Huntington Beach Hospital

“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: 39199 Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. This failure had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services. Findings: The hospital failed to ensure the MSE was completely provided to determine whether or not an EMC existed for one of 20 sampled patients (Patient 1). Cross reference to A2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 39199 Based on interview and record review, the hospital failed to ensure one of 20 sampled patients (Patient 1) received an appropriate MSE to determine whether an emergency medical condition existed prior to discharge from the ED. The hospital discharged Patient 1 before the physician completed the MSE or authorized the patient’s discharge. As a result, the physician-ordered diagnostic evaluation, including a CT scan of the abdomen and pelvis, was not completed, preventing the physician from determining whether Patient 1 was medically and psychiatrically stable for discharge. Less than one hour after being discharged from Hospital 1, Patient 1 was transported by ambulance to another hospital’s ED, where he continued to report suicidal ideation, received a psychiatric evaluation, and was transferred to a psychiatric hospital the following day. Findings: Review of the hospital’s P&P titled Medical Screening Examinations reviewed 9/2025 showed: - Emergency Medical Condition (EMC): A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. - Medical Screening Examination (MSE): The screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition does or does not exist. - The hospital will provide a screening examination for every person who comes to the emergency department making a request for examination and treatment. - The MSE will be based on the patient’s condition and prior history. - The scope of the examination is tailored to the patient’s presenting complaint and the medical history of the patient. The MSE is an ongoing monitoring process, which continues until a medical emergency condition is found not to exist or until appropriate steps to stabilize the presenting emergency medical condition begin. Review of the hospital’s P&P titled Psychiatric Patients in the ED dated 6/2025, showed patients will be discharged, admitted, or transferred based on the mental health evaluation. On 7/2/26, a record review of Patient 1’s medical record from Hospital 1 was initiated with the CNO and RN 2. Medical record review for Patient 1 showed Patient 1 arrived in the ED on 4/26/26 at 1733 hours. Review of the ED Triage Note dated 4/26/26 at 1754 hours, showed Patient 1 was brought to the ED by ambulance with chief complaints of suicidal ideation and active vomiting. Review of the ED Provider Note dated 4/26/26 at 1816 hours, showed Patient 1’s chief complaint was suicidal ideation with a plan to suffocate himself. Patient 1 reported he had been feeling suicidal for the past two weeks, was recently hospitalized for depression, and also reported nausea, vomiting, and generalized abdominal cramping. Review of the physician’s order dated 4/26/26 at 1907 hours, showed an order for a stat CT scan of the abdomen and pelvis due to abdominal pain, vomiting, and leukocytosis (white blood cell count higher than normal). Review of the ED Notes Addendum entered by RN 1 dated 4/26/26 at 1927 hours, showed Patient 1 continued to be noncompliant with the plan of care by drinking water to induce vomiting. The documentation showed Patient 1 was informed he must comply with the plan of care and verbalized understanding but continued to drink water. The documentation further showed Patient 1 was documented as having eloped; however, the same entry also documented that Patient 1 was escorted off hospital property by PSOs. Review of Patient 1’s Patient Care Timeline showed RN 1 removed Patient 1’s peripheral IV (intravenous) catheter on 4/26/26 at 1925 hours. The Patient Care Timeline further showed Patient 1 was discharged at 1940 hours. Review of the PSO documentation dated 4/26/26 at 1930 hours, showed PSO 1 and another PSO assisted the ED nursing staff with escorting Patient 1 off hospital property because of noncompliance. However, review of Patient 1’s medical record showed the physician-ordered CT scan was not completed and there was no physician’s order authorizing Patient 1’s discharge. On 7/3/26 at 1100 hours, during the concurrent interview and record review of Patient 1’s medical record, the CNO and RN 2 verified the findings. On 7/2/26 at 1441 hours, an interview was conducted with PSO 1. PSO 1 stated that on 4/26/26, he received a call from RN 1 requesting assistance in the ED. PSO 1 stated he and another PSO responded to the ED, where RN 1 informed them that Patient 1 was not cooperating, was not following directions, and was ready for discharge. PSO 1 stated he observed Patient 1 still wearing a hospital identification band and informed RN 1, who then removed the band. PSO 1 stated he asked Patient 1 why he was not cooperating, and Patient 1 responded that he was just vomiting. After being asked whether Patient 1 wanted to leave or was removed from the ED, PSO 1 stated that staff asked Patient 1 to leave. On 7/2/26 at 1701 hours, an interview was conducted with RN 1, who stated the incident occurred at the beginning of her shift on 4/26/26, and recalled that Patient 1 was repeatedly instructed to stop drinking water because he would vomit every time he drank it, but he did not comply. RN 1 stated she explained to Patient 1 that staff could not continue to treat him if he did not comply with instructions and informed him that he could stay if he complied or leave. RN 1 stated that at one point Patient 1 said he wanted to leave, at which time she removed his IV catheter. RN 1 stated Patient 1 continued returning to the sink instead of gathering his belongings and leaving the ED, so she called the PSOs to assist, and the PSOs escorted him out of the ED. RN 1 stated she was unaware that Patient 1 had presented to the ED with a chief complaint of suicidal ideation because she had not received a complete report from the previous nurse and had not yet reviewed the patient’s medical record. RN 1 stated she would not have given Patient 1 the option of leaving if she had known he had suicidal ideation. RN 1 verified there was no physician’s order to discharge Patient 1 and that she did not speak with the physician prior to Patient 1 being discharged. RN 1 stated it was her decision to involve the PSOs to ensure the situation remained safe and to escort Patient 1 out of the ED. RN 1 acknowledged that she documented Patient 1 had eloped but confirmed Patient 1 did not elope and was discharged without a physician’s order authorizing the discharge. On 7/3/26 at 1002 hours, a telephone interview was conducted with Physician 1. Physician 1 stated Patient 1’s chief complaint was suicidal ideation with a plan, and the need for a psychiatric evaluation. Physician 1 stated Patient 1 reported consuming alcohol earlier that day and was vomiting in the ED after drinking water. Physician 1 stated the medical workups included a CT scan of the abdomen and pelvis to medically clear Patient 1. Physician 1 stated the MSE for Patient 1 was started but not completed because the diagnostic workup was incomplete, and he would have wanted Patient 1 to complete all ordered testing. Physician 1 stated he could not determine whether Patient 1 was medically stable because the ordered diagnostic testing had not been completed. Physician 1 stated he considered Patient 1’s condition stable but guarded, that Patient 1 required a psychiatric evaluation, and that Patient 1 was not psychiatrically cleared because he first required medical clearance before evaluation by the psychiatric team. Physician 1 stated the CT scan was ordered to rule out an emergent medical condition and that he was awaiting the CT scan results before determining Patient 1’s disposition. Physician 1 stated he was unaware Patient 1 was leaving the ED, was not notified before Patient 1 left, and verified there was no physician’s order authorizing Patient 1’s discharge. Review of Patient 1’s medical record from Hospital 2 showed Patient 1 was brought by ambulance to Hospital 2’s ED less than one hour after being discharged from Hospital 1. Review of Patient 1’s Patient Care Timeline from Hospital 2 showed Patient 1 arrived in the ED on 4/26/26 at 2001 hours, with a complaint of suicidal ideation. Patient 1 was alert and oriented, reported having suicidal thoughts for the previous two weeks, and stated he was just kicked out of Hospital 1. Patient 1 wished to be dead, had thoughts of killing himself, and had thought about how he might kill himself. Review of Patient 1’s medical record from Hospital 2, showed Patient 1 remained in the ED, received a psychiatric evaluation, and was transferred to a psychiatric hospital the following day.”

“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: 39199 Based on observation, interview, and record review, the hospital failed to ensure the hot water temperature in two of two showers in the geropsychiatric unit were maintained between 105 to 120 degrees Fahrenheit per the hospital’s P&P. This failure posed the risk of inadequate personal hygiene and patient discomfort during bathing. Findings: Review of the hospital’s P&P titled Domestic Hot Water Temperature Log dated March 2025 showed in the interest of patient, visitor, and employee safety, it is the policy of the hospital that the domestic hot water temperature is maintained between 105 to 120 degrees Fahrenheit at the fixture of any patient room, shower, or restroom. On 1/7/26 at 1355 hours, a tour of the geropsychiatric unit was conducted with the CNO, RN 4, Plant Operations Supervisor, and the Plant Operations Engineer. The Plant Operations Engineer was observed in the utility room running water from the faucet. The Plant Operations Engineer stated they were flushing cold water that had been sitting in the pipes to allow hot water to reach the fixture. The Plant Operations Supervisor stated that the building was older and it could take approximately five minutes of running the water for the hot water temperature to reach the appropriate range, stating the hot water temperature should be between 105 and 120 degrees Fahrenheit. On 1/7/26 at 1400 hours, the Plant Operations Engineer began running the hot water in Shower Room 1. At 1408 hours, after running the hot water for eight minutes, the highest temperature the water reached was 94 degrees Fahrenheit. On 1/7/26 at 1409 hours, the Plant Operations Engineer began running the hot water in Shower Room 2. At 1416 hours, after running the water for seven minutes, the highest temperature the water reached was 84.9 degrees Fahrenheit. Soiled patient clothing was observed lying on the floor of Shower Room 2, to which RN 4 stated that the shower room had been used earlier by a patient and the staff had not yet cleaned the shower room. On 1/7/26, after testing the temperature of the hot water in both shower rooms, the Plant Operations Supervisor and the Plant Operations Engineer verified the hot water temperature did not reach the minimum required temperature of 105 degrees Fahrenheit. On 1/8/26 at 1330 hours, an interview was conducted with CNA 1 who stated it usually took a while for the water to get slightly warm; however, recently the patients have been complaining that it was not getting warm or hot, and the water coming out of the showers had been cold. On 1/8/26 at 1341 hours, an interview was conducted with MHW 1, who stated the lack of hot water in the two showers had been an ongoing issue. It could take up to 15 minutes or more for the water to get hot, and on some days there was no hot water, requiring patients to take cold showers. On 1/8/26 at 1350 hours, an interview was conducted with RN 5, who stated the lack of hot water in the two shower rooms had been an ongoing and known issue for management. RN 5 stated they had given patients showers when there was no hot water, adding that it was unfortunate, but some patients had to “just suck it up” and take a cold shower. RN 5 acknowledged that many patients complained about the lack of hot water, but it had been this way since RN 5 started working there. On 1/8/26 at 1357 hours, an interview was conducted with RN 6, who stated the lack of hot water in the showers was an ongoing issue, which RN 6 reported to the Plant Operations department many times, but it had not been fixed.”

“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: 29558 Based on observation, interview, and record review, the hospital failed to ensure the triage nurse categorized the ESI level as per the hospital’s P&P for two of 20 sampled patients (Patients 2 and 3). This failure had the potential to result in poor clinical outcomes and serious adverse events for the patients in the ED. Findings: Review of the hospital’s P&P titled Triage dated December 2016 showed the following: * The Emergency Severity Index 5-tier Triage System categorizes Emergency Department patients by acuity and expected resources needed. Acuity is determined by using the patient’s vital signs and potential for life, limb or organ threat. Resources are defined as the number of resources or interventions a patient is expected to need to reach a disposition. * Triage Level One (Emergent) requires immediate life-saving intervention (such as cardiac arrest, respiratory arrest, overdose, critically injured trauma patient). * Triage Level Two (Urgent): High Risk Situation (such as unstable patient, severe pain or distress, behavioral emergency, ALOC). * Triage Level Three (Potentially Unstable): Requires 2 or more resources and VS may not be in “Danger Zone.” If VS are in the “Danger Zone,” then this patient should be upgraded to an ESI level of Two as per the ESI algorithm. (An example of ESI Level Three may be a patient with acute abdominal pain or frank pain indicating kidney stones). 1. Review of the hospital’s P&P titled Stroke Management dated September 2021 showed the activation of Code Stroke occurs when any patient exhibits signs or symptoms of a stroke or TIA. The P&P also showed Code Stroke is the emergent process for recognition and treatment of acute stroke patients who either present to the hospital within 6 hours of onset of symptoms. On 5/13/25, Patient 2’s closed medical record was reviewed. Patient 2’s closed medical record showed Patient 2 arrived at the ED on 5/12/25 at 0308 hours and was admitted to the hospital on 5/12/25 at 2029 hours. Review of the Patient Care Timeline dated 5/12/25, showed the following: * At 0321 hours, the code stroke was activated. * At 0322 hours, Patient 2 was moved to CT. * At 0332 hours, Patient 2’s ESI level was 3. On 5/13/25 at 0933 hours, an interview and concurrent medical record review was conducted with the ED Director. When asked, the ED Director stated Patient 2’s ESI level should have been at least 2. 2. On 5/12/25 at 0820 hours, the ED Triage area was toured with RN 1. When asked, RN 1 stated that RN 1 was assigned to be a triage nurse today. When asked, RN 1 stated the ESI level would be determined based on ESI Algorithm posted on the wall in the triage area. Review of the ESI Algorithm showed the following: * ESI level 1 requires immediate life-saving intervention. * ESI level 2 would be for patients who were in a high-risk situation, confused/lethargic/disoriented, or in severe pain/distress. * ESI level 3 would be for patients needing many different resources. If patients with ESI level 3 had danger zone vitals (for example, HR >100 beats per minute or RR >20 breaths per minute, SaO2 <92% for patient’s older than 8-year-old), then an ESI level 2 would be considered. On 5/12/25 at 0840 hours, Patient 3 was observed arriving at the ambulance bay. RN 1 was observed receiving a report from the EMT. On 5/13/25, Patient 3’s medical record was reviewed. Patient 3’s medical record showed Patient 3 arrived at the ED on 5/12/25 at 0854 hours and was admitted to the hospital on 5/12/25 at 2310 hours. Review of the Patient Care Timeline dated 5/12/25 showed the following: * At 0854 hours, Patient 3’s arrival complaint was shortness of breath. * At 0855 hours, Patient 3’s heart rate was 127 beats per minute and the respiration rate was 30 breaths per minute. * At 0859 hours, RN 1 documented Patient 3 needed “Many” different resources. RN 1 documented Patient 3 did not have danger zone vitals. RN 1 documented Patient 3’s ESI level was 3. On 5/13/25 at 0933 hours, an interview and concurrent medical record review was conducted with the ED Director. When asked, the ED Director stated Patient 3’s ESI level should have been at least 2 because Patient 3’s vitals were in the danger zone.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 45560 Based on observation, interview, and record review, the hospital failed to ensure the signage for EMTALA rights with respect to the examination and treatment for EMC and women in labor were posted conspicuously in the ED areas as evidenced by: * Failure to ensure the EMTALA signage was posted in the ED’s triage area. * Failure to ensure the EMTALA signage was posted in the ED’s treatment rooms/bays. * Failure to ensure the EMTALA signage was posted in the ED’s obstetric treatment room. These failures had the potential to result in individuals not being aware of their rights to the examination and treatment in the event of an EMC. Findings: Review of the hospital’s P&P titled EMTALA Transfer Policy reviewed May 2024 showed under Signage, Hospital shall post signs conspicuously in lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs in the form required by CMS that specifies the rights of individuals to examination and treatment for emergency medical conditions. Signs shall be posted in the Emergency Department, Labor and Delivery, ambulatory clinics and other locations where patients may present for emergency services. On 5/13/25 at 0910 hours, the hospital’s ED was toured with the ED Director. There was no EMTALA signage posted in the ED triage area, treatment rooms/bays 3,4,5,6,7, and 11, and the obstetric treatment room (room 10). In a concurrent interview, the ED Director verified and acknowledged the findings. On 5/13/25 at 1210 hours, a conference was held with the Chief Executive Officer, Chief Nursing Officer, and the ED Director. They were notified and acknowledged the above findings.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the ED central log included all the items as per the hospital’s P&P. This failure had the potential to result in the hospital not being able to accurately track the care provided to the patients who presented to the ED for treatment for an emergency medical condition. Findings: Review of the hospital’s P&P titled EMTALA Compliance: Emergency Medical Treatment and Active Labor Act dated December 2024 showed each department of the hospital that provides medical screening examination shall maintain a central log recording the following: a. Patient’s name b. DOB c. Sex d. Chief complaint e. Arrival time f. Triage time g. Registration time h. MSE time i. Medical record/Account number j. Mode of arrival k. Name of LIP who provided MSE l. If admitted Name of admitting LIP m. Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged. On 5/12/25 at 1027 hours, an interview and concurrent record review was conducted with the ED Director. Review of the hospital’s ED central log showed the patient’s name, MRN, admission date and time, physician’s name if admitted, and point of origin. However, the log did not show the DOB, sex, chief complaint, arrival time, triage time, registration time, MSE time, and name of LIP who provided MSE. On 5/13/25 at 1210 hours, the CNO and ED Director verified the above findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 29798 Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital’s P&P for two of five sampled patients (Patients 1 and 3) when the nursing staff did not notify the patients’ family members about the use of restraints for Patients 1 and 3. This failure posed the potential to result in poor health outcomes to the patients. Findings: Review of the hospital’s P&P titled Restraints: Non Violent Behavior dated June 2024 showed in part: * Definitions: - Restraint: Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. - Family: The person who plays a significant role in the patient’s life, which may include a person(s) not legally related to the patient. The person is often referred to as the surrogate decision-maker, if authorized to make care decisions for the patient if he or she loses decision-making capacity. * Purpose: To provide guidelines for the for the provision of a safe patient environment in which restraints are distinguished from devices not used as restraints and the least restrictive alternative to the use of restraints are pursued in order to reduce and minimize the utilization of restraints. * Policy: The patient and family are educated to the best extent as possible. Education should include the purpose for restraint use, the criteria for termination and the monitoring/care that will be provided. * Documentation: Use Electronic Medical Record Restraint Flow Sheet, restraint order form and narrative notes to document all pertinent information in the medical record including but not limited to physician/family notifications. 1. On 10/8/24 at 1242 hours, an interview and concurrent record review of Patient 3’s medical record was conducted with the CNO. Patient 3’s medical record showed the patient was admitted to the hospital on 10/6/24. Review of the physician’s order dated 10/6/24 at 1947 hours, showed to use soft restraints to the bilateral upper extremity. The restraint reason was for the interference with the medical treatment. However, further review of Patient 3’s medical record did not show the RN notified the patient’s family/responsible party of the restraint order/initiation. On 10/2/24, the above findings were acknowledged by the CNO. 38660 2. On 10/8/24 at 0940 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Nursing Manager of Behavior Health. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/1/24. Review of the restraint flowsheet dated 10/7/24, showed Patient 1’s bilateral soft restraint on left and right wrists were started at 1100 hours. Review of the physician’s order dated 10/7/24 at 1956 hours, showed to use soft restraints to bilateral wrists. The restraint reason was for the interference with the medical treatment. However, further review of Patient 1’s medical record failed to show the nursing staff notified the patient’s family/responsible party about the use of restraint for Patient 1. The Nursing Manager of Behavior Health confirmed the above findings.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the medication orders were verified and administered for one of five sampled patients (Patient 1) as per the hospital’s P&P. This failure posed the risk of inappropriate care and treatment for the patient. Findings: Review of the hospital’s P&P titled Medication Administration dated March 2024 showed the following: * Except in an emergency, a pharmacist will review the medication order prior to administration. * Prior to administration, the practitioner will: - Verify the prescriber’s order against the medication being administered. - Discuss any unresolved, significant concerns about the medication with the prescriber or physician covering the patient and/or relevant staff involved with the patient’s care, treatment and services. - Review the medication administration record (MAR) for any special considerations that would influence the administration of medications, including but not limited to, clinical parameters, NPO status, medications at odd hours, one time only medications, or medications that must be given with food. - Verify that the medication is stable based on visual examination or particulates, or discoloration and that the medication has not expired - Verify that there is no contraindication/allergy for administering the medication. * If the patient refuses a medication: scheduled medications may be given early or late or may be omitted under specific circumstances, such as but not limited to patient absence from unit, patient refusal, or nausea/ vomiting. If administration of a scheduled medication will be or has been delayed or administered early beyond allowable expectations: - Document the medication that is being non administered - Document the discussion of risks and benefits of the medication and also the refusal of the medication - Evaluate the need to change the timing of future doses - Notify the physician and document name of person notified and response to notification. On 10/8/24 at 1400 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the Nursing Manager of Behavior Health. Patient 1’s medical record showed Patient 1 was admitted to the hospital on 10/1/24. a. Review of Patient 1’s laboratory blood test report dated 10/2/24 at 0102 hours, showed the TSH blood level was 0.110 µU/mL (reference ranges is 0.400 - 4.500 µU/mL). Review of Patient 1’s MAR showed the physician’s order dated 10/2/24 at 1230 hours showing levothyroxine (a medication used to treat hypothyroidism) 200 mcg tablet oral before breakfast. The MAR showed the levothyroxine was not given to Patient 1 from 10/3-10/8/24. Review of hospital pharmacy’s Intervention Audit Trail showed the pharmacist tried to contact the physician on 10/4/24 at 0845 hours, about the order of levothyroxine. The Nursing Manager of Behavior Health stated Patient 1’s blood TSH level was low. The pharmacist tried to contact the physician to adjust the dose of the levothyroxine order, but the physician did not respond. b. Review of Patient 1’s MAR showed the physician’s order dated 10/2/24 at 1230 hours, for vortioxetine (antidepressant) 20 mg tablet by oral in the morning. The MAR showed the vortioxetine was not given to Patient 1 from 10/3-10/8/24. Review of hospital pharmacy’s Intervention Audit Trail showed the pharmacist tried to contact the physician on 10/2/24 at 1230 hours about the order of vortioxetine. Further review of Patient 1’s medical record, there was no documentation to show the nursing staff attempted to contact the physician regarding these above missing medications. The Nursing Manager of Behavior Health verified the above findings and stated the vortioxetine medication was not formulated by the hospital. The pharmacist tried to reach the physician for an alternative treatment or request patient’s own supply, but no response from the physician. c. Review of Patient 1’s MAR showed the physician’s order with the started date as of 10/2/24 and ended date as of 10/14/24, for azithromycin (antibiotic medication) 500 mg oral daily. There was no documented evidence to show azithromycin was administered to the patient on 10/7/24. Further review of Patient 1’s medical record did not show if Patient 1 refused the medication. The Nursing Manager of Behavior Health verified the above findings and stated she was not sure if Patient 1 refused medication, or the medication was not administered to Patient 1.”

“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: 38660 Based on interview and record review, the hospital failed to ensure the nursing staff followed the physician’s order of blood transfusion for one of five sampled patients (Patient 4). This failure had the potential to impact the patient’s health and safety or result in in the prolonged hospitalization. Finding: Review of the hospital’s P&P titled Blood and Blood Component Therapy, Nursing Management of Non-Emergent, Urgent, Massive dated March 2024 showed the following: * Purpose: To assure blood/ blood component use is appropriate and the informed consent has been obtained by the patient’s physician prior to blood bank release of blood/components and administration is carried. To ensure that patient care is delivered in a safe and effective manner utilizing the nursing process. * After appropriate confirmation, blood and blood components may be administered when indicated, per physician’s order, in a safe and effective manner. On 10/8/24 at 1650 hours, an interview and concurrent review of Patient 4’s medical record was conducted with the Nursing Manager of Behavior Health and Director of ED and ICU. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 9/15/24. Review of Patient 4’s laboratory blood test report showed Patient 4’s hemoglobin (Hgb) level was 6.1 g/dL (normal ranges 13.5- 17.5 g/dL) on 9/25/24 at 0600 hours, 7.4 g/dL on 9/25/24 at 0925 hours, 7.2 g/dL on 9/26/24 at 0600 hours, and 8.5 g/dL on 9/26/24 at 1405 hours. Review of the physician’s order dated 9/25/24 at 1326 hours, showed to transfuse one unit of Red Blood Cell (RBC) for the Hgb level less than 8 g/dL. Review of Patient 4’s medical record failed to show documentation the nursing staff had administered one unit of RBC as per the physician’s order when Patient 4’ Hgb was 7.4 g/dL on 9/25/24 at 0925 hours. Review of the Transfusion Record showed 300 ml (one unit) of RBC was transfused to Patient 4 on 9/26/24 at 1025 hours. The Nursing Manager of Behavior Health and Director of ED and ICU verified the above findings.”