giving one at a time, that is something we have taught, scan one, draw one, give one.” DWN stated RN 1’s practice was not according to the hospital’s policy. During a review of PT 6’s MAR dated 2/15/24, PT 6’s MAR indicated, Dextrose 5% solution was administered at a rate of 50 ml/hour on 2/10/24 from 7:55 p.m. to 2/11/24 3:10 a.m., and on 2/11/24 from 3:39 a.m. to 3:40 p.m., Dextrose 50% solution, 50 ml on 2/10/24 at 7:48 p.m., 8:50 p.m., 9:54 p.m., 11:25 p.m., and on 2/11/24 at 00:30 a.m., 1:15 a.m., 2:57 a.m., 3:47 a.m., and 5:20 a.m. LDCS stated the physician ordered 50 ml of Dextrose 50% solution as needed for low blood sugar less than 100. A review of PT 6’s “Glucose Management Records (GMR)”, PT 6’s “GMR” indicated a blood sugar of 87 on 2/10/24 at 7:46 p.m., 96 on 2/10/24 at 8:49 p.m., 96 on 2/10/24 at 9:51 p.m., 80 at 11:15 p.m., 95 on 2/11/24 at 00:20 a.m., 88 on 2/11/24 at 1:07 a.m., 87 on 2/11/24 at 2:33 a.m., 86 on 2/11/24 at 3:42 a.m., 96 on 2/11/24 at 4:48 a.m. During a review of PT 6’s “Perinatal Note (PN)”, dated 2/12/24, the PN indicated, “betamethasone was ordered, and patient received 2 ml of insulin 200 [units] instead of betamethasone and had issues with low blood sugars which have since resolved.” During an interview on 3/14/24 at 11:17 a.m. with MSO and Pharmacist in Charge (PIC), MSO stated PT 6 was administered Dextrose 5% and Dextrose 50% solution intravenously (in the vein) with frequent monitoring to avoid severe hypoglycemia. MSO stated patients suffering from hypoglycemia could suffer from altered mental status, tremors, or dizziness. PIC stated a contributor to the medication error was RN 1 taking the insulin vial out of the medication room. PIC acknowledged RN 1 did not barcode scan the insulin vial prior to PT 6’s insulin administration at 6 p.m. and at 6:29 p.m. PIC stated the importance of bar code scanning was to validate the use of the right product for the right patient, and the expectation was for nursing to barcode scan all medications prior to administration. PIC stated the practice expectation was to prepare one medication at a time, which included scanning, preparation, and administration. PIC stated, “It would help prevent accidental mistakes during administration. There was barcode scanning but the preparation was inaccurate, leading to inaccurate administration.” During an interview on 3/18/24 at 2:32 p.m., with Director of Risk Management (DRM), DRM stated a root cause analysis was still in progress for the insulin medication error involving RN 1 and PT 6. During a review of Lexicomp, a nationally recognized drug database, the manufacturer for insulin lispro indicated, “The most common adverse effect of insulin is hypoglycemia ... Profound and prolonged episodes of hypoglycemia may result in convulsions, unconsciousness, temporary or permanent brain damage, or even death ...” During a review of Institute for Safe Medication Practices (ISMP)’s article titled, “ISMP List of High-Alert Medications in Acute Care Settings”, dated 2024, the article indicated, “All forms of insulin, subcutaneous and IV, are considered a class of high-alert medications.” During a review of the hospital’s Policy and Procedure (P&P) titled, “Medications- Single and Multi-Dose Vials”, dated 6/13/22, the P&P indicated, “A multi-dose vial may only be used for more than one patient if the vial is accessed in a medication clean area located outside the immediate patient care area.” During a review of the hospital’s P&P titled, “Medications- Orders, Administration, Storage, Documentation”, dated 12/19/23, the P&P indicated, “Medications shall be administered using Bar Code Medication Administration (BCMA) in all areas that BCMA is implemented ... it is the expectation of the organization that all areas scanning medications prior to administration will be compliant with medication scanning ... it is the responsibility of the person administering the medication to verify the following a. drug allergies b. the right drug c. the right patient d. the right dose e. the right time f. the right route ...””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 45977 Based on observation, interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled “Blood Products Transfusion”, for one of one patients (Patient (Pt) 22) was administered blood products and the intravenous (IV) (into the blood stream) line was not prepared before giving the blood. This failure had the potential to place Pt 22 at risk for a delay in receiving administered blood products and negative health outcomes. Findings: During a record review of Pt 22’s “History and Physical (H&P-the complete assessment of the patient and the problem),” dated 3/5/234, the H&P indicated, “ ... 76 y.o. [year old ]female, with history of hypertension, brought in by ambulance from home for shortness of breath upon waking this morning. Reports she was up half the night because she couldn’t sleep unclear if related to anxiety. She has been having trouble sleeping for 2 days ... She has felt fluid overloaded for a few days but no lower extremity edema [swelling caused by fluid in the body’s tissues]. She endorses some fatigue. En-route Given 6 nitro [medication to widen the openings in blood vessels] and 1 inch nitro paste en route with some relief. No history of congestive heart failure [a weakened heart condition that causes fluid buildup] or chronic obstructive pulmonary disease [a chronic lung disease that causes obstructed airflow from the lungs] ... Currently smokes tobacco, states she is trying to quit. Denies chest pain, diarrhea, nausea, vomiting, diarrhea, or cough....” During a record review of Pt 22’s “Transfusion Orders,” dated 3/29/24 at 5:59 a.m., the orders indicated, “Transfuse Red Blood Cells (Adult) ... Released Time ... 03/19/24 1038 [a.m.] ... Transfusion duration per unit 3 (hrs [hours]) ...” During an observation on 3/19/2024 at 11:11 a.m., with Registered Nurse (RN) 7, in room 2413, RN 7 prepared and administered the blood to Pt 22 with the assistance of RN 8. During the process, RN 7 did not follow the policy when RN 7 did not prepare the patient before transfusion. RN 7 did not prime the blood transfusion filter Y-tubing (special tubing used for administering blood products that flushes the blood to the patient) prior to obtaining the blood product from the Blood Bank (a place where blood is collected and stored before it is used for transfusions). RN 7 spiked the Y tubing after obtaining the blood and after verifying the patient with RN 8. RN 7 primed the blood transfusion filter and tubing with normal saline and then spiked the blood product. RN 7 then connected the IV line to the patient. During a concurrent interview and record review on 3/19/23 at 11:40 a.m., with RN 7, the hospital’s policy and procedure (P&P) “Blood Products Transfusion”, dated 3/19/24 was reviewed. RN 7 stated, she was familiar with the policy. RN 7 read from the policy, which indicated, “ ... D. Preparation of Patient before Transfusion ... 1. Verify patient informed consent is documented and that there is an active order to transfuse. ... 2. Gather the equipment needed to complete the transfusion. (see section IV Equipment) ... 3. Perform hand hygiene. ... 4. Prime the blood transfusion filter and tubing with normal saline ... “. RN 7 stated she did not prime the IV tubing prior to obtaining the blood. RN 7 stated, this is important to not cause a delay in giving the blood as there is a four hour window to give the blood to the patient. During a concurrent interview and record review on 3/19/23 at 11:45 a.m., with NM 2, the hospital’s P&P “Blood Products Transfusion”, dated 3/19/24 was reviewed. NM 2 stated, RN 7 should follow the policy as the blood needs to be administered as efficiently as possible so that there is no delay. NM 2 stated, the blood should be administered within the four hour window as per the policy. During an interview on 3/28/24 at 9:05 a.m., with the Chief Nursing Officer (CNO), the CNO stated, her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important ensure that blood is efficiency administered as appropriate. During a review of the hospital’s P&P titled, “Blood Products Transfusion”, dated 3/19/24, the P&P stated, “ ... H. Routine Handling of Blood at Point of Service ... 1. Transfusion of blood products must be completed within four hours after the time of issue from Blood Bank. ... 2. Begin the transfusion as soon as possible after the blood is issued from Blood Bank. ... a. There is not a requirement that transfusion must be initiated within 30 minutes of blood issue, but it should be started as soon as possible to avoid wastage....””

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 45977 Based on interview and record review the facility failed to obtain a History and Physical (H&P) (a term used to describe a doctor’s examination of the patient) update within 24 hours of a surgery for one of thirty-four patients (Patient 17 ). This failure had the potential for the surgical team not having the most up to date information prior to surgery. Findings: During a concurrent interview and record review, on 3/15/2024 at 11:30 a.m., with Director of Women and newborn & Labor and Delivery (DWN), Patient 17’s medical record was reviewed. Patient 17 had surgery on 3/12/2024 for a cesarean section (a surgical delivery of a baby through a cut made in the mother’s abdomen and uterus). Patient 17 had a medical H&P completed on 3/10/2024. An update to the H&P was missing on 3/12/2024 in the medical record. During an interview on 3/15/24, at 11:35 a.m., with the DWN, the DWN stated, per hospital policy, an update to the H&P should be done 24 hours prior to the surgery. DWN stated, it appears it was not done and it was missed for this patient . During a review facility’s policy and procedure (P&P) titled, “[Name of Hospital] Medical Staff Bylaws”, February 4, 2020, the P&P indicated “... 10.6. History and Physicals ... When the medical history and physical examination is completed within thirty (30) days before admission or registration, the Medical Staff member or other qualified licensed individuals in accordance with state and federal statute must complete and document an updated examination of the patient within twenty-four (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services ...””

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 41166 Based on observation, interview, and record review, the hospital failed to ensure medications were stored according to manufacturer’s specification. This failure had the potential for render medications unsafe and/or ineffective for patients. Findings: During a concurrent observation and interview on 3/13/24 at 11:38 a.m. in the hospital’s main pharmacy, 20 100-ml (milliliter- unit of measure) bottles of Isovue-300 (contrast media used to increase the contrast of structures or fluids within the body in medical imaging), 22 100-ml bottles of Isovue-370 and 20 100-ml bottles of Isovue-250 were observed to not be protected from light in the pharmacy carousel. Pharmacist in Charge (PIC) acknowledged the Isovue bottles are to be protected from light and stated they should be stored in the manufacturer provided carton or amber bags. PIC stated protecting the Isovue bottles from light was related to the stability of the drug. During an interview on 3/18/24 at 10:10 a.m. with Director of Pharmacy (DOP), DOP stated that expectation was for medications that should be protected from light are protected from light to protect the integrity of the medications. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for iopamidol indicated, “Storage/Stability ... protect from light ...””

“PHARMACY DRUG RECORDS CFR(s): 482.25(a)(3) Current and accurate records must be kept of the receipt and distribution of all scheduled drugs. This Standard is not met as evidenced by: 41166 Based on interview and record review, the hospital failed to implement an effective system for reconciliation of all controlled drug (medications with high probability of addiction and are controlled by the federal government) losses and reconcile control drug discrepancies promptly. These failures had the potential to result in hospital staff diverting controlled drugs, which could place patients at risk for potential adverse outcomes including inadequate pain relief, as well as the potential for hospital staff to abuse controlled controls drugs. Findings: During an interview on 3/13/24 at 11:49 a.m. with Pharmacy Manager of Quality and Education (PMQE), PMQE stated the Controlled Substance Coordinator (CSC) was responsible for investigating discrepancies with nursing and if not solvable, drug diversion investigation team would review discrepancy that was not accounted for. During a concurrent interview and record review on 3/13/24 at 3:19 p.m. with CSC and PMQE, the hospital’s “Closed Reconciliation Report”, dated 1/1/24 to 1/31/24 was reviewed. The “Closed Reconciliation Report” indicated discrepancies were created on 1/4/24 for an unaccounted midazolam (controlled drug for anxiety) 5 mg dose for Patient (PT) 43, and on 1/11/24 for an unaccounted fentanyl (controlled drug for pain) 25 mcg dose for PT 42. CSC stated that for PT 42, the discrepancy for the unaccounted fentanyl 25 mcg dose was reconciled the next day by the prescriber, and for PT 43, the discrepancy for the unaccounted midazolam 5 mg dose was reconciled on 1/9/24 by the prescriber. CSC stated that the providers “back charted” to reconcile. During a review of PT 43’s “Order History” for midazolam, the “Order History” indicated, midazolam 5 mg was recorded on 1/9/24 to having been administered on 1/4/24 by anesthesiologist. During a review of PT 42’s “Order History” for fentanyl, the “Order History” indicated, fentanyl 25 mcg was recorded on 1/12/4 to having been administered on 1/11/24 by provider. CSC was unable to provide documentation for monitoring of “back charting” by providers for diversion prevention. During a record review on 3/13/24 at 3:57 p.m., the hospital’s “Pyxis Report” dated 1/18/24 was reviewed. The “Pyxis Report” indicated Anesthesiologist (ANT) 1 dispensed a 2 ml vial of midazolam 1mg//ml and a 2 ml vial of fentanyl 50 mcg/ml on 1/18/24 for PT 44. During a concurrent interview and record review on 3/14/24 at 11:27 a.m.., with PIC and PMQE, PT 44 and PT 45’s “Medication Administration Record (MAR)” dated 1/18/24 were reviewed. PIC acknowledged ANT 1 dispensed fentanyl and midazolam under PT 44’s profile and administered the medications to PT 45. A review of PT 45’s MAR indicated an order for fentanyl 25 mcg every five minutes prn breakthrough pain, may repeat up to maximum total dose of 100 mcg. PT 45’s MAR indicated, ANT 1 documented an administration of fentanyl 50 mcg on 1/18/24 at 1:11 p.m., 1:22 p.m., 1:27 p.m., and 1:36 p.m. PT 45’s MAR also indicated an order for midazolam 1 mg every 5 minutes prn agitation. PT 45’s MAR indicated, ANT 1 documented an administration of midazolam 2 mg on 1/18/24 at 1:07 p.m., and 1:31 p.m. PIC acknowledged ANT 1 did not administer fentanyl and midazolam according to PT 45’s orders. During an interview on 3/14/24 at 11:47 with PIC, PIC stated expectation is for documentation to match physician order. PIC stated, he was unaware of the discrepancy until the prior day when the discrepancy was identified. PIC stated, he became involved when discrepancies cannot be reconciled by CSC. PIC acknowledged fentanyl and midazolam incident with ANT 1 had been marked as resolved discrepancy. During an interview on 3/14/24 at 12:04 p.m. with Director of Pharmacy (DOP), DOP acknowledged tools to ensure accurate reconciliation, correct control dispense to correct patient and correct order, was not being used. During an interview on 3/15/24 at 10:10 a.m. with CSC and DOP, CSC acknowledged she did not have a monitoring system for discrepancies involving “back charting”. DOP stated, “We have not been sending high user report to anesthesiology for review. We identified that late yesterday.” DOP stated high user reports was a tool to help identify potential controlled substance mishandling, and to not do that for practitioner population left a gap. During a review of the hospital’s Policy And Procedure (P&P), titled, “Controlled Substance- Surveillance System”, dated 9/12/23, the P&P indicated, “Unreconciled dispenses are reviewed by unit leadership and pharmacy every weekday ... unreconciled dispenses are identified, resolved or investigated ... Pharmacy generates an ADC [automated dispensing cabinets] report that identifies ADC end users with high activity of controlled substance withdrawals in comparison to a similar cohort ... this report is reviewed by the pharmacy leadership and unit nursing leadership to ensure appropriate use of controlled substances. Nursing leadership attests compliance on a monthly basis.””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 45977 Based on observation, interview, and record review the hospital failed to ensure patient care equipment were properly maintained and ready for use when one vital sign monitor (a device used to measure the body’s basic medical indicators of health- temperature, pulse, breathing, and blood pressure) and one bladder scanner (a device used to assess the volume of urine retained within the bladder) was used for patients without preventative maintenance (the process in performing regular scheduled maintenance to help prevent unexpected failures). These failure had the potential risk to affect equipment performance and not functioning at their peak efficiency which could result in patient harm. Findings: During a concurrent observation and interview on 3/13/24, at 2:10 p.m. in cardiac Progressive Care Unit (CPCU- a special unit of the hospital that is dedicated to treating patients with serious heart issues) with the CPCU Nurse Manager (NM) 2 and Registered Nurse (RN) 16, one vital sign monitor preventative maintenance sticker was dated 2/2024. RN 16 stated she notified biomedical department (personnel that installs and maintain patient care equipment) and was told the vital sign monitor can be used 30 days past the date on the preventative maintenance sticker. NM 2 stated the vital signs monitor should be taken out of service for maintence and should not be used for patients. During a concurrent observation and interview on 3/13/24, at 2:25 p.m., with NM 2, a bladder scanner had a preventative maintenance sticker dated 2/2023. NM 2 stated the bladder scanner should have been taken out of service and should not be used for patients. NM 2 stated the bladder scanner without preventative maintenance had the potential risk for not working properly and harm a patient. During an interview on 3/14/24 at 9:25 a.m., with Biomedical Technician (BMT) 1, BMT 1 stated the preventative maintenance sticker on the patient care equipment shows the last day the equipment should be used as per hospital policy and procedure. During an interview on 3/28/24 at 9:05 a.m., with the Chief Nursing Officer (CNO), the CNO stated hospital staff should not use patient care equipment with a past due preventative maintenance and should be taken out of service. The CNO stated patient care equipment without a preventative maintence had the potential risk to result in patient harm. During a review of the facility’s policy and procedure (P&P) titled, “Medical Equipment Management Plan,” dated June 16, 2023, the P&P indicated, “... The objective of the Medical Equipment Management Plan ls to minimize the risks of using medical equipment through Inspections, scheduled maintenance and education in the safe use of medical equipment ... The management of medical equipment is a shared effort of the clinical and non-clinical departments and services, with the primary objective to provide safe, operational efficiency and reliability of medical equipment used on our patients. ... 1. Inspection, testing and maintenance. ... a. Inspection, testing and maintenance on a regular and consistent basis are part of the process to assure equipment performance. The initial inspection and test are part of the acceptance of new equipment. Ongoing inspection, testing and maintenance increases reliability, equipment life and user confidence. The intervals for inspection, testing and maintenance are based on the needs of the equipment and manufacturer’s recommendations. The specification of an annual interval ls not intended to be the standard in the hospital. The intervals may be less than or more than one year ... “”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47888 Based on observation, interview and record review, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infections for all patients, visitors and staff when the hospital placed Patient 53 in the Emergency Department (ED) North Hall while on contact precautions (special precautions for staff and visitors that are intended to prevent the transmission or spread of infectious agents) for a positive multi-drug resistant organism (MDRO- bacteria that have become resistant to certain antibiotics). As a result of these failures all patients, visitors and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms [small living things that could cause disease] are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: During a review of Patient 53’s “Electronic Health Record (EHR)” dated 3/8/24 to 3/14/24, the EHR indicated, Patient 53 was admitted to the hospital on 3/8/24 for Altered Mental Status (a change in the mental function that stems from illness, disorders and injuries that have affected the brain). The EHR indicated that even though the patient was admitted, she remained in the Emergency Department (ED) and was never moved into a private room. Patient 53 was in the ED during her hospital stay. During a review of Patient 53’s “Infections and Isolations (II)”, dated 3/8/24 to 3/14/24, the II indicated, “ ...PATIENT INFECTION STATUS: ESBL (Extended-spectrum beta-lactamases- an antibiotic resistant enzyme (small protein found in a living cell) that is found in some strains of bacteria) ... E. Coli (a bacteria that produces small proteins [enzymes] called ESBLs) ... Onset: 3/8/24 ... Added: 3/11/24 ... Last Indicated: Culture Urine (lab test to check for bacteria or other germs in a urine sample) ... PATIENT ISOLATION STATUS: ...Contact .... Added: 3/11/24 by (Infection Preventionist 2) ... Removed: 3/14/24 Encounter Ended (Patient 53 discharged) ...Specimen information: Urine ...”. During a review of Patient 53’s “Infections- Micro Results (IMR)” dated 3/13/24, the IMR indicated, “Infection Review: 3/8: ESBL and E. Coli in the urine + [positive], antibiotic through 3/14/24 at [8:59 p.m.] after 6 doses. Patient transitioned to comfort care (care that improves the quality of life by relieving suffering and providing practical, emotional, and spiritual support), antibiotic stopped so patient needs to remain on isolation ...”. During an observation on 3/13/24 at 11:40 a.m., in the Emergency Department (ED) North Hall (a hallway with patients, staff and visitors walking by) bay 11 (space in hallway considered to be the room number), Patient 53 laid on a gurney with patients in gurneys at her feet and head separated by a privacy screen at her feet and head only. There was no contact precaution signage present with staff, patients, and visitors passing by within an arm’s length of the patient. During a concurrent observation and interview on 3/13/24 at 3:45 p.m., with Registered Nurse (RN) 9 in the ED North Hall, RN 9 turned Patient 53 on her side without the use of personal protective equipment (PPE- equipment worn to protect the wearer from spread of infection or illness). RN 9 stated it was not safe for Patient 53 to be held in a hallway. During an interview on 3/14/23 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was responsible for Patient 53’s care. LVN 3 stated she did not know Patient 53 was on contact precautions for any positive test results. During a concurrent interview and record review on 3/21/24 at 3 p.m., with the Emergency Department Director (EDD), Patient 53’s EHR dated 3/8/24 to 3/14/24 was reviewed. The EHR indicated, Patient 53 was on contact precautions for ESBL and E. Coli in the urine. The EDD stated Patient 53 should have had signage over her gurney that indicated contact precautions. The EDD stated other patients and staff could have been exposed to ESBL or E. Coli because they did not follow contact precaution guidelines. The EDD stated this was a patient safety issue. The EDD stated staff did not follow the policy and procedure for isolation precautions. During an interview on 3/25/24 at 9:45 a.m., with the Infection Preventionist (IP) 1, the IP 1 stated that staff should have adhered to contact precaution guidelines when they interacted with Patient 53. IP 1 stated Patient 53 was on contact precautions from 3/11/24 to her time of discharge on 3/14/24. IP 1 stated that because staff did not follow contact precautions guidelines there was a risk for cross-contamination to other patients and staff to occur. IP 1 stated that Patient 53 and other patients in that hallway safety was put at-risk. IP 1 stated that Patient 53 should have been moved to a private room and not in a hallway. IP 1 stated the policy and procedure “Standard Precautions and Transmission [spreading of germs] Based Isolation and Isolation Guidelines”, were not followed. During a review of the facility’s Policy and Procedure (P&P) titled, “Standard Precautions and Transmission Based “, dated 8/12/21, the P&P indicated, “I. PURPOSE: To Prevent transmission of disease within the hospital to patients, staff and visitors. The intent of this policy is to provide guidance for placement of patients with known or suspected infectious diseases and address appropriate barriers to prevent disease transmission. II. DEFINITIONS: ... G. ESBL: Extended-spectrum B-Lactamases are enzymes that mediate resistance to extended-spectrum (third generation) cephalosporins (anti-microbials [inhibit the development and reproduction of microorganisms- bacteria, fungi, and viruses]) and monobactams (anti-microbials) ... IV. PROCEDURE: A. Contact Precautions 1. Contact precautions are initiated, in addition to stand precautions, for patients known or suspected to be infected or colonized with resistant organisms ... or other epidemiologically (diseases that are to be studied in terms of distribution and change to evaluate strategies to prevent illness from spreading, or management of that disease in person where it has already developed) important organisms ... 2. The patient’s RN or designee places a yellow contact precautions sign outside the patient’s room door where the sign is easily visible. The designated patient care unit staff or IP updates the EHR with the identified/suspected infectious organism(s) to indicate that the patient requires contact precautions ... 4. Equipment and supplies: a. Use disposable noncritical patient-care equipment (blood pressure cuff, thermometer, and stethoscopes) and keep them inside the patient’s room. b. Equipment which cannot be left in the patient’s room, must be thoroughly cleaned with a hospital approved disinfectant [kill germs] after use ... 5. Personal Protective Equipment (PPE) a. In addition to standard precautions, staff must always don gloves and gown when entering the patients room ... c. PPE is required for the healthcare worker if contact with the patient is anticipated ... 8. Visitors: a. All visitors should wear gown and gloves while in the contact precautions room ... b. It is the responsibility of staff to instruct visitors in the correct use of PPE and the importance of appropriate hand hygiene ...”. During a review of the facility’s P&P titled, “Isolation Guidelines “, dated 8/9/21, the P&P indicated, “See attached Isolation Guidelines Reference to obtain information regarding various diseases, what precautions are needed to care for patients, mode of transmission and other general information ... ISOLATION GUIDELINES REFERENCE: ... MDRO ... Precaution Notes: Contact Precautions ... Multi-drug resistant organism include ... ESBL ...”.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 42321 Based on interview and record review, the hospital failed to implement Emergency Department policies and procedures and failed to have ongoing monitoring for one of 34 patients (Patient 33) when nurses did not accurately assess the emergency severity index for Patient (Pt) 33. Pt 33 was brought in by level 1 (meaning urgent) ambulance transport on 3/13/24 at 5:35 a.m. with chief complaints of hematemesis (vomiting of blood), severe abdominal pain, low blood pressure and history of chronic urinary infections (a repeated or prolonged bladder infection) and atrial fibrillation (irregular heartbeat) and was not placed on a cardiac monitor (a device used to watch the electrical activity of the heart to ensure it is working normally) and frequent monitoring was not implemented in accordance with hospital policy and procedures (P&P). The physician did not prioritize and recognize the severity of Pt 33’s signs and symptoms and did not consider Pt 33’s past medical history and did not order additional diagnostic tests to determine the underlying reasons for Pt 33’s illness. Nurses placed the patient on a gurney in a hallway that did not provide direct line of sight and did not conduct monitoring and vital signs in accordance with the Pt 33’s needs and in accordance with Emergency Department (ED -a hospital area staffed 24 hours a day, 7 days a week, and provides unscheduled outpatient services to patients with conditions requiring immediate medical care) policy and procedure. These failures resulted Pt 33 not being monitored at the frequency needed to address his illness and a family member who was at the side of Pt 33 had to get the attention of ED nurses due to Pt 33’s unresponsiveness on 3/13/24 at approximately 9:30 pm. Pt 33 died at approximately 10:14 pm on 3/13/24. Because of the serious actual harm to Pt 33 related to not following Emergency Department policies and procedures and not providing ongoing nursing care and monitoring and not providing the medical services to address Pt 33’s clinical signs and symptoms, an Immediate Jeopardy (IJ a situation in which the provider’s noncompliance with one or more conditions of participation has caused or is likely to cause serious injury, harm, impairment, or death to a patient) was called on 3/22/24 at 5 p.m. under CFR 482.55(a)(3) A1104 (Code of Federal Regulations- a set of requirements issued by a federal government agency to implement laws) with the Chief Nursing Officer (CNO), Chief Medical Officer (CMO), Chief Operating Officer (COO), Vice President of Operations (VPO), Vice President of Quality Regulatory (VPQR), Vice President of Quality Outcomes (VPQO), Director of Quality Outcomes (DQO), and the Director of Accreditation and Licensure (DAL).The IJ template was provided to the facility. The hospital submitted an acceptable IJ Plan of Removal (Version 2) on 3/26/24 at 12:02 p.m., which addressed the actions needed to remove the IJ situation. The IJ Plan of Removal included but was not limited to the following: 1) An incident report completed for Pt 33 and case referred to Medical and Nursing Peer Review; 2) All ED staff received a case review of IJ concerns including the need for a comprehensive assessment of all patients entering the ED, integration of patients past medical history, ensuring continued assessment of presumptive diagnosis (identifies the likely condition of the patient) and consideration of alternative causes of abnormal vital signs. 3) Policies for ESI (ESI-the process to categorized patients from level 1, the most critically ill, to level V, the least critically ill) and Triage (to sort patients and receive medical care based on the urgency or severity of their needs) reviewed and deemed appropriate. Mandatory training on Triage Competency, which includes assigning an accurate ESI designation was assigned to all ED Registered Nurses (RNs) 4) ED Standards of Practice Policy reviewed and deemed appropriate added 3 inpatient RNs to every shift in the ED and 2 additional Patient Care Technicians (PCTs) are scheduled on every shift for monitoring, vs, and turning of patients. Written test was given to staff. 5) Cardiac Monitoring policy reviewed and deemed appropriate to ensure policy is being followed additional staff will be used (see 4). Education provided on cardiac monitoring and documentation. Written test was given to staff. 6) Provider Order policy reviewed and deemed appropriate staff educated on following orders and process if there is a delay in labs or other testing. 7) Audits were done to ensure staff are following the processes reiterated by the IJ education. Training and competencies of staff were validated. The components of the IJ Plan of Removal were validated onsite through observations, interviews, and record review. The IJ was removed on 3/27/24 at 4:30 p.m. with the facility Chief Nursing Officer (CNO), Vice President of Quality (VPQ), Director of Risk, Regulatory, and Patient Safety (DRRP), and the Supervisor of Licensing and Accreditation (SLA). Following the IJ removal, the facility remained in substantial noncompliance at the Condition level. Findings: During a review of Patient (Pt) 33’s ambulance run report dated 3/13/24 at 4:45 a.m., the run report indicated, “ ... Mode: Emergent (Immediate Response) ... Primary Impression: Lower GI (gastrointestinal - stomach) Bleeding Complaint: Vomiting Blood Other Symptoms: Pain, Abdomen. Pt is a 68 Y O M (year old male) CC (chief complaint)/ coffee ground emesis (vomit) w(with)/ Abd (abdominal) pain x [times] 1 day. Pt + (positive) [Brand Name] (medication blood thinner), + Hx (history) of bleeding ulcers, + hypotension (low blood pressure). Pt extensive Hx (history) of GI bleeds, BT (blood thinner), Afib (Atrial fibrillation irregular heart rhythm), paraplegic (loss of ability to move lower extremities Quad [meaning all four extremities are paralyzed]), dementia (progressive loss of intellectual functioning, impaired memory, and abstract thinking, often with personality changes, disease of the brain). Pt compliant w/meds (medication). Pt skin pale, hot, dry. Pt VSS (Vital signs stable) W/borderline hypotension ... Vitals Time 04:58 BP (blood pressure) 86/48 Mean Arterial[pressure [a measurement of the blood flow, resistance, and pressure within the arteries] 61 Pulse 100 Rhythm Irregularly [improper beating of the heart], Irregular Resp (respirations) 12 SPO2 (oxygen level) 95 (percentage of oxygen in the blood) at room air Pain 10 [meaning pain level is the highest 10 of 10] ... 05:28 BP 104/80 Pulse 100 Rhythm Irregularly Irregular afib Resp 12 SpO2 98 on oxygen Pain 10 ... ... Arrive Dest (Destination hospital): 03/13/2024 05:31:34 Transfer of Care: 03/13/2024 06:05:28 ...” During a review of Pt 33’s “Face sheet (a document that contains a summary of a patient’s personal and demographic information) dated 3/20/24, indicated Pt 33 was brought to the hospital ED by ambulance on 3/13/24 a 05:35 a.m. With admitting diagnosis of GI Bleed. Inpatient admission date/time: 3/13/2024 1:11 p.m.; Discharge Date/Time: 3/13/2024 10:14 p.m.; Disposition: Deceased/Expired. During a concurrent interview and record review on 3/20/24, at 2:30 p.m., Pt 33’s ED Pt Care Timeline and Electronic Health Records (EHR), dated 3/20/24 was reviewed with the Emergency Department Manager (EDM). Pt 33’s chronology of ED care as documented in the EHR was reviewed with the EDM. The EDM confirmed Pt 33 arrived by ambulance to the ED on 3/13/24 at 5:35 am and died at 10:14 p.m. the same day, 3/13/24. The EDM confirmed Pt 33 came in with a chief complaint of Hematemesis (vomiting of blood), was on a blood thinner, first set of vital signs (vs) were the following: temperature (T) 37.2 C (Celsius; 98.9 F), Heart rate (HR) 106, respiratory rate (RR) 14, BP 103/69, SpO2 94 % (percent) on room air. Pt 33 had a GCS (Glasgow Coma Scale score used to determine one’s consciousness) of 13, was confused but obeyed commands. The EDM confirmed at 5:49 a.m. Pt 33 reported abdominal pain as 10/10. The EDM stated the Triage Registered Nurse (RN) 18 would have gotten a verbal report from the ambulance crew while she was triaging the patient. RN 18 assigned Pt 33 an Emergency Severity Index score (ESI used in ED to determine the timing, urgency and location patient will go to in the ED ESI Level 1 Resuscitation (the action of reviving someone from unconsciousness or apparent death) ESI Level 2 Emergent ESI Level 3 Urgent ESI Level 4 Less Urgent ESI Level 5 Non Urgent) of 3 (3 urgent but not emergent) and Pt 33 was placed in the Yellow zone which was reserved for non-emergent patients. Pt 33 was assigned a provider who was a Doctor of Osteopathic medicine (a whole person approach to medicine) (DO 1), and DO 1 assessed the patient and ordered labs, nausea medication, and [Brand Name] (proton pump inhibitor ( medications used to decreased stomach acid production) The EDM confirmed Pt 33’s HR 114, SpO2 95 on room air and Pt 33 threw up three times and DO 1 ordered IV fluids but no repeat labs to see if Pt 33’s blood levels had dropped. The EDM confirmed at 11:30 a.m. Pt 33 had a fever, temperature of 38 C (100.4 F), HR 118, RR 20, BP 92/57 (note no Oxygen levels taken/documented at this time) and DO 1 placed an order for [Brand Name] (fever reducer), oxygen therapy, nursing to monitor HR, RR, Manual BP, T, O2 saturations (percentage of blood saturated with oxygen), and for Pt 33 to be placed in a location of the ED where continuous monitoring is available. The EDM stated DO 1 also ordered Sepsis (body’s extreme response to an infection) Management protocol (which included to contact physician for further antibiotic orders, if no infection specific antimicrobial therapy (medications used to kill bacteria) is ordered; Broad spectrum antibiotic administered within the last 24 hours; blood cultures (a test that looks for germs) sodium chloride 0.9% (indicated for replenishing fluid and for restoring sodium concentration in the body) bolus (administration of an entire medication over a short period of time), 1000 milliliters (ml - unit of measurement); [Brand Name] (oral antibiotic enteral coated [a barrier to prevent the gastric acids in the stomach from dissolving drugs after you swallow]) tablet 500 milligrams (mg - unit of measurement) (oral [mouth]); Lab Lactic acid (lab done when sepsis is suspected, will be elevated if the patient is in sepsis) Sepsis (serious condition resulting from the presence of harmful microorganisms (living organism that are too small to be seen with the naked eye) in the blood or other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). The EDM confirmed at 1:12 p.m. Pt 33’s admitting doctor (MD 1) include cardiac monitoring (monitor placed on patient to watch heart rate and rhythm) and at 1:17 p.m. placed order for EKG (Electrocardiogram measures the electrical activity of the heart) and chest x ray (image of chest to see if there is an infection in the lungs). The EDM stated after reviewing Pt 33’s Electronic Health records (EHR) that no cardiac strips were documented, and this should have been done. The EDM confirmed [Brand Name fever reducer was given at 1:16 p.m. for temperature that was taken at 11:30 a.m. and the next set of vs were done at 6:33 p.m. The EDM stated vital signs should have been done every four hours or sooner depending on the status of the patient. The EDM stated she was not sure how many patients were assigned to RN 19 this day. At 1:58 p.m. MD 1 notified of Lactic Acid results 4.2 (normal is 0.5 2.2). MD 1 ordered Zosyn (a medication used to treat infections) IVPB (intravenous piggyback-a small bag of medication attached to the primary bag of intravenous [into the veins] fluids) at 6:37 p.m. The EDM stated Pt 33 had more antibiotics ordered later but that Pt 33 never received any antibiotics during this visit. The EDM stated the expectation was the nurses would follow the doctor’s orders and give the antibiotics as soon as they could. The EDM stated that after reviewing Pt 33’s EHR she felt Pt 33 should have been an ESI of 2, there was a delay in his care, and the patient did not get adequate treatment in this hospital. During a concurrent interview and record review on 3/20/24, at 2:40 p.m., Pt 33’s Electronic Health Record (EHR) was reviewed with the EDM. The EHR indicated Pt 33 last visit to this hospital was on 3/4/24, when Pt 33 came in for kidney stones (a hard deposits made of minerals and salts that form inside the kidneys [a pair of organs in the body]) urinary tract infection (UTI infection in the bladder) and had to have a stent (a tubular structure placed to help relieve an obstruction) placed in his ureter (the duct in which urine passes from the kidney to the bladder). The EHR indicated Pt 33 had a past medical history of Quadriplegia, neurogenic bladder (nerves that carry messages to the bladder do not function properly) with use of chronic urinary catheter (tube placed in bladder to help remove urine), chronic afib, hypotension, and diabetes. The EDM stated the patient’s pertinent history should have been considered when determining the ESI of a patient coming into the ED, and for Pt 33 the pertinent history was not considered in establishing the ESI. During a concurrent interview and record review on 3/26/24, at 7:54 a.m., with RN 18, Pt 33’s “ED Pt Care Timeline” for visit dated 3/13/24 was reviewed. RN 18 stated when she triaged a patient that has come into the ED, she looks at their physical presentation, report is given by the ambulance crew or patient, signs, and symptoms they are having, vital signs, previous health conditions and then gets their current vital signs. RN 18 stated she asked the ambulance crew and Pt 33 if he had been vomiting in the ambulance and stated she would have remembered if he had black on his face from the vomit, but she does not recall this. RN 18 stated she asked Pt 33 if he was in pain per her documentation on the timeline Pt 33 reported having 10/10 abdominal pain. RN 18 stated she assigned Pt 33 an ESI of 3 but if he had been actively vomiting when he came in or if his HR was in the 130’s she may have assigned him an ESI of 2 but his presentation at the time of triage was stable. RN 18 stated she was not told that Pt 33 was on [Brand Name blood thinner] and was in Afib but then changed her statement when she saw her documentation that he was on [Brand Name blood thinner]. RN 18 stated Pt 33’s blood pressure (the force of circulating blood on the walls of the arteries) was at 103/69, HR 106, RR 14, SpO2 94 % on room air and T 37.2 C. RN 18 stated she did not recall if Pt 33 had a foley catheter and stated all patients that come into the ED are vulnerable. During a concurrent interview and record review on 3/21/24, at 2:50 p.m., with Clinical Nurse Supervisor (CS) 3, Pt 33’s “ED Pt Care Timeline” for visit 3/13/24 was reviewed. CS 3 stated he was the CS on 3/13/24 from 7 a.m. to 7 p.m. and after reviewing Pt 33’s timeline that he does not recall this patient. CS 3 stated staffing on 3/13/24 placed all nurses at six patients to one nurse ratio or more and ED ratios are supposed to be four patients to one nurse. CS 3 stated Pt 33 was placed in a hallway bed in yellow zone which was identified as YY 02, he stated for visibility purposes of the patients and no power for patient equipment to be hooked up to, this area was closed end of last week. CS 3 stated after reviewing Pt 33’s ED timeline for 3/13/24 based on his vs he could be an ESI of 3 but since he was in for GI bleed and on [Brand Name blood thinner] he would have assigned the patient an ESI of 2 and put him in the red zone to get treatment started. CS 3 stated because Pt 33 was in afib, tachycardic (tachy heart rate faster than 100 beats a minute) and was in for GI bleed cardiac monitoring would be appropriate and vs should probably be done every 15 30 minutes, but frequent vital signs were not done. During a concurrent interview and record review on 3/25/24, at 9:30 a.m., with RN 19, RN 19 stated she worked on 3/13/24 and took care of Pt 33 from 7 a.m. to 7 p.m. and Pt 33 was originally put in the yellow zone in a hallway bed and was here for a GI bleed. RN 19 stated depending on where you were at the nurses station you could see Pt 33 but if you were sitting down this area was not visible. RN 19 stated Pt 33 had family at the bedside a good part of her shift. RN 19 remembers she talked with them and provided education on what she was doing and what medications she was giving to Pt 33. RN 19 stated she believes Pt 33 vomited at least once on her shift. RN 19 stated she had five patients that day and felt she was able to care for all of her patients’ needs. RN 19 stated Pt 33 was on a cardiac monitor, she remembers putting him on it, as for the strips she said normally the techs monitoring the rhythms will call them with any changes and bring them the strips to put in the patients record but does not recall if this happened. RN 19 stated normally the techs are responsible to do the vs on the patients, but it is ultimately the nurse’s responsibility to make sure the vs and the rhythm strips were done and reviewed and this was not done per hospital policy. During a concurrent interview and record review on 3/21/24, at 4:15 p.m., with RN 20, Pt 33’s ED Pt Care Timeline for visit dated 3/13/24 was reviewed. RN 20 stated on 3/13/24 she was floated (a nurse assigned to work in a different unit to meet staffing needs) to work in the ED that night from 7 p.m. to 7 a.m. and had five patients. RN 20 stated Pt 33 was in for vomiting and was supposed to get an EGD (Esophagogastroduodenoscopy tube with camera placed down patient’s throat to see where the bleeding is coming from) that night. RN 20 stated she first went to check on Pt 33 around 8:30 p.m. and stated, “he didn’t look good, he was pale and tachy”. RN 20 stated a house supervisor was passing by at that time and she grabbed him and told him what was going on with Pt 33. RN 20 stated this house supervisor took Pt 33 immediately over to the red zone. RN 20 stated while she was at the bedside of Pt 33 before he was moved Pt 33’s second lactic acid came back at 10.6 (high) and she called the hospitalist (a physician who cares for inpatients) on call. RN 20 stated she had not provided any treatment to Pt 33 so far on her shift. RN 20 stated she was told by RN 19 that Pt 33 was stable and a GCS of 14 but RN 19 did not mention Pt 33 was in afib. RN 20 stated she does recall that Pt 33 had a cardiac monitor on him. During a review of Pt 33’s Significant Event Note dated 3/13/24, at 10:01 p.m., the note indicated, “I [MD 2] was notified by RN that the family noticed that the patient became unresponsive. Repeat lactic acid is up to 10.6. I [MD 2] assessed the patient at bedside ...” During a concurrent interview and record review on 3/22/24, at 9:40 a.m., with DO 1, Pt 33 EHR for 3/4/24 and 3/13/24 were reviewed. The DO 1 stated when he is assigned a patient in the ED, he will go assess the patient, start orders, and sometimes if he is at a computer, he will look at the patient’s history. DO 1 stated he is not sure if he saw Pt 33’s history but did look at the triage note that indicated Pt 33 was a quad, had afib, and was on a blood thinner. DO 1 stated since Pt 33 came in with GI bleed. DO 1 stated he would not have ordered the patient urine to be tested for infection right away even if he was just here 3/4/24 with a UTI. DO 1 stated, “You don’t always worry about infection” when referring to patients with chronic foley catheter use. DO 1 stated if there are critical results for labs the lab will usually call the nurse or the doctor right away. DO 1 confirmed that the record indicated Pt 33 had a temp of 38 C at 11:30 a.m. on 3/13/23 and an order for Tylenol 1,000 mg was ordered by him. DO 1 stated Erythromycin (a medication use to treat infections) was an appropriate medication to be ordered at this time because he believed that Pt 33 was having a GI bleed and not a different infection at that time. The EHR for Pt 33 on 3/13/24 indicated a lactic acid was ordered at 11:57 a.m. by DO 1, this lactic acid did not result until 1:22 p.m. as 4.2 (high). The DO 1 stated at this time the patient was no longer on my list and was under the care of MD 1. Pt 33’s EHR indicated DO 1 ordered a Lactic Acid at 1:56 p.m. DO 1 stated if there is an emergency for an admitted patient still waiting in the ED the ED MD would assist in the care of the patient. Pt 33’s EHR indicated the next complete blood count or hemogram (a blood test used to look at overall health) was not ordered until 1:17 p.m. by MD 1. During a concurrent interview and record review on 3/21/24, at 4:37 p.m., with MD 1, Pt 33’s EHR for 3/13/24 was reviewed. MD 1 stated Pt 33 was a Quad, he was from a nursing home and came into the ED for coffee ground emesis times two days; labs were done and the hemoglobin (hgb- a protein inside the red blood cells that carries oxygen) was lower but not critical, white blood cells (wbc- part of the body’s immune system that fights infection and diseases) were slightly elevated but could have been due to his GI bleed. MD 1 stated Pt 33 was being admitted for a GI bleed. MD 1 stated he remembered speaking with the patient’s son at the bedside and the patient himself was not a good historian. MD 1 stated he noted Pt 33 had crackles (the clicking, rattling noise made by the lungs with a respiratory disease) at the base of his lungs and ordered a chest x ray to rule out an infection, a liter of fluids, a hemoglobin (per the EHR these were ordered at 1:17 p.m. also cardiac monitoring, EKG, and phosphorus level and magnesium levels (a chemical used by the body) Pt 33 ‘s EHR indicated lactic acid of 4.2 was called to MD 1 at 1:56 p.m. MD 1 stated when he came back to check on Pt 33 he noticed the labs had not been drawn and there were no recent vital signs and asked the nurse to follow up with lab to get them done. MD 1 also requested the RN to get a set of vital signs; once the vital signs were done, he noted Pt 33’s vital signs had seemed to improve with the intravenous fluid and Pt 33 was awaiting an EGD to be done (per the EHR this occurred at 6:42 p.m.). MD 1 stated he also ordered [Brand Name] (antibiotic) for possible aspiration pneumonia (occurs when food or liquids is breathed into the lungs) per the EHR this was ordered at 6:37 p.m. after the chest x ray resulted). MD 1 stated he got off his shift at 7 p.m. that night and signed out to a hospitalist on duty for admitted patients. MD 1 stated when he came back the next morning, he reviewed the chart and found out what happened to Pt 33. MD 1 stated he called Pt 33 ‘s daughter and apologized that Pt 33 was in the hallway bed and explained that Pt 33 probably had aspiration pneumonia due to his vomiting and reviewed what had happened to the patient. MD 1 stated, “I expect nursing staff to follow my orders and give the antibiotics. I expect the labs I order to get done and if there are issues, for staff to inform me (referring to the labs not getting done in a timely manner)”. During an interview on 3/26/24, at 3:13 p.m., with the Medical Director of ED (EDDIR), the EDDIR stated the hospital has done a thorough review of Pt 33’s ED visit on 3/13/24. The EDDIR stated Pt 33 received “Zero” antibiotics during this ED visit. The EDDIR stated he felt that DO 1 appropriately treated and assessed Pt 33 on 3/13/24 because Pt 33 came in stable with possible GI bleed, “Yes” he was tachy, but this could have been due to the GI bleed. The EDDIR stated a patient’s medical history should be considered when treating a patient. The EDDIR stated Pt 33 did not spike a fever until later and the DO 1 treated it. The EDDIR stated Erythromycin was appropriate for a patient with a GI bleed, but it would not treat pneumonia or a UTI that may have caused the fever. The EDDIR stated when Pt 33’s lactic acid came back at 4.2, he should have been getting the antibiotics and thinks MD 1 could have ordered them sooner but even then, they were not given and should have been. During an interview on 3/28/24 at 9 a.m., with the Chief Nursing Officer (CNO), the CNO stated the expectation is that nursing staff will follow physician orders. The CNO stated part of vital signs is checking the SpO2 and vital signs should be monitored per policy and per patient specific orders. The CNO stated orders for labs should be drawn on time and if there are issues (meaning there is a difficulty drawing the blood sample from the patient), the phlebotomist (a medical professional trained to perform blood draws) should contact the nurse to let them know. During a review of the Hospital’s policy and procedure (P&P) titled, “Triage EMS (Emergency Medical Services)”, effective date 8/2/2021, indicated, “I. PURPOSE A. To provide a timely response to patients presenting to the emergency department with medical and or psychiatric complaints. B. To prioritize patients’ needs and maintain control of patient flow and care. C. To allow prompt recognition of change in patient status. II Policy. A. All persons requesting treatment in the emergency department will be triaged by a registered nurse who has completed the triage orientation and has documented competency. B. Patients will be triaged prior to the completion of registration. C. Nursing staff will conduct an ongoing assessment of those patients’ awaiting placement into the treatment area. III. Procedure. A. Patients in need of immediate intervention will be taken directly to the treatment area. B. Patients that do not require immediate lifesaving interventions. will be assessed including 1. Chief complaint and history of present illness, including physical findings and care before arrival. 2. Travel history 3. Pertinent past medical history 4. Complete vital signs Temperature, Pulse, Respirations, Blood Pressure, O2 Saturations and Pain Assessment. 5. Medication, allergies, place allergy armband when appropriate ... C. RN will assign priority using the Emergency Service Index (ESI). D. RN will update the flag in electronic health record (EHR). and designate the patient as a Trauma, Burn, Cardiac or Psychiatry E. Reassessment of triaged patients will be based on the ESI priority assigned to the patients: 1. at least every four hours for urgent patients. 2. at least every one hour for emergent patients. 3. as warranted by patient condition and response to treatment...” During a review of the Hospital’s P&P titled, “Emergency Severity Index Policy”, effective date 7/7/2021, indicated, “I. PURPOSE To provide guidelines for all patients presenting to the Emergency Department. All patients presenting to the Emergency Department will undergo an Emergency Severity Index Assessment by the triage nurse to initiate a Medical Screening Examination and determine the timing, urgency, and appropriate location in the ED for completion of the Medical Screening examination and disposition of the patient. II.POLICY A. Patients will have the Emergency Severity Index assessment at the Triage area of the Emergency Department or within the treatment area of the Emergency Department. Ill. PROCEDURE A. The triage nurse will categorize the patient into one of the following five (5) ESI Levels. The levels will be determined by using the following: Index Level Definitions, Data Base, and ESI algorithm. INDEX LEVEL DEFINITIONS: ESI Level 1 Resuscitation ESI Level 2 Emergent ESI Level 3 Urgent ESI Level 4 Less Urgent ESI Level 5 Non-Urgent DATA BASE: A. 1. Chief Complaint 2. Appearance 3. Vital Signs 4. Brief description of relevant history of illness or injury 5. Age 6. Previous medical history 7. Mental status 8. Skin color, warmth, and moisture 9. Pain severity 10. Focused physical exam. Example location and depth of a laceration (skin wound) with presence or absence of abnormal neurovascular (nerves and blood vessels) findings and observation of ability to ambulate ... ESI Flow Chart Level 1 Requires immediate lifesaving interventions Level 2 High risk situation or confused, lethargic or disoriented or severe pain or distress Level 3 2 or more resources Level 4 1 expected resource Level 5 No expected resource ... Patients who have a pain rating of 7 / 10 or greater should be considered for meeting ESI Level 2 criteria. It is up to the discretion of the triage nurse to determine whether the clinical condition and pain rating in combination warrant a rating of ESI Level 2. During a review of the Hospital’s P&P titled, “Standard of Practice for Emergency Department”, effective date 9/14/2022, indicated “I. PURPOSE These standards of practice are necessary and realistic levels of the nursing process, which assure that quality of care is given to each patient. The purpose of these standards are to outline the baseline care a patient can expect to receive in by the Emergency Department (ED) of [Name of hospital]. II. Definition. Provider Attending physician, Fellow, resident physician, or Advanced Practice Professional (APP). III. Policy. A. The patient and in the ED will receive care in accordance with the Standards of Practice for the ED area. The Standard of Practice categories are adopted by [name of hospital], which the Licensed Nurse must address when caring for each patient. B. Standards of Practice are to form the basis for monitoring and evaluating patient care in the ED. IV. Procedure. A. STANDARD OF PRACTICE: Safety, Medication, IV therapy, Infection Control. The patient will be provided a safe, therapeutic environment for the delivery of health care. The Licensed Nurse will: 1. Maintain patient confidentiality all times. 2. Adhere to all established [hospital name] policies and procedures 3. Intervene appropriately to correct unsafe situations. 4. Follow the infection control policies found in the infection control manual. 5. Maintain the bed in a low position would not at the bedside. 6. Maintenance of the side rails in the up position will be dependent upon the patient’s assessed needs ... 8. Administer medications as prescribed by professional and legal standards and those guidelines adopted by [name of hospital] and directed by physician order ... B. STANDARD OF PRACTICE: Patient Rights & Nursing Process. The patient will have a systematic and continuous assessment of their health status performed by a licensed nurse. Utilizing the nursing process. The RN will: 1. Collect, document, and communicate data to the interdisciplinary (a group of professionals working together with a common goals) team. The frequency of data collection will vary according to the gravity of patient’s problems/needs as well as individual standardized procedure and physician’s order.... F. Vital signs with pain assessment a minimum of every four hours unless otherwise ordered or warranted.... D. Standards of Practice: Emergency Measures. 1. Provide care in such a way as to direct and or prevent complications and life-threatening situations. 2. Patient care staff will initiate immediate treatment for life threatening situations...” During a review of the “Hospital Emergency Department Agreement”, effective date 3/2/2012, indicated it is between [name of hospital 2] and [name of hospital 1] and [name of Physician medical group] who agrees as follows: ... “AGREEMENTS In Consideration of the mutual promises set forth in this agreement, hospital and [name of provider group] agree as follows: I. Medical services provided by [name of provider group]: 1.1 Medical Director ... 1.3 Patient Care Services. 1.3.1 The attending [name of provider group] Physician in the department shall render medical services within the standards of emergency medical practice to patients arriving at the department. Physicians shall provide treatment to stabilize each patient’s condition and then shall make a reasonable effort to refer the patient to his/her own private physician. Or to an appropriate staff physician... 1.4 Standards of Care. 1.0.1. Physicians who attend the Department shall perform medical services and conduct the Department in accordance with the requirements and recommendations of the Joint Commission in (TJC) and other similar organization with deemed CMS status [a designation granted to healthcare facilities accredited by an approved accrediting organization], Regulatory agencies, the policies and procedures of Hospital, and the bylaws and rules and regulations of the Hospital’s medical staff....” During a review of the Hospital’s policy titled, “Cardiac and Remote Monitoring Inpatients 14 and Older”, effective date 4/14/22, indicated, “I. PURPOSE a period to provide guideline for cardiac monitoring of patients 14 and older at [Name of Hospital]. 2. Definitions. A. Cardiac monitoring Continuous cardiac monitoring, which is the visualization of the electrical activity in the heart through a portable or hardwired monitoring system with the use of telemetry transmitter. 3. POLICY ... B. Patients are to receive the care appropriate for their diagnosis or procedure, including cardiac monitoring, ordered by a physician.... D. All telemetry cardiac monitoring. Patients are to receive continuous cardiac monitoring unless otherwise ordered by a physician. E. Information about the patient’s cardiac rhythm is to be included in handoff of communication ... G. Staff assigned to units providing continuous cardiac monitoring will demonstrate competencies as described in procedure.... 4. PROCEDURE .... All monitor patients will have rhythm strips printed for admission, transfer, temporary removal and rhythm abnormalities, and every four hours for the duration of the cardiac monitor order... 3. Registered nurse or clinical supervisor reviews and initials the strip... K. In the event of emergent and non-emergent baseline rhythm changes: ... 3. The RN/CS Notified will respond and physically assess the clinical status of the patient to make determination about physician notification and appropriate intervention ... R. All cardiac rhythm strips will be placed in the patient’s thin chart to be scanned into the EHR after discharge ... VI. DOCUMENTATION A. the assigned RN/designee is responsible for validating and documenting the patient’s rhythm and any changes and interventions that occur. B. The RN will date and sign the cardiac monitoring strip printed by the Monitor Technician (a skilled professional trained to observe the patient’s heart electrical activity) every 4 hours. C. Any contact with the physician ... D. Routine Cardiac monitoring documentation includes the patient’s rate, rhythm, ectopy (extra or skipped heartbeat), PR interval, QRS complex, QT interval (the heart electrical impulse/travel). The documentation will be a minimum of every 8 hours or by unit standard in the EHR ...” During a review of the Hospital’s policy titled, “Provider Orders”, effective date 8/25/23, indicated, “I. PURPOSE a. To provide guidelines for initiating and or updating the physician’s therapeutic treatment plan.... II. DEFINITIONS ... C. Order Categories 1. Routine ... within 24 hours ... 2. Urgent/As Soon As Possible (ASAP) ... initiated and completed within 4 hours of request ...””