Uci Health - Los Alamitos

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 45560 Based on interview and record review, the hospital failed to ensure the nursing staff monitored and assessed the patient’s status and response to restraints for one of six sampled patients (Patient 3) as per the hospital’s P&P. This failure posed the risk of substandard outcomes for the patient. Findings: Review of the hospital’s document titled Restraints and Seclusion; Policy and Nursing Documentation Changes and Updates, undated showed under frequency, complete documentation under “Restraint Placement/Monitoring” and “Restraint Patient Assessment,” to be done at the beginning and end of the shift or with any changes in the patient’s condition or restraints. On 6/30/25, Patient 3’s medical record was reviewed with the Director of Quality. Review of Patient 3’s medical record showed Patient 3 was admitted to the hospital on 6/25/25. Review of the Restraint Initiation Non Violent order dated 6/26/25 at 2200 hours, showed the soft limb restraints were to be applied to Patient 3’s bilateral upper extremities. An additional review of Patient 3’s physician’s orders showed the order for restraints was renewed on 6/27/25 and 6/28/25. Review of the Restraint Placement Flowsheet dated 6/28/25, showed the restraint monitoring was completed for Patient 3 at 0700 hours (start of day shift). The Director of Quality was unable to locate documentation showing the restraint monitoring was completed at the end of the day shift on 6/28/25. On 7/1/25 at 1330 hours, the Director of Quality acknowledged and verified the above findings.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care and services to two of seven sampled patients (Patients 1 and 2) as evidenced by: 1. For Patient 2, the pain assessment and reassessment were not performed before and after the morphine (narcotic pain reliever) 2 mg IVP was given to the patient. In addition, the nursing staff failed to ensure Patient 2 received the oxygen as per the physician’s order. 2. For Patient 1, the nursing staff failed to provide Patient 1 food or fluids for approximately 28 hours while they were waiing for the transfer to another facility. These failures posed the increased risk of substandard health outcomes to the patients. Findings: 1. On 2/10/25 at 1140 hours, Review of Patient 2’s closed medical record was conducted with the Director of Clinical Quality Improvement. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 12/11/24, and discharged on 12/22/24 at 1027 hours. a. Review of the hospital’s P&P titled Pain Management dated January 2024 showed the following: * Definitions: A. No pain : 0 B. Minor or Mild pain: scale 1-3. 1. Very mild - very slight pain. Most of the time not even noticeable (1). 2. Disconcerting - Minor, noticeable but not overwhelming (2) 3. Tolerable - Very noticeable but not unbearable and overtime, frequently are able to adapt to the pain (3). C. Moderate: Scale 4-6 1. Distress - strong deep pain similar to a toothache or stubbing your toe (4). 2. Very distressing - Strong, deep piercing pain, similar to walking on a sprained ankle. The pain is not only noticeable but the patient is being preoccupied with management of the pain (5). 3. Intense - Strong deep, piercing pain so strong it seems to partially dominate patient senses causing them to think somewhat unclearly (6). D. Severe: Scale 7-10 1. Very Intense - same as 6 hours but the pain completely dominates the patient senses (7). 2. Utterly Horrible - pain so intense the patient can no longer think clearly (8). 3. Excruciating Unbearable - pain so intense it is intolerable and must be relieved immediately (9). 4. Unimaginable - most people have never experienced this type of pain, so severe loss of conscious (10). * Policy: A. All patients will be assessed for the presence, absence and history of pain, and will receive individualized treatment and support in the management of their pain. - Assessment or reassessments will be made: at a minimum of every 4 hours; after any: known pain-producing event, pain management intervention, change in the level of care; with vital signs or per unit policy; within 30-60 minutes following medication administration; and as needed. B. Pain assessment will be performed using the appropriate tool after determining the patient’s ability to self-report. - For patients who are able to self-report, the Numeric and Faces pain scales will be used. - Some pain scales for specific patients’ population who are not able to self-report are as follows: a. CPOT (Critical Patient Observation Tool) b. FLACC (Face, Legs, Arms, Crying and Consolability) c. Other scales are available in the electronic medical record based on patient location and diagnosis. Review of the Order Sheet showed on 12/11/24 at 1446 hours, an order to give morphine 2 mg/ml, IVP, every 2 hours, PRN for moderate pain. On 2/12/25 at 1037 hours, review of Patient 2’s eMar was conducted with the Critical Care Manager. Patient 2’s eMar and CPOT pain assessment showed the following: - On 12/12/24 at 1721 hours, morphine 2 mg IVP was given for CPOT 4 (moderate pain). When asked for the pain reassessment, the Critical Care Manager stated she did not see a reassessment for pain. - On 12/12/24 at 2022 hours, Patient 2 was given morphine 2 mg IVP for CPOT 6 (moderate pain). When asked for the pain reassessment, the Critical Care Manager stated she did not see a reassessment after the pain medication was given. The Critical Care Manager was asked if the reassessment for pain after intervention was to be done within 60 minutes. The Critical Care Manager stated if that was what it said in the hospital’s P&P. When asked to verify the pain reassessment on the hospital’s P&P, the Critical Care Manager stated she had it memorized. On 2/12/25 at 1355 hours, a continued review of Patient 2’s medical record showed on 12/14/24 at 0400 and 0800 hours, the pain assessment showed Patient 2’s CPOT was 0. Review of Patient 2’s eMar showed on 12/14/24 at 0507 hours, the patient was given morphine 2 mg IVP for moderate pain as ordered. However, there was no documented evidence of the pain assessment and reassessment using CPOT pain scale for the indication of morphine 2 mg IVP at the pain assessment section. b. On 2/12/25 at 0915 hours, review of Patient 2’s medical record was conducted with the Critical Care Manager. Review of the physician’s order dated 12/11/24 at 1416 hours, showed continuous oxygen therapy by nursing, two liters/minute of oxygen via nasal cannula, and the oxygen saturation goal of greater than 92%. Review of the Patient 2’s vital signs on 12/12/24, showed the following: - At 0000 hours, the patient’s HR was 104 bpm. The patient’s cardiac rhythm was atrial fibrillation. The patient’s RR was 22 breaths/minute. The patient’s BP was 118/106 mmHg. The patient’s oxygen saturation was 92% on room air. - At 0030 hours, the patient’s temperature was 36.5 degrees C. - At 0100 hours, the patient’s HR was 110 bpm. The patient’s RR was 23 breaths /min. The patient’s BP was 125/91 mmHg. The patient’s oxygen saturation was 91% on room air. - At 0200 hours, the patient’s HR was 117 bpm. The patient’s RR was 24 breaths/min. The patient’s BP was 120/103 mmHg. The patient’s oxygen saturation was 90% on room air. - At 0202 hours, the patient’s HR was 119 bpm. The patient’s RR was 26 breaths/min. The patient’s oxygen saturation was 92% on room air. The Critical Care Manager was asked to show documentation the reason for keeping the patient on room air when Patient 2’s oxygen saturation was 90% and 91%. The Critical Care Manager stated there was no documented reason for the patient being on room air. 45560 2. Review of the hospital’s P&P titled Patient Rights and Responsibility dated September 2022 showed the patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity. Consideration shall be given to the psychosocial, spiritual and cultural variable influencing the patient. On 1/21/3005 at 0648 hours, a complaint was received at the California Department of Public Health alleging Patient 1 was not offered food or water during their stay at the hospital’s ED. Review of Patient 1’s closed medical record was initiated on 2/10/25. Patient 1’s medical record showed Patient 1 arrived at the hospital’s ED by ambulance on 1/11/25 at 1635 hours. Review of the physician’s orders for Patient 1 showed an order for a regular diet dated 1/12/25 at 1413 hours. Review of ED discharge form dated 1/12/25 at 2005 hours, showed Patient 1 was transferred to another healthcare facility on 1/12/25 at 2005 hours. On 2/11/25 at 1545 hours, an interview and concurrent record review was conducted with the ED Director. The ED Director stated although the order for diet was entered on 1/12/25 at 1635 hours, it did not necessarily mean Patient 1 was not provided food. The ED director stated the department secretary would at times order trays directly from dietary for patients that had been in the ED for a prolonged amount of time. When asked to locate documentation in Patient 1’s EMR showing Patient 1 received food and/or fluids while they were in the ED, the ED Director was unable to locate such documentation. On 2/12/25 at 1600 hours, Director of Clinical Quality Improvement was notified and acknowledged the above findings.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff developed the care plan related to cardiac and respiratory problems for one of seven sampled patients (Patient 2). This failure posed an increased risk of substandard health outcomes to the patient. Findings: Review of the hospital’s P&P titled Interdisciplinary Plan of Care dated June 2021 showed the following: * Purpose: - To ensure that care, treatment, and rehabilitation are planned and appropriate to the patient’s needs and severity of illness. - To identify individualized patient care goals and interventions and to achieve those goals in collaboration, interdisciplinary manner. * Policy: - The RN will initiate a plan of care after completion of the admission assessment. - All members of the interdisciplinary team involved in the care of the patient are responsible for contributing to the plan of care throughout the patient’s hospitalization. Documentation will be in the patient’s medical record. - Assessment, planning, and evaluation are based upon actual or potential problems, anticipated length of stay, assessed needs, policies, patient care standards, cultural issues, available resources and will be consistent with other therapies and or disciplines. - Expected patient outcomes (goals) will be realistic and measurable. - The plan of care will be reviewed every shift and updated as patient progress indicates. - The patient will be reassessed prior to discharge to determine to what extent the identified outcome was met. - The patient, and the family and/or partner-in-care will participate in the plan of care, as appropriate. - Discharge planning is initiated upon admission to the inpatient area and will address the continuum of care and referrals. * Procedure: - Care plan can be initiated from the Orders section of the EMR. - The suggested care plan (based on the patient diagnosis) found in the orders section of the EMR can be initiated if appropriate to the patient’s clinical status and modified as the patient processes through the continuum of care. - Additional plan of care can be added as needed. - The plan of care will be reviewed, modified as needed, or completed and/or discontinued at least once a shift. On 2/12/25 at 0915 hours, an interview and concurrent review of Patient 2’s closed medical record was conducted with the Critical Care Manager. Patient 2’s closed medical record showed the patient was admitted to the hospital on 12/11/24, with diagnosis of rapid A-fib with RVR rate of 185 bpm. The patient was admitted to the SDU on 12/11/24 at 1737 hours and was on diltiazem (a medication used to control rapid heartbeats or abnormal heart rhythms) drip. A code blue was called for the patient on 12/12/24 at 0524 hours. The patient presented with lethal arrhythmia VT. The patient was orally intubated indicated for respiratory failure, respiratory distress, and airway protection. After the patient had ROSC and intubated, the patient was transferred to ICU. Patient 2 was in the ICU with BP support medication and sedation and maintained intubated. On 12/19/24 at 0836 hours, Patient 2 had another episode of cardiac arrest presented with Vtach and Vfib and stabilized with A-fib after the ACLS CPR. Review of the Plan of Care showed the care plan for pain, fall, tube feeding, and asthma. On 2/12/25 at 1452 hours, the Critical Care Manager was asked about the plan of care for rapid A-fib, when the patient’s condition had changed, had cardiac arrest twice on 12/12 and 12/19/24, intubated for respiratory failure, and was on blood pressure support and sedation. The Critical Care Manager stated the care plan had to be related to cardiac and respiratory problems. When asked for the respiratory related plan of care, the Critical Care Manager stated there was a care plan for asthma. However, the Care Plan for Asthma did not show a plan of care for the patient intubated with respiratory failure. The Critical Care Manager was asked to show a care plan related to cardiac problems for the patient’s reason of admission of A-fib with RVR and on blood pressure support after the two code blue, when the patient had cardiac arrested. The Critical Care Manager could not show a plan of care related to cardiac problems.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the licensed staff implemented the hospital’s P&Ps for one of seven sampled patients (Patient 2) as evidenced by: 1. The code blue records on 12/12 and 12/19/24 were not documented accurately and completed for Patient 2 as per the hospital’s P&P. 2. The PRBC amount infused was not recorded at the end of blood transfusion for Patient 2 as per the hospital’s P&P. In addition, there was no documented evidence the PRBC transfusion was infused at 125 ml per hour during the first 15 minutes for Patient 2 as per the hospital’s P&P. These failures posed the increased risk of substandard health outcomes to the patient. Findings: On 2/10/25 at 1140 hours, interview and concurrent review of Patient 2’s closed medical record was conducted with the Director of Clinical Quality Improvement. Patient 2’s closed medical record showed the patient was admitted to ED on 12/11/24. Review of the ED MD Note dated 12/11/24 at 0942 hours, showed Patient 2 was complaining of worsened SOB and described as constant and severe. Patient 2 also complained of mild chest pressure and feeling anxious. The ED Medical decision making was Rapid A-fib, dysrhythmia, heart failure, and planned to admit to inpatient. Patient 2 was admitted to the hospital’s SDU on 12/11/24 at 1737 hours and expired on 12/22/24. Review of the Discharge Summary dated 12/23/24, showed Patient 2 expired on 12/22/24. Patient 2 had cardiac arrests on 12/12 and 12/19/24. 1. According to the AHA dated 2020, the Adult Cardiac Arrest Algorithm showed the initial step is to start CPR, to give the patient oxygen, and attach the patient to a monitor or defibrillator. The CPR quality includes to push hard and fast chest compression of 100 to 120 per minute and allow the chest to recoil, minimize interruptions in compressions, if there is no advance airway such as ET, give 30 compressions to 2 ventilation. Check the pulse and rhythm for no more than 10 seconds every 2 minutes. Determine if the rhythm was shockable or not. For VF or pulseless VT, charge the defibrillator and resume chest compression until the defibrillator was charged. Shock the patient for initial dose of 120 to 200 joules as recommended with the use of Biphasic defibrillator. Resume CPR for 2 minutes and establish IV or IO access. Check for pulse and rhythm and if shock is indicated such as VF or pulseless VT to administer the shock. Continue CPR for 2 minutes and give the patient epinephrine every 3 to 5 minutes and consider advanced airway and capnography giving 1 breath every 6 seconds once ET is in place. Check the pulse and rhythm for no more than 10 seconds, deliver the shock if the rhythm was shockable then continue with CPR for 2 minutes. Consider giving antiarrhythmia for VF or pulseless V tach and treat reversible causes such as hypoxia, cardiac tamponade, hypovolemia etc. On the start of the CPR, once the pulse and rhythm are checked, if the rhythm was not shockable such as PEA or asystole, give the patient epinephrine (a medicaiton used to treat low blood pressure or used for patient with cardiac arrest) and continue CPR. Establish IV or IO access. Give patient epinephrine every 3-5 minutes and consider advanced airway and capnography. Check the pulse and rhythm after 2 minutes of CPR. If the rhythm was not shockable continue CPR and treat reversible causes. Check the pulse and rhythm after 2 minutes of CPR. If the rhythm is not shockable, no signs of ROSC, repeat the process to do CPR and give epinephrine or shock the patient if the rhythm is shockable. If the patient had ROSC, proceed to post-cardiac arrest care and consider appropriateness of continued resuscitation. Review of the hospital’s P&P titled Code Blue/Code White Procedure dated January 2023 showed the following: * Definitions: - Code Blue is the emergency code for an adult cardiopulmonary arrest. - Code Blue or Rapid Response Team is a multidisciplinary team that oversees the practices and equipment requirements for Emergency cardiac or resuscitative care. The committee reports to the Department of Emergency Medicine. - AED is an Automated External Defibrillator. * Purpose: - To define the policies and procedures guiding actions for prompt resuscitation of persons experiencing cardiopulmonary arrest. - To define oversight of care provided during cardiopulmonary arrest situation. - To establish a mechanism for evaluation analysis and process changes, as necessary, to promote optimal outcomes. * Policy: - A code blue or white will be initiated per protocol on patients whose wishes are they be resuscitated in the event of an impending or actual cardiopulmonary arrest. - Current American Heart Association (AHA) guideline for BLS, Pediatric, ACLS, and Neonatal Resuscitation Provider will be followed at all times. Standard Precaution will be followed. - RNs with ACLS certification may initiate and direct ACLS protocol until the physician arrives. - A Code Blue or White evaluation will be completed after the code and forwarded to the Code Blue or RRT for analysis and follow-up, as necessary. Analysis of the data will be utilized to improve practices or process and presented to the Department of Emergency Medicine at least quarterly. * Procedure: - The person identifying the cardiopulmonary arrest will initiate BLS and stay with the patient until the code blue team arrives.... A designated RN from Critical Care and Emergency Response Team will respond to every code, and a designated RN from the ED will respond to every code white. - Members of the Code Team will include (but is not limited to): ED physician, ERN, Critical Care Nurse (Code Blue and Code White), ED Nurse (Code White), Respiratory Therapist, RN Administrative Supervisor or designee, Staff Nurse, Pharmacist 0700 to 2200 hours, Laboratory. * Responsibility of Code team members: 1. The ED physician or designee is the Team Leader. 2. The CN, Primary Care Nurse and/or designee: - Obtains medications from the Automated Dispensing Unit (ADU) as needed during the code. - Assures completion of the cardiac arrest record which includes documentation of ECG monitor strips. - Completes evaluation form. - Assures notification of attending physician or family 3. ACLS certified providers (including ERN and or Critical Care Nurse) - Assist with BLS. - Initiates IV access if needed. - Administers ACLS medications - Oversees monitoring 4. Staff nurse caring for the patient - Initiates or assist with BLS - Assists the emergency response team - Remains at patient’s bedside to provide information related to code status, admission history, and medications. 5. Respiratory Therapist: - Assist with BLS, airway management. * Code Blue procedure (adult cardiopulmonary arrest) 1. Assess for unresponsiveness. 2. Dial call code blue to room location. 3. Begin BLS protocol per AHA guidelines. Place AED hands free pads on patient when the defibrillator arrives. Remove intubation tray, medication trays from crash cart and open in preparation for use. 4. Establish IV access if none present. 5. Proceed with BLS or ACLS guidelines as appropriate. * After the Code is completed: 1. The ED physician or responding physician(s) will enter orders electronically as necessary to provide continuing care for the patient if the attending physician is unavailable. 2. If necessitated by the patient condition and medical needs, the patient will be transported on a monitor to Critical Care with ERN and RT (as needed) in attendance. Hand off communication will be given by the staff nurse caring for the patient to the Critical Care Nurse and documented in the patient’s medical record. 3. The Cardiac arrest record will be filled out as completely as possible...The pink copy with a complete evaluation of the code is forwarded to the Quality Department for analysis and needed follow up. .... The debriefing form will be completed and forwarded to the Critical Care Director for follow up as needed. a. Review of the Code Blue Record dated 12/12/24, showed the following: - The code blue was recognized at 0524 hours at Room B. The code blue was witnessed, Patient 2 was unconscious and had ECG and pulse oximeter monitoring at the time of the onset of the code blue. Patient 2 was breathing spontaneously. However, there was no documentation the patient was on or with oxygen during the code blue for assisted ventilation during the code blue. At 0540 hours (after 16 minutes) was the first assisted ventilation via an ET tube. The section of the person who intubated the patient was left blank. - At 0526 hours, Patient 2’s cardiac rhythm was VT and chest compression was performed. - At 0527 hours, an AED was attached on the patient and 200 joules (electric energy to shock the heart) was delivered to the patient. However, the cardiac rhythm section was left blank, for the indication of the shockable cardiac rhythm. - At 0528 hours, Patient 2’s cardiac rhythm was PEA and chest compression was provided. Epinephrine was checked; however, there was no dose and route the medication was given. - At 0530 hours, Patient 2’s cardiac rhythm was left blank. The section of Epinephrine was checked; however, there was no dose and route the medication was given. The section of Sodium Bicarb (minerals and electrolytes) was checked; however, it did not show the dose and route the medication was given. - At 0532 hours, the patient’s cardiac rhythm was PEA. However, the chest compression, treatment for PEA as per the AHA was not documented as performed. - At 0534 hours, the patient’s cardiac rhythm was ST. However, there was no documentation the pulse and blood pressure were checked. - At 0540 hours, the comment section showed the patient was intubated. It was documented as the time first assisted ventilation. There was no documentation on the comment section of patient’s vital signs, response to intervention, or other notes. There was no document of the patient’s BP when the patient’s cardiac rhythm was ST. The Time Resuscitation Event Ended section showed 0534 hours. The patient status was alive. The two RNs and the Scribe signed the code blue record. However, the RT and the Physician’s name and signature were left blank. On 2/10/25 at 1215 hours, the Director of Clinical Quality Improvement was asked for the EKG rhythm monitor strips documentation during the code blue. The Director of Clinical Quality Improvement stated there were no EKG rhythm monitor strips for the code blue event on 12/12/24. On 2/10/25 at 1551 hours, an interview with the Director of Critical Care was conducted. The Director of Critical Care was asked about the Code Blue Record. When asked for the vital signs recorded during the code blue, the Director of Critical Care stated the patient was coding, the rhythm was VT and PEA, there would be no BP. However, there was no documented evidence the vital signs were checked even when the patient’s cardiac rhythm was ST. On 2/11/24 at 0925 hours, a follow-up interview and record review was conducted with the Director of Critical Care. The Director of Critical Care was asked for the assisted ventilation during the code blue, before the patient was intubated. The Director of Critical Care stated they were bagging the patient before the intubation. However, the code blue record did not show the patient was bagged or bag-mask valve was used before the intubation. The Director of Critical Care was asked if the physician as the team leader had to sign the code blue form. The Director of Critical Care stated the physician wrote a post code blue note. Review of the ED Note Physician dated 12/12/24 at 0639 hours, showed at 0524 hours, the code blue was overhead paged. CPR was as per ACLS guidelines. The patient was cardioverted 200 joules upon arrival, had a short period of pulses and then coded again, please see the Code Blue sheet for all specific interventions and time frames. However, the Code blue record documentation was not completed as per the AHA ACLS interventions. Further review of the ED Note Physician showed the emergent endotracheal intubation was performed on 12/12/24 at 0533 hours for respiratory failure, respiratory distress, airway protection. The section of procedural sedation showed to see nurse’s notes. The section of monitoring showed the patient’s cardiac, blood pressure, continuous pulse oximetry. However, review of the vital signs did not show monitoring of the blood pressure and pulse oximetry during the code blue. The patient was orally intubated with 7.5 mm (size) ETT. However, the Code Blue Record showed the patient was intubated with size 7 mm ETT. The physician also documented it was a difficult intubation. The total time for intubation was 10 minutes. The ED Physician documented after intubation, the patient’s BP was 177/122 mmHg, the patient’s HR was 130 bpm, and the patient’s oxygen saturation was 99%. b. On 2/11/25 at 0935 hours, review and concurrent interview of Patient 2’s Code Blue Record dated 12/19/24 at 0836 hours was conducted with the Director of Critical Care. The Code Blue Record showed at 0849 hours, Patient 2’s cardiac rhythm was VF, and 200 joules was delivered to shock the patient. The Time Resuscitation Event Ended section showed 0850 hours; however, there was no documentation of Patient 2’s cardiac rhythm when the code ended. On 12/12/25 at 0938 hours, an interview and concurrent record review was conducted with RN 6, the Critical Care Manager and Patient Safety Officer. RN 6 identified himself as an ED nurse and would be assigned to respond to the code blue. When asked about the Code Blue Record dated 12/12/24 at 0524 hours for Patient 2, RN 6 stated the scribe was the ICU CN. When asked, RN 6 stated they got the team to sign the code blue record. The ED MD went back to the ED right after the code blue after the patient was stabilized. 2. Review of the hospital’s P&P tiled Administration of Blood and Blood Products dated January 2024 showed in part: * Procedure: - Begin the transfusion: Unclamp the tubing and begin infusion slowly (approximately 2 ml per minute or 125 ml per hour) for the first 15 minutes. Document the transfusion start time in the EMR. Stay with the patient during this time as reactions can occur after a small volume enters the patient’s circulation. - At the completion of uncomplicated transfusion, record a set of vital signs within 15 minutes of completion, and completed required documentation including the time the transfusion was completed, and amount transfused. Document the volume infused in the intake and output section. On 2/11/25 at 1140 hours, review of Patient 2’s closed medical record was conducted with the Director of Critical Care. Review of the physician’s order dated 12/20/24 at 1742 hours, showed to transfuse PRBC to Patient 2. Review of Patient 2’s medical record showed the transfusion of the PRBC was started on 12/20/24 at 1840 hours and stopped at 2020 hours. On 2/12/25 at 1020 hours, an interview and concurrent review of Patient 2’s medical record was conducted with the Critical Care Manager. The Critical Care Manager was asked to show the documentation of the PRBC transfusion was infused at 125 ml per hour during the first 15 minutes. The Critical Care Manager could not show documented evidence the PRBC transfusion was infused at 125 ml per hour during the first 15 minutes. The Critical Care Manager stated the hospital’s computer system did not dictate on the blood transfusion documentation. The Critical Care Manager was asked to show the documentation of the amount of RBC transfused in the intake and output section. The Critical Care Manager showed the amount of PRBC transfused in the intake and output section was recorded at 1800 hours. However, the blood transfusion started at 1840 hours and ended at 2000 hours. The findings were shared with the Critical Care Manager.”

“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: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the propofol (sedative/anesthesia medication) IV Infusion Titration Per Pharmacy Protocol and physician’s order for one of seven sampled patient (Patient 2). This failure created an increased risk of substandard health outcomes for the patient. Findings: Review of the hospital’s P&P titled IV Infusion Titration Per Pharmacy dated October 2024 showed in part: * Definition: Titration orders are orders for medications whereby the dose may be increased or decreased in response to patient condition, physiologic target, or therapeutic goal. * Policy: - Complete IV infusion titration medication orders are required prior to administration by the nursing staff. - Deviation orders for IV vasopressors and sedative agents are added to the IV infusion parameter medication orders in the event that the patient response is less than adequate after a dose and adjustment per the physician’s order. - The time frame of the RASS documentation will be at minimum every 2 hours and as needed based on the titration dose administration by the nursing staff. * Procedure: - A pharmacy per protocol will be initiated only when physician order has missing titration order elements (i.e. starting dose, titration dose, titration frequency, maximum dose, and deviation orders). Otherwise, a pharmacist will follow a specific complete order by a physician. - Any emergent drip titration orders outside of the approved protocol will be covered by policy as along as patient’s condition and documentation support the titration, a provider is notified, and the order is updated. This will include the nurse initiating emergency measures (i.e. stopping the medication) in the event that the patient becomes hemodynamically unstable while awaiting a return call from the physician. - The provider will be notified as soon as reasonably possible and additional orders will be instituted. On 2/12/25 at 1048 and 1315 hours, an interview and concurrent review of Patient 2’s closed medical record was conducted with the Critical Care Manager. Patient 2’s closed medical record showed the patient was admitted to the hospital’s SDU on 12/11/24 at 1737 hours and expired on 12/22/24. Review of the physician’s verbal order dated 12/12/24 at 0720 hours, showed an order for propofol drip 1000 mg in 100 ml, start at 5 mcg/kg/min, titrate by 5 mcg/kg/min every 5 minutes for goal of RASS - 2, maximum dose of 100 mcg/kg/min, and notify provider if and hold the drip if the SBP less than 90 mmHg. Deviation order when above mentioned parameters were not met despite titration of the propofol times two, were to increase the dose by 10 mcg/kg/min every 3-15 minutes to achieve the clinical response, not exceed the maximum dose, and notify the provider if ordered parameters were not met at the maximum dose. Review of Patient 2’s IV drip for propofol IV showed the following: * On 12/12/24, - At 0818 hours, the propofol drip was started at 5 mcg/kg/min. - At 1100 hours, the dose was increased to 10 mcg/kg/min as per the physician’s order. The patient’s RASS score was -2. - At 1200 hours, the dose was increased to 15 mcg/kg /min as per physician’s order. The patient’s RASS score was -2. The Critical Care Manager stated Patient 2’s RASS -2 was at goal until 1900 hours. - At 2000 hours, the patient’s RASS score was - 1, the propofol drip was increased to 20 mcg/kg/min. - At 2027 hours, the patient’s RASS score was -1, the propofol drip was increased to 25 mcg/kg/min. * On 2/12/24 at 2100 hours to 12/13/24 at 0000 hours, the propofol drip was infusing at 25 mcg/kg/min. However, there was no RASS assessment documented until 0145 hours on 12/13/24; and after 0000 hours, there was no documentation of the propofol drip infusion. There was no nursing documentation the propofol drip was discontinued, stopped, or held. The Critical Care Manager was asked for the RASS assessment. The Critical Care Manager verified there was no RASS assessment until 12/13/24 at 0145 hours. The Critical Care Manager was asked for the P&P of RASS assessment and propofol infusion or titration. The Critical Care Manager stated there was no P&P for propofol IV titration or infusion. However, when Quality Coordinator was asked for the IV Infusion Titration Protocol, the P&P for the IV infusion titration protocol was provided. The Critical Care Manager was asked what the hospital’s P&P for RASS assessment was. The Critical Care Manager stated whatever it was on the P&P. The findings were shared with the Critical Care Manager.”

“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: 35310 Based on observation, interview, and record review, the facility failed to ensure the nursing staff provided the necessary nursing care as evidenced by: 1. The nursing staff failed to activate the nursing care plan for one of five sampled patients (Patient 3) who was on airborne isolation. 2. The nursing staff failed to placed a verbal order when discontinuing the isolation precaution for one of five sampled patients (Patient 3). 3. The medication was left unattended. These failures increased the risk of substandard healthcare outcomes to the patients. Findings: 1. Patient 3’s medical record was reviewed on 12/9/24, with the Director of Clinical Quality Improvement. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 12/4/24. a. Review of the hospital’s P&P titled Interdisciplinary Plan of Care dated 06/2021, showed the following: * Care plans can be initiated from the orders section of the EMR. * The “suggested” care plans (based on the patient diagnosis) found in the orders section of the EMR can be initiated if appropriate to the patient’s clinical status and modified as the patient processes through the continuum of care. * Additional plan of care can be added as needed. * The plan of care will be reviewed, modified as needed, or completed and/or discontinued at least once a shift. On 12/9/24 at 1019 hours, Patient 3’s door was observed wide oped. The airborne signage was also observed on the door. Review of the Physician’s Order dated 12/8/24 at 0720 hours, showed to place an airborne precaution to rule out TB. Review of the Physician’s Order dated 12/9/24 at 1027 hours, showed to discontinue the airborne precaution for Patient 3. However, further review of medical record showed failed to show the nursing care plan was activated for airborne isolation precaution. b. Review of the hospital’s P&P titled Physician Orders (Verbal or Telephone) dated 1/2024 showed a licensed nurse (RN), pharmacist, or other authorized person enters the order (telephone or verbal) follows the order entry process. On 12/9/24 at 1019 hours, Patient 3’s door was observed wide open. The airborne signage was also observed on the door. On 12/9/24 at 1021 hours, RN 1 was interviewed. When asked, RN 1 stated he cared for Patient 3 yesterday and today. RN 1 also stated the physician verbally stated that Patient 3 could be de-isolated from the airborne isolation precautions. Review of the Physician’s Order dated 12/8/24 at 0720 hours, showed to place an airborne precaution to rule out TB. Review of the Physician’s Order dated 12/9/24 at 1027 hours, showed to discontinue the airborne precaution for Patient 3. The airborne isolation precaution was discontinued prior to the physician’s order. 2. Review of the hospital’s P&P titled Medication Handling dated 8/2023 showed the following: * All medications obtained from an approved medication storage area will be removed just prior to the designated administration time. * Once medications are removed from the approved storage area, they will remain with a licensed individual at all times, and will not be left unattended (unless appropriately labeled and secured). During a tour of Med 1 with the ED Director on 12/9/24 at 1015 hours, a vial of Admelog (insulin) 100 unit/ml with high alert warning sticker was observed on the nurses’ rolling working station. On 12/9/24 at 1500 hours, the Director of Clinical Quality Improvement verified the above findings.”

“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: 39199 Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital’s P&P for the administration of blood and blood products for one of five sampled patients (Patient 5) as evidenced by: a. Complete vital signs were not assessed or documented during the blood transfusion. b. There was no documentation of the blood transfusion rate. c. A urine specimen was not collected after a suspected transfusion reaction. These failures posed the risk of potential complications, including undetected changes in the patient’s condition, delayed interventions, and overall compromised patient safety during and after the blood transfusion process. Findings: Review of the hospital’s P&P titled Administration of Blood and Blood Products dated 1/2024 showed the following: * Take the patient’s vital signs (temperature, pulse, respirations, and blood pressure) before beginning the infusion and document them in the EMR. Do not document vital signs more than 30 minutes prior to starting the transfusion. Record vital signs at 15 minutes after starting the transfusion, every hour during the transfusion, and within 15 minutes of completion. * Begin the transfusion by unclamping the tubing and starting the infusion slowly (approximately 2 mL per minute or 125 mL per hour) for the first 15 minutes. Stay with the patient during this time, as reactions can occur after a small volume enters the patient’s circulation. Record vital signs at the end of 15 minutes. If no signs or symptoms of a reaction occur, increase the infusion rate appropriately based on the patient’s condition. * If signs or symptoms of an adverse reaction occur at any time during the infusion, immediately clamp the tubing to stop the transfusion, notify the Blood Bank and physician, and keep the vein open with normal saline and new IV tubing. A Rapid Response may be called as needed. As soon as possible, the nurse will collect and label a urine specimen, complete a Per Protocol order for a Urobilinogen test, and send it to the lab with “suspected transfusion reaction” indicated on the request. On 12/9/24 at 0944 hours, review of Patient 5’s medical record was conducted with the Clinical Informatics Specialist, MD 1, Lead Clinical Lab Scientist, and the LIS Manager. Patient 5’s medical record showed the patient was admitted to the hospital on 11/12/24. Review of the physician’s order dated 12/6/24, showed an order to transfuse one unit of platelets to Patient 5. Review of Patient 5’s medical record showed the transfusion of the platelets was started on 12/6/24 at 1205 hours, and stopped at 1237 hours. a. Review of Patient 5’s medical record showed the patient’s respiratory rate was not assessed or documented at the completion of the transfusion. b. Review of Patient 5’s medical record did not show documented evidence the transfusion was infused slowly at 125 ml per hour during the first 15 minutes as per the hospital’s P&P. On 12/9/24, during the record review, the Clinical Informatics Specialist verified Patient 5’s respiratory rate was not assessed or documented at the completion of the transfusion, and there was no documentation to show the transfusion was infused at 125 ml per hour during the first 15 minutes. The Clinical Informatics Specialist added that it was not the hospital’s practice to document the infusion rate for blood transfusions. c. Review of the Nursing Narrative dated 12/6/24 at 1346 hours showed that Patient 5 complained of itching on her ears and forehead. Upon assessment, the patient had an elevated heart rate of 122 beats per minute and was noted to have hives on her face, chest, and lower back. The patient also began complaining of lightheadedness and a feeling of passing out. A Rapid Response was called at 1306 hours. The patient had just completed a platelet transfusion. The physician and blood bank were notified of a potential platelet transfusion reaction, and the reaction protocol was initiated. Review of Patient 5’s medical record did not show that a urine specimen was collected as soon as possible after the patient had a suspected blood transfusion reaction. On 12/9/24, during the interview and concurrent record review, MD 1 stated the purpose of the urine collection was to detect hemolysis (the breakdown of red blood cells, releasing hemoglobin into the bloodstream), which was one component of the transfusion reaction workup, along with collecting blood samples. MD 1 stated the urinalysis was to detect hemoglobinuria (the presence of free hemoglobin in the urine, often a sign of hemolysis) or elevated urobilinogen, which can indicate hemolysis and may lead to severe consequences such as kidney damage or failure. On 12/9/24, during the interview and concurrent record review, the LIS Manager confirmed a urine specimen was not collected.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36703 Based on observation, interview, and record review, the hospital failed to ensure one of eight sampled patients’ (Patient 4) whiteboard in the room was updated with pertinent information. This failure posed the risk of the patient to not be involved or knowledgeable of his plan of care. Findings: Review of the hospital’s P&P titled Hourly Rounding dated May 2022 showed the nurses will make the hourly patient rounds to ensure patient safety, comfort and encourage patient participation in his or her daily care. Rounding will be documented on either the white board or paper, depending on the patient care unit. Nurses will make rounds every hour focusing on pain, positioning, bathroom needs, patient safety, and equipment safety. Patients will be educated and encouraged to participate in the rounding process. On 10/22/24 at 1307 hours, an observation of Patient 4 in Bed A was conducted with the Director of Clinical Quality Improvement. Patient 4’s whiteboard was observed on the wall to the left of the patient’s bed. The whiteboard was blank. The areas to show the date, RN and NA name, diet, activity, and care goals were not filled in. The Director of Clinical Quality Improvement acknowledged the findings and stated the whiteboard was being immediately corrected.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the medical record was secured for one of eight sampled patients (Patient 3). This failure posed the risk of violating the patient’s rights. Findings: Review of the hospital’s P&P titled Information Management Plan dated October 2024 showed the patients’ individual records are deemed confidential. On 10/22/24 at 0910 hours, the ED was toured with the ED Director and Director of Clinical Quality Improvement. When toured the triage area in the ED, Patient 3’s electric medical record was observed in the computer screen. Patient 3’s electric medical record was opened unattended. The Director of Clinical Quality Improvement verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure one of eight sampled patients’ (Patient 4) care plan was updated to reflect the use of non-violent restraints during the hospitalization. This failure created the risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraint Orders, Application, and Management dated June 2024 showed use of restraints must be addressed in the patient’s modified plan of care. On 10/22/24, Patient 4’s open medical record review was initiated with RN 3 and Nurse Manager 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 10/21/23. Review of physician’s order dated 10/22/24 at 0405 hours, showed the non-violent BUE soft limb restraints were ordered for Patient 4. Review of the Restraint Flowsheet dated 10/22/24 at 0230 and 0430, showed Patient 4 was restrained on the BUE with soft limb restraints. However, further review of Patient 4’s medical record failed to show the patient’s care plan was updated to address the use of non-violent restraints. On 10/23/24 at 0930 hours, the above findings were shared and acknowledged by the Directof of Clinical Quality Improvement.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the physician’s phone read-back orders for non-violent restraint telephone order were authenticated for two of eight sampled patients (Patients 4 and 5). This failure created the risk of substandard outcomes to the patients. Findings: Review of the hospital’s General Rules and Regulations dated 3/22/24, showed the restraint orders will be authenticated, dated and times by the prescriber or the attending physician responsible for the patient’s care at the time the orders are given or covering physician within 24 hours. 1. On 10/22/24, Patient 4’s open medical record review was initiated with RN 3 and Nurse Manager 2. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 10/21/23. Review of the physician’s order dated 10/22/24 at 0405 hours, showed the non-violent BUE soft limb restraints were ordered for Patient 4. The order source showed RN 4 entered a “Phone Read Back - Authorization Required” for MD 1 for non-violent BUE soft limb restraints on Patient 4. On 10/23/24 at 0930 hours, the Director of Clinical Quality Improvement verified the restraint order had not been authenticated by MD 1. 2. On 10/22/24, Patient 5’s open medical record review was initiated with Nurse Manager 2. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 10/13/24. Review of the physician’s order dated 10/16/24 at 2300 hours, showed the non-violent BUE soft wrist restraints were ordered for Patient 5. The order source showed RN 5 entered the order as a “Phone Read Back - Authorization Required” for MD 2. Further review of the validation portion of the order showed MD 2 signed the order on 10/18/24 at 0124 hours. Review of the physician’s order dated 10/18/24 at 2000 hours, showed the non-violent BUE soft wrist restraints were ordered for Patient 5. The order source showed RN 6 entered the order as a “Phone Read Back - Authorization Required” for MD 2. Further review of the validation portion of the order showed MD 2 refused the signature authentication on 10/19/24 at 1020 ours. The refusal reason showed, “Not my patient - Please forward to...” MD 3. On 10/23/24 at 0930 hours, the above findings were shared and acknowledged by the Director of Clinical Quality Improvement.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure one of eight sampled patients (Patient 5) had the progress notes from the physician which addressed the need for continued use of non-violent restraints every calendar day. This failure created the risk of substandard outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraints Orders, Application, and Management dated June 2024 showed the physician’s progress note must address the need for continued use of non-violent restraints every calendar day. On 10/22/24, Patient 5’s open medical record review was initiated with Nurse Manager 2. Patient 2 was admitted to the hospital on 10/13/24. Patient 5’s medical record showed Patient 5 was admitted to the hospital on 10/13/24. Review of the physician’s order dated 10/19 at 0755 hours and 10/20/24 at 2102 hours, showed Patient 5 was placed on nonviolent BUE soft limb restraints. However, review of the physician progress notes failed to show the covering physician addressed the need for continued use of restraints on Patient 5 on 10/19 and 10/20/24. On 10/23/24 at 0930, the Director of Clinical Quality Improvement was informed and acknowledged the above findings.”