Kaiser Foundation Hospital - West La

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) was met, as evidenced by: 1. The facility failed to ensure the Emergency Department (ED) staff provided continues telemetry monitoring (real-time tracking of the heart’s electrical activity through electrodes placed on the chest) and response to persistent, critical alarms, in accordance with the facility’s policy regarding cardiac (heart) monitoring, for one of 30 sampled patients (Patient 1), who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), based on clinical judgment. This deficient practice regarding the lack of monitoring and response, delayed the recognition of Patient 1’s deteriorating condition and hindered the facility’s ability to evaluate and improve emergency care and may have contributed to Patient 1’death. (Refer to A-0063) 2. The facility failed to ensure the Emergency Department’s (ED) Policy and Procedures aligned with current clinical practice for two of two reviewed ED’s policy and procedure (Cardiac monitoring and emergency response documentation). The policy titled “Cardiac Monitoring (Adult),” dated 5/3/2022, indicated that monitor rhythm strip (a visual representation of a person’s heart’s electrical activity over time, essentially a graph of the heart’s electrical signals) would be printed when a patient was placed on a cardiac monitor (initial strip, records the heart rate and rhythm), when telemetry (the automated process of measuring and transmitting data from remote locations for monitoring and analysis) was discontinued (final strip), or when there was a rhythm change (any variation in the heart’s electrical activity, as detected by the monitor, that differs from the patient’s initial or normal heart rhythm). The same policy also required registered nurses to carry assigned clinical communication devices to receive telemetry alarm alerts. However, these practices were not followed. This deficient practice resulted in the governing body’s inability to ensure that hospital staff adhered to the written policies for cardiac monitoring and emergency response documentation. This created the omission in required monitoring and documentation that impacted Patient 1’s care and had the potential to affect the care for other ED patients. (Refer to A-0063) 3. The facility failed to ensure there was a written process for submitting work orders to Biomedical Engineering department (department involved in designing, developing, and maintaining medical devices, equipment, and systems), when telemetry equipment (a remote sensing system that automatically collects and transmits data from a distance) was suspected of malfunctioning. On 2/10/2025, following the discovery of Patient 1 unresponsive (not reacting or responding to communication) and concerns that telemetry (heart and oxygen monitoring’s) alarms may not have functioned as expected, no work order (a formal document that initiates and manages a specific task or project, for maintenance, repairs, or operations) was placed to have the telemetry equipment evaluated. This deficient practice resulted in the inability to ensure that a malfunctioning telemetry equipment was promptly identified, reported, and removed from use. The delay in sequestering and evaluating the telemetry unit used by Patient 1 resulted in a three-day gap (from 2/10/2025 date of incident through 2/13/2025), during which the equipment remained in use and could have affected other patients in the ED. (Refer to A-0063) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met as evidenced by: 1. The facility failed to ensure one of 30 sampled patients (Patient 1), who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), received uninterrupted monitoring and staff response to persistent, critical alarms. This deficient practice resulted in a delay in recognition and intervention during a deteriorating cardiopulmonary condition (a worsening of both the heart and lung’s function, leading to a decline in overall health and potentially life-threatening situations) and may have contributed to Patient 1’s death. (Refer to A-0144 IJ Tag) The effect of this deficient practice resulted in the facility’s inability to provide quality health care 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: 46333 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Quality Assurance and Performance Improvement was met, as evidenced by: 1. The facility’s Quality Assurance and Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) program team failed to measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment) and establish clear expectations for safety when the facility failed to: 1.a. Ensure implementation of an effective process to ensure Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) telemetry alarms (alerts triggered by a heart and oxygen monitoring to notify operators or users about unusual or abnormal events or conditions within a monitored system) were audible and responded to by staff. The facility did not have a system in place to alert staff to critical telemetry alarms when they were engaged with other patients. The telemetry system was not integrated with staff communication devices, such as phones or badges in accordance with the facility’s “Cardiac Monitoring (supplies data about your heart rhythm)” policy and procedure. In addition, there were no staff assigned to continuously monitor the central telemetry (the display station showing vital signs for all monitored patients). This issue was not identified or corrected through the QAPI program before the incident involving one of 30 sampled patients (Patient 1). This deficient practice resulted in Patient 1 being found unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025 and created a risk that other ED patients might not be promptly assessed when telemetry (real-time tracking of the heart’s electrical activity through electrodes placed on the chest) alarms are not responded to by staff. (Refer to A-0286) 1.b. Ensure that the “Cardiac Monitoring” and “Code Blue (a medical emergency code signifying a cardiac [heart] or respiratory [ breathing] arrest, or other life-threatening situation) policies and procedures reflected the current Emergency Department (ED) practice. This deficient practice resulted in the QAPI program not identifying that the policy for Cardiac Monitoring and Code Blue was not implemented as written, in the ED. This misalignment between ED practice and written policy resulted in incomplete and inconsistent documentation and responses during emergency events, which may place patients at risk of delayed or inadequate care. (Refer to A-0286) 1.c. Report a serious adverse event (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment), within 5 days, to the California department of Public Health (CDPH, department that works to protect the public’s health) involving one of 30 sampled patients (Patient 1), in accordance with the facility’s “National Crosswalk of Sentinel (a serious adverse event that results in patient death, permanent harm, or severe temporary harm) Events,” policy and procedure when Patient 1 was found on 2/10/2025 at 8:40 p.m., disconnected from supplemental oxygen and cardiopulmonary monitor, unresponsive (a patient is not reacting or responding to external stimuli, such as voice, touch, or pain), and was pronounced dead at 8:57 p.m. on 2/10/2025. The facility reported the incident to CDPH on 3/5/2025 (23 days later). This deficient practice delayed external regulatory review and the opportunity for oversight, which may affect patient safety when an investigation is not immediately undertaken to ensure corrective action plans are implemented and that the facility is taking strong enough steps to reduce the risk of a similar future event. (Refer to A-0286) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure that one of 30 sampled patients (Patient 16), received treatment for self-reported pain during their (Patient 16’s) stay in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), in accordance with the facility’s policy regarding pain assessment and management. This deficient practice had the potential for Patient 16 to experience increased pain and discomfort, worsening of Patient 15’s condition, and delayed recovery from illness. (Refer to A-0395) 2. The facility failed to ensure one of 30 sampled patient’s (Patient 27) Columbia Suicide Severity Rating Scale (C-SSRS, an evidence-based tool used for suicide risk screening and assessment) screen, was completed in triage (the process of rapidly assessing patients to determine the severity of their condition and prioritize care), in accordance with the facility’s policy regarding suicide (when someone harms themselves with any intent to end their life) risk screening, when Patient 27 was seen in the emergency department (ED) for overdose (OD, is the ingestion of a drug or other substance in quantities much greater than are recommended). This deficient practice had the potential of failing to identify Patient 27’s level of risk for suicide which can result in patient harm or even death. (Refer to A-0395) 3. The facility failed to ensure for one of 30 sampled patients (Patient 19), a plan of care (a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Heart Failure (also known as congestive heart failure, occurs when the heart can’t pump enough blood to meet the body’s needs, leading to symptoms like shortness of breath, fatigue, and swelling), was developed and implemented upon completion of assessment (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for not addressing Patient 19’s care needs and risks, which may delay the implementation of necessary interventions resulting in complications such as kidney damage, irregular heartbeat, and cardiac arrest (when the heart stops beating). (Refer to A-0396) 4. The facility failed to ensure assessment and monitoring of a patient’s condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) every 15 minutes, for one of 30 sampled patients (Patient 26), while placed on violent restraints (bilateral wrist and ankle restraints- the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient’s violent behavior poses an immediate danger to themselves or others. Example vest restraints and wrist restraints), as per facility’s policy and procedure regarding restraints use. This deficient practice had the potential for increased risk of injury (such as skin and circulatory [blood flow] impairment), psychological distress, and/or death. (Refer to A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that for one of 30 sampled patients (Patient 15), a complete pain assessment evaluation, was documented, in accordance with the facility’s policy regarding pain assessment and management. This deficient practice had the potential for Patient 15’s pain to be inadequately managed, potentially leading to prolonged discomfort and overall negative impact on Patient 15’s recovery process. In addition, incomplete pain assessment documentation had the potential to disrupt the continuity of care for Patient 15, making it difficult for other healthcare providers to understand Patient 15’s pain level, response to interventions and delays the implementation of other alternative pain management strategies. (Refer to A-0449) 2. The facility failed to ensure the medical record for one of 30 sampled patients (Patient 1) contained complete documentation of a code blue event (a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation). The “Code Narrator report (a tool that helps document and track key events during a code)” for Patient 1 lacked the required clinical elements including cardiac rhythm (the timing and pattern of the heart’s electrical signals, which determine how the heart beats), timing of chest compressions (push on the person’s chest in resuscitation), pulse checks (moments when medical staff checks for a heartbeat), and code team member roles, in accordance with the facility’s code blue policy. This deficient practice impeded the facility’s ability to review what actions were taken during emergency, to understand how care was provided, and to identify ways to improve future emergency responses. (Refer to A-0450) 3. The facility failed to ensure that the medical record for one of 30 sampled patients (Patient 1) included a complete and authenticated documentation of care, as required by the Physician Assistant (PA, a healthcare professional licensed to practice medicine under physician supervision) 1’s practice agreement, and the facility’s medical staff rules and regulations. Specifically, the Emergency Department (ED) triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note, documented by PA 1, was not co-signed by a supervising physician, as required. This deficient practice resulted in the medical record lacking documentation required to validate that the services provided by the PA 1 were reviewed by a supervising physician. The absence of a co-signature prevented confirmation that oversight was performed in accordance with the practice agreement and facility policy, which may have an impact on patient safety. (Refer to A-0450) 4. The facility failed to ensure that one of 30 sampled patients’ medical records (Patient 9) were complete, containing documentation of justification for the continued use of restraints (the use of physical or mechanical devices to limit patient movement. Example wrist restraints), in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential to compromise Patient 9’s safety by allowing restraints to be applied without oversight and evaluation, increasing the risk of physical (example: skin breakdown [damage to the skin], circulatory issues [any condition such as tightly applied wrist restraints that impede blood flow]) and psychological harm (example: anxiety [a feeling of dread and uneasiness], trauma, etc.) to the patient (Patient 9). (Refer to A-0450) 5. The facility failed to ensure that the medical record for one of 30 sampled patients (Patient 1) included documentation from the physician (MD 1) who discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation). MD 1 did not record a physical assessment (a hands-on examination), clinical observations, or actions taken in response, in accordance with the facility’s policy regarding medical records content. This deficient practice resulted in an incomplete medical record and impaired the facility’s ability to evaluate the care provided, ensure continuity of care (the consistent and coordinated management of a patient’s treatment across shifts or providers), prevented a full understanding of the patient’s condition during the emergency, and made it harder for the facility to review and improve its emergency procedures. (Refer to A-0464) 6. The facility failed to ensure that medical records for two of 30 sampled patients (Patient 9 and Patient 14) were complete, when: 6.a. Patient 9’s medical records had no documentation of a physician’s order for continuous cardiac (heart)monitoring (encompasses all methods of heart rate and rhythm (the pattern and regularity of the heart’s beat) monitoring, including remote monitoring and often involves bedside displays), in accordance with the facility’s policy regarding cardiac monitoring. This deficient practice had the potential to compromise Patient 9’s safety by delaying timely placement of Patient 9 on a cardiac monitor and potentially preventing timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 9. (Refer to A-0467) 6.b. Patient 14’s medical record had no documentation of the following: 6.b.1. Physician’s order for continuous cardiac monitoring was not placed by the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care to patients with urgent health issues) provider, in accordance with the facility’s policy regarding cardiac monitoring and policy on Rules and Regulations for the Professional Staff. This deficient practice had the potential to compromise Patient 14’s safety by delaying timely placement of Patient 14 on a cardiac monitor and/or not continuously monitoring Patient 14’s heart rhythm potentially delaying timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 14. (Refer to A-0467) 6.b.2. No documentation of cardiac rhythm in the flowsheet assessment record despite Patient 14 being observed to be connected to a cardiac monitor, in accordance with the facility’s policy regarding cardiac monitoring and documentation. This deficient practice had the potential to compromise Patient 14’s safety by preventing other healthcare providers not to be able to promptly recognize and respond to changes in the Patient 14’s cardiac condition, leading to potential delays in necessary treatment and intervention. (Refer to A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 46333 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Emergency Services was met, as evidenced by: 1. The facility failed to ensure that qualified medical personnel (QMP, a healthcare provider authorized by the facility to evaluate and treat emergency patients) fulfilled responsibilities to evaluate and document emergency care for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy regarding medical records content. Specifically, the physician (MD 1) who found Patient 1 unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025, did not document any clinical findings, assessments (medical evaluation of the patient’s condition), or medical interventions (steps taken to treat the patient [Patient 1]). This deficient practice resulted in the facility being unable to confirm whether timely and emergency care was provided. This omission limited the facility’s ability to verify the care rendered during the critical event and prevented staff from fully understanding and evaluating the effectiveness of the emergency care provided. (Refer to A-1104) 2. The facility failed to ensure that emergency department staff documented in the Code Narrator (a tool that helps document and track key events during a code)” report regarding Patient 1’s cardiac rhythm (pattern of the heart’s electrical activity), time of pulse checks (moments when medical staff checks for a heartbeat), initiation of chest compressions (starting of manual pressing on the chest to restore circulation), or identification of responding team members during the code blue (a hospital-wide emergency called when patient is experiencing cardiac [heart] or respiratory arrest [stopped breathing]) on 2/10/2025. This deficient practice impeded the facility’s ability to assess the adequacy of the emergency response and limited the continuity of care (coordinated and consistent care among healthcare team members) by preventing post-event clinical evaluation, hindering quality assurance (a proactive approach to ensuring that services and amenities consistently meet or exceed established standards for excellence, guest satisfaction, and operational efficiency) processes, and restricted the facility’s ability to identify areas for improvement in resuscitation (the act of reviving a patient from apparent death) practices. (Refer to A-1104) 3. The facility failed to ensure the annual educational requirements (the mandated training and continuing education that employees must complete each year to maintain their knowledge skills and compliance with regulatory standards) for three of 10 sampled Emergency Department (ED) employees (E2, E5 and E7), were completed, in accordance with the facility’s annual educational requirements for employees and regulatory standards. This deficient practice had the potential to compromise quality of patient care delivered by employees who may lack current knowledge and training necessary to provide effective treatment. (Refer to A-1110) 4. The facility failed to ensure Annual competencies (assessments and evaluations to determine if employees possess the necessary skills and abilities required for their positions) for one of 10 sampled Emergency Department staff member (E5), were completed as indicated by the facility’s procedures regarding annual competency trainings. This deficient practice had the potential to result in compromised patient safety and quality of care when healthcare professionals may not be equipped with the knowledge to provide safe, effective, and high-quality care to patients. (Refer to A-1110) 5. The facility failed to ensure that four of four sampled registered nurses (E2, E4, E6, and E8), working in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), fully met the written standardized emergency procedure (established protocols that define the actions, responsibilities, and practices that registered nurses must initiate based on patients’ chief complaints and presenting symptoms prior to an evaluation of the Emergency Department physician [when no triage -the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) physician was available to perform a rapid medical exam [RME, a process in emergency departments that initiates testing and evaluation of patients while they are still in the waiting room, aiming to improve patient flow and reduce wait times]) requirements and competencies needed, to be authorized to perform standardized procedures in the facility’s ED. This deficient practice had the potential to compromise patient care and safety by increasing the risk of inadequate responses to emergency situations, leading to delays in treatment and ultimately adverse patient outcomes when employees do not possess the necessary competencies in accordance with the facility’s policy regarding Standardized Emergency Registered Nurse procedures. (Refer to A-1112) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility’s Governing Body (the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital’s overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to: 1. Ensure the Emergency Department (ED) staff provided continues telemetry monitoring (real-time tracking of the heart’s electrical activity through electrodes placed on the chest) and response to persistent, critical alarms, in accordance with the facility’s policy regarding cardiac monitoring, for one of 30 sampled patients (Patient 1) who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]) based on clinical judgment. This deficient practice regarding the lack of monitoring and response, delayed the recognition of Patient 1’s deteriorating condition and hindered the facility’s ability to evaluate and improve emergency care and may have contributed to Patient 1’death. 2. Ensure the Emergency Department’s (ED) Policy and Procedures aligned with current clinical practice for two of two reviewed ED’s policy and procedure (Cardiac monitoring and emergency response documentation). The policy titled “Cardiac Monitoring (Adult),” dated 5/3/2022, indicated that monitor rhythm strip (a visual representation of a person’s heart’s electrical activity over time, essentially a graph of the heart’s electrical signals) would be printed when a patient was placed on a cardiac monitor (initial strip, records the heart rate and rhythm), when telemetry (the automated process of measuring and transmitting data from remote locations for monitoring and analysis) was discontinued (final strip), or when there was a rhythm change (any variation in the heart’s electrical activity, as detected by the monitor, that differs from the patient’s initial or normal heart rhythm). The same policy also required registered nurses to carry assigned clinical communication devices to receive telemetry alarm alerts. However, these practices were not followed. This deficient practice resulted in the governing body’s inability to ensure that hospital staff adhered to the written policies for cardiac monitoring and emergency response documentation. This created the omission in required monitoring and documentation that impacted Patient 1’s care and had the potential to affect the care for other ED patients. 3. Ensure there was a written process for submitting work orders to Biomedical Engineering department (department involved in designing, developing, and maintaining medical devices, equipment, and systems), when telemetry equipment (a remote sensing system that automatically collects and transmits data from a distance) was suspected of malfunctioning. On 2/10/2025, following the discovery of Patient 1 unresponsive (not reacting or responding to communication) and concerns that telemetry (heart and oxygen monitoring’s) alarms may not have functioned as expected, no work order (a formal document that initiates and manages a specific task or project, for maintenance, repairs, or operations) was placed to have the telemetry equipment evaluated. This deficient practice resulted in the inability to ensure that a malfunctioning telemetry equipment was promptly identified, reported, and removed from use. The delay in sequestering and evaluating the telemetry unit used by Patient 1 resulted in a three-day gap (from 2/10/2025 date of incident through 2/13/2025), during which the equipment remained in use and could have affected other patients in the ED. Findings: 1. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), Patient 1’s telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1’s bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate (breathing patterns that deviate from the patient’s normal breathing pattern). DRM confirmed the alarms continued until patient 1 was found unresponsive (not reacting to voice, touch, or stimulation) around 8:40 p.m. on 2/10/2025. During an interview on 4/2/2025 at 10:15 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system (the process of automatically collecting, transmitting, and analyzing data from remote sources to a central location for monitoring and control) in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed. During an interview on 4/2/2025 at 3:46 p.m. with the ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter (a medical device that measures the amount of oxygen in a person’s blood) and all, but one cardiac monitor lead (provides different views of the heart’s electrical activity), was disconnected. MD 2 also confirmed that Patient 1’s oxygen tube was not in his (Patient 1) nose. MD 2 stated MD 1 checked Patient 1’s pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse. During an interview on 4/3/2025 at 10:39 a.m. with primary registered nurse (RN) 1 assigned to Patient 1, RN 1 stated that she (RN 1) did not hear Patient 1’s alarms because she (RN 1) was responding to an ambulance run (an ambulance arrives at the ED with a patient, and the nurse takes over the patient’s care). During an interview with the Administrator of Quality (AQ) on 4/4/2025 at 2:19 p.m., AQ stated that the telemetry alarm monitoring was not tracked before the incident involving Patient 1. During an interview on 4/4/2025 at 5:15 p.m. with the Senior Vice President (SVP), SVP stated the governing body was responsible for patient safety and quality of care provide in the facility. The board’s responsibility extends to oversight of the hospital’s Quality Assurance and Performance Improvement (QAPI) program, which included conducting periodic review and ensuring patient safety. During a review of the facility’s “Hospital Quality and Patient Safety Program Description: Annual Work Plan and Evaluation,” date 2024, the plan indicated, “The Board of Directors of (name of facility), the governing body, through its Quality and Health Improvement Committee (“QHIC”), oversees each hospital’s Quality and Patient Safety Program (“Program”). The QHIC assures each hospital’s executive and Professional Staff leadership develops the hospital’s program consistent with the hospital’s mission, vision and values. The hospital leadership is accountable to the QHIC to assure the planning and implementation, including establishing priorities for the Quality and Patient Safety Program with respect to the delivery of existing services and the implementation of new hospital services.” 2. During an interview on 4/1/2025 at 2:05 p.m. with Registered Nurse (RN, nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 5, RN 5 stated they were not required to print cardiac strips/telemetry strips (a recording of the heart’s electrical activity over a specific period, typically 10 seconds) when placing a patient on the cardiac monitor unless there was an event or code (Code blue, a medical emergency code signifying a cardiac [heart] or respiratory arrest [stopped breathing], or other life-threatening situation). RN 5 stated the nurses do not carry phones. RN 5 also confirmed that ED never assigned a staff for monitoring the central cardiopulmonary monitor (a device used to continuously observe and record vital signs [VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions] related to the heart function and respiratory [breathing] systems). During an interview on 4/2/2025 at 10:15 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed. During a concurrent interview and record review on 4/4/2025 at 2:05 p.m. with the Assistant Clinical Director (ACD) 2, the facility’s Code Blue policy and procedure, dated 6/21/2021, was reviewed. The policy indicated staff should document on the “Code Blue Record” form found in Appendix C. ACD2 stated the ED no longer uses the paper Code “Blue Record” form and instead documents during codes using the electronic “Code Narrator” system. ACD 2 confirmed that the required documentation elements were the same in both the “Code Narrator” and the “Code Blue Record.” However, the policy did not reflect the ED’s current practice of using the “Code Narrator” instead of the paper form. During an interview on 4/4/2025 at 5:06 p.m. with the Regional Senior Director Accreditation Regulation and Licensing (RSDAR), RSDAR confirmed that while the current “Cardiac Monitoring” (dated 5/3/2022) policy was applicable hospital-wide, including to the ED, practice in the ED did not reflect the current policy’s requirements. Requiring printing of cardiac telemetry strips when patient was placed on the cardiac monitor (Initial Strip), when patient had telemetry monitoring discontinued (Final Strip), and use of phone to alert nurses for alarms, was not consistent with the written policy. During a review of the facility’s emergency department policy and procedure (P&P) titled, “Standard Emergency Registered Nurse Procedures,” dated 10/21/2024, the P&P indicated, “Responsibilities: The Emergency Department is responsible for ensuring that this standardized procedure is accurate, relevant, and current. Maintenance: This policy and procedure shall be reviewed at least every three (3) years, and revised periodically, to assure continuing relevance and compliance with regulatory and accrediting standards, hospital bylaws, rules and regulations, legal statutes and current practice.” During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (Adult),” dated 5/3/2022, the P&P indicated the following: The Emergency Department shall perform cardiac monitoring as needed, according to the physician’s orders, and based on the patient’s chief complaint and condition. Monitor rhythm strip(s) will be printed when: A patient is placed on the monitor (Initial Strip),A patient has telemetry discontinued (Final Strip), there is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient, alternative monitoring equipment is used, patient is placed back on telemetry monitoring, after alternative monitoring equipment use. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.). RNs will carry assigned clinical communication devices at all times except: When on breaks or meals.” During a review of the facility’s policy and procedure (P&P) titled, “Code Blue Response- Adult Medical Center Campus,” dated 6/21/2021, the P&P indicated, “Documentation: A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. Appendix C: Code Blue Record ...” 3. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), Patient 1’s telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1’s bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate (breathing patterns that deviate from the patient’s normal breathing pattern). DRM confirmed the alarms continued until patient 1 was found unresponsive (not reacting to voice, touch, or stimulation) around 8:40 p.m. on 2/10/2025. During an interview on 4/3/2025 at 5:35 p.m. with Charge Nurse (RN 9), RN 9 stated that if telemetry equipment was not functioning, staff could place a work order and Biomedical Engineering would typically respond the same day. During an interview on 4/4/2025 at 1:40 p.m. with Biomedical Technician (BMT 2), BMT 2 stated that no work order had been placed on 2/10/2025 when the incident occurred. BMT 2 stated he (BMT 2) only learned about the alarm concern for Patient 1 in room ABC on 2/13/2025, while responding to an unrelated equipment issue in the ED. BMT 2 stated the ED supervisor informed him (BMT 2) at that time that the alarm in room ABC may not have gone off. BMT 2 stated that he (BMT 2) then sequestered the cardiac monitor and checked the central telemetry system. BMT 2 stated it was important for staff to place a high-priority work order when alarm issues were suspected. During a concurrent interview and record review on 4/4/2025 at 1:50 p.m. with Biomedical Technician (BMT 1), the “Equipment and Case Information,” containing work orders history, was reviewed. The document report indicated, on 2/13/2025, a work order was entered for a “scanner not working.” On 2/18/2025, a separate work order was documented under type “Hazard/Recall/Safety,” with a summary reading “Patient incident evaluation.” BMT 1 confirmed that this second order was placed by the biomedical team. During an interview on 4/4/2025 at 2:10 p.m. with the Administrator of Quality (AQ), AQ stated that the facility had no policy outlining when or how to place work orders, nor who was responsible. AQ provided a general guidance document titled “How to Report an Issue,” but it did not contain specific instructions on reporting equipment issues or escalation procedures. During an interview on 4/4/2025 at 5:15 p.m. with the Senior Vice President (SVP), SVP stated the governing body held responsibility for patient safety and oversight of the QAPI (Quality Assurance Performance Improvement, a data-driven, proactive approach to improving the quality of care and services) program, including ensuring that appropriate actions were taken in response to safety concerns. During a review of the facility’s policy and procedure (P&P) titled, “Southern California Regional Unusual Occurrence Reporting (UOR),” dated 5/3/2023, the P&P indicated, “To reduce risk for (facility name) members, employees, physicians, and visitors. To protect the organization against unplanned financial loss through risk Identification, analysis, evaluation, and corrective action for identified problems. To promote a safe environment for patients, visitors, physicians, and staff by identifying within a Just Culture environment the system problems/issues that contribute to unusual occurrences rather than focusing on individuals. Provisions/Procedures: If a medical device or equipment is involved in an event, it shall be taken out of service and maintained unaltered until turned over to the Risk Department or Clinical Technology.””

“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: 46333 Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 1), who had an order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), received uninterrupted monitoring and staff response to persistent, critical alarms. This deficient practice resulted in a delay in recognition and intervention during a deteriorating cardiopulmonary condition (a worsening of both the heart and lung’s function, leading to a decline in overall health and potentially life-threatening situations) and may have contributed to Patient 1’s death. IJ Statement: On 4/2/2025 at 5:38 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Senior Vice President (SVP), Chief Operating Officer (COO), Regional Senior Director, Accreditation, Regulatory& Licensing (RSDAR ), Administrator Quality Department (AQ), Director of Accreditation, Regulatory & Licensing (ARLD), Chief Nursing Executive (CNE), and Assistant Medical Group Administrator (AMA). The facility failed to ensure that Patient 1, who had a physician’s order for continuous oxygen saturation monitoring (real-time tracking of oxygen levels in the blood using fingertip sensor) and was placed on continuous cardiac monitoring (ongoing tracking of heart rate and rhythm through chest electrodes [conductive patches placed on the chest]), received uninterrupted monitoring and timely staff response to alarms. This deficient practice resulted in delay in recognizing a life-threatening cardiopulmonary (a problem with either the heart or lungs, or both, that could be fatal if not addressed quickly) emergency and contributed to Patient 1’s death. Patient 1 arrived in the Emergency Department (ED) on 2/10/2025 at 5:00 p.m. with symptoms including shortness of breath (difficulty breathing), chest discomfort, upper epigastric pain (abdominal pain), nausea (a feeling of sickness with an inclination to vomit), and coughing. Patient 1 was triaged (the preliminary assessment of patients in order to determine the urgency of their need for treatment and the nature of treatment required) as Emergency Severity Index (ESI, a 5-level triage algorithm used in emergency departments to quickly assess the acuity [severity] of a patient’s condition and determine the resources needed for their care, prioritizing patients for treatment) as level 1, indicating a life-threatening condition. An electrocardiogram (EKG, a test that records the electrical activity of the heart, showing how it’s beating and if there are any problems with its rhythm or function) indicated sinus tachycardia (a condition characterized by a heart rate faster than normal [over 100 beats per minute]) and ST elevation (a section of the heart muscle is potentially not getting enough oxygen, which can be a sign of a heart attack or other serious heart problem). At 5:28 p.m., a physician ordered continuous pulse oximetry (oxygen monitoring). Based on clinical risk, the ED staff also placed Patient 1 on continuous cardiac monitoring. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), the “Event History Report,” for the telemetry system (the automated process of measuring and transmitting data from remote locations for monitoring and analysis), dated 2/10/2025, was reviewed. The telemetry system began displaying critical alarm messages beginning at 8:01 p.m. on 2/10/2025, Patient 1’s bedside monitoring system generated multiple critical alarms over a span of 42 minutes. These alarms indicated: -The oxygen saturation probe was either disconnected or not functioning properly, -The device could not detect a pulse or oxygen readings, -Patient 1’s heart and breathing pattern were unstable, -Cardiac electrodes were detached or malfunctioning, -And, ultimately, that alarms were manually silenced by staff when Patient 1 was found unresponsive. Despite these numerous and escalating warnings, no staff responded to the alarms. The central telemetry station, which displays these alerts for staffing monitoring, was unattended, and no alerts were forwarded to nurses’ communication devices as required by the facility’s cardiac monitoring policy and procedures. At 8:40 p.m., Patient 1 was found unresponsive in their room. Patient 1’s high-flow oxygen delivery system was not connected to Patient 1’s nose, and cardiac monitoring leads (the electrical connections, or pairs of electrodes, that detect and display the heart’s electrical activity, providing different “views” of the heart’s activity) were disconnected, except one. Cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of a patient’s chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest [heart stop]) was started, and Patient 1 was intubated (insert a tube into a person or a body part, especially the windpipe for ventilation). However, Patient 1 remained in pulseless electrical activity (PEA, a condition where electrical signals are detected, but the heart is not pumping blood). Patient 1 was pronounced dead at 8:57 p.m. On 4/3/2025 at 5:58 p.m., the IJ was removed in the presence of the Regional Senior Director, Accreditation, Regulatory & Licensing (RSDAR), Administrator of Quality (AQ), and Director of Accreditation, Regulatory& Licensing (ARLD). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview and record review. The IJ Removal Plan indicated: -Responsible Parties for Oversight and Training: Assistant Clinical Directors (ACD) and Charge Nurses 1. Reeducation of Staff: Education was reassessed and reinforced beginning April 2, 2025, with focused instruction on alarm types, urgency, response expectations, and escalation protocols. 2. Refresher Training Implementation: Beginning April 2, 2025, mandatory in-person refresher sessions were conducted during pre-shift huddles on all shifts. Topics covered: Response to alarms 3. Staffing Enhancements for Central Monitor: Effective April 2, 2025, four dedicated monitor technicians were assigned to the central monitors located in Pods A, B, C, and D. Each technician completed a structured orientation, including roles, responsibilities, and clear escalation protocols for abnormal cardiac rhythms and pulse oximetry 4. Ongoing Monitoring and Accountability: A monitor technician is assigned to each pod during every shift to ensure continuous observation of patient data. Monitor technicians are responsible for real-time identification and escalation of abnormal readings to licensed and/or certified clinical staff. If the primary nurse is unavailable, the Charge Nurse will be notified 5. Infrastructure and Equipment Verification: All four ED pods are fully equipped to provide cardiac monitoring and pulse oximetry in every patient care room. On April 3, 2025, the central monitors were assessed and verified to be fully functional and calibrated, ensuring accurate alarm display and sound notification. Cardiac Monitoring Procedures: Cardiac monitoring and/or pulse oximetry are initiated per physician order or under Standardized Emergency Registered Nurse Procedures Policy Alarm Verification: Staff are responsible for confirming that audible alarms at the patient’s bedside and central monitor are active and functional upon initiation of the monitor. This is documented on the monitoring log. Escalation of Alarms: If the monitor technician is unable to reach the primary RN: The Charge Nurse will be notified Red Alarm Response, red alarms are lethal arrhythmia (a condition in which the heart beats with an irregular or abnormal rhythm) this include asystole (also called “flatline” no heartbeat), ventricular fibrillation (V-fib, a a dangerous heart rhythm where the heart’s lower chambers (ventricles) quiver or shake uncontrollably instead of beating normally, preventing the heart from pumping blood effectively), ventricular tachycardia (VT, a fast heartbeat that potentially leading to a dangerous lack of blood flow to the body), desaturation (a drop in the amount of oxygen in the blood), and apnea (brief stop in breathing): In the event of a red alarm, the monitor technician will immediately notify both the assigned RN and the physician. Alarm Response Protocol: All staff are trained to respond to all alarm levels (red, yellow, blue). Upon any alarm, the monitor technician verbally notifies the assigned RN immediately. Physician Education and Engagement: Responsible: Chief of Emergency Department and Assistant Chiefs of ED On April 3, 2025, all physicians and physician assistants were educated on the ED cardiac monitoring policy. Emphasis was placed on ensuring that orders for cardiac monitoring and pulse oximetry are promptly placed based on patient condition. Physicians were instructed to immediately respond to the red alarm when they are made aware Emergency Staffing Coverage: In the event of multiple patients requiring resuscitation in the emergency department, the ACD and/or Charge Nurse will immediately: Assess staffing and reassign as needed. Maintain appropriate levels of nursing care and monitoring coverage. Ongoing Monitoring: Daily audits will be conducted to verify alarm functionality. Verification of assessment and intervention when needed, as documented on the monitoring log. Findings: During a review of Patient 1’s “ED (emergency department, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) Provider Notes,” dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history which included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a review of Patient 1’s “triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note,” dated 2/10/2025, the note indicated Patient 1 was assigned an Emergency Severity Index (ESI, a 5-level triage system that categorizes patients based on their acuity and resource needs, from most urgent [Level 1] to least urgent [Level 5]) Level 1 (most urgent level requiring immediate life-saving intervention). During a review of Patient 1’s “Electrocardiogram (EKG, a diagnostic tool that records the heart’s electrical activity), dated 2/10/2025 at 5:19 p.m., the report indicated sinus tachycardia (abnormal a heart rate that is faster than normal [heart rate over 100 beats per minute]), nonspecific T-wave abnormalities (irregularities in the heart’s electrical cycle), and ST elevation (a possible sign of heart attack or heart muscle damage). During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with Director of Risk Management (DRM), Patient 1’s telemetry event report, was reviewed. The telemetry event report (a report of monitor alerts), dated 2/10/2025, indicated starting at 8:01 p.m., Patient 1’s bedside monitor generated multiple escalating alarms indicating critical deterioration as follows: -“At 8:01:02 p.m., indicated, “Message Display: Sp02 Probe Off (oxygen sensor disconnected)” -“At 8:01:21 p.m., indicated, “Message Display: Sp02 Pulse Search (cannot read)” -“At 8:01:54 p.m., indicated, “Message Display: Sp02 Alarm (possible critical low oxygen level)” -“At 8:02:03 p.m., indicated, “Message Display: Sp02 Unstable Pulse (irregular or changing heart rate)” -“At 8:03:01 p.m., indicated, “Message Display: Irregular RR (respiratory rate)” -“At 8:03:06 p.m., indicated, “Message Display: Check Electrodes (monitor leads disconnected or failing to detect signal)” -“At 8:13:22 p.m., indicated, “Message Display: Sp02 Alarm” -“At 8:13:23 pm., indicated, “Message Display: Check Electrodes” -“At 8:142 p.m., indicated, “Message Display: Sp02 Alarm” -“At 8:13:50 p.m., indicated, “Message Display: Alarms Silenced (alarm was silenced manually)” -“At 8:13:58 p.m., indicated, “Message Display: Check Electrodes” -“At 8:15:25 p.m., indicated, “Message Display: (Sp02) Alarm” -“At 8:15:27 p.m., indicated, “Message Display: Check Electrodes” -“At 8:19:52 p.m., indicated, “Message Display: SpO2 Alarm” -“At 8:20:07 p.m., indicated, “Message Display: Check Electrodes” -“At 8:24:39 p.m., indicated, “Message Display: Sp02 Alarm.” -“At 8:24:47 p.m., indicated, “Message Display: Check Electrodes” -“At 8:43:40 p.m., indicated, “Message Display: (SpO2) Alarm.” During the same interview on 4/1/2025 at 1:15 p.m. with Director of Risk Management (DRM), the DRM confirmed the alarms continued until Patient 1 was found unresponsive (a patient is not reacting or responding to external stimuli, such as voice, touch, or pain) around 8:40 p.m. During an observation and interview on 4/1/2025 at 2:05 p.m. with Director, Assistant Clinical Director (ACD) 2, in the emergency department at the central telemetry monitor (the central screen that displays patient heart and oxygen status), the ACD 2 confirmed that at the time of the incident, no staff were assigned to observe or respond to telemetry alarms at the central telemetry monitoring. ACD 2 stated the ED did not assign staff for central telemetry monitoring because this was not their practice. During an interview on 4/2/2025 at 10:15 a.m. with Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed. During a concurrent interview and record review on 4/2/2025 at 10:26 a.m. with Assistant Clinical Director (ACD 1), Patient 1’s electronic medical record (EMR, a digital version of the paper charts in hospitals) document titled “Orders,” dated 2/10/2025, was reviewed. ACD 1 stated Patient 1 had a physician order for continuous pulse oximetry monitor (monitoring of blood oxygen level via a finger probe), but no written order for telemetry. ACD 1 stated that telemetry monitoring was initiated based on ED protocol for patients presenting with chest pain and ST elevation. During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with Assistant Clinical Director (ACD 1), Patient 1’s “Code Narrator Report (a record of emergency response activity), dated 2/10/2025, was reviewed. The report indicated that a code blue (emergency cardiac arrest [when the heart stops beating] response) was initiated at 8:40 p.m. and Patient 1 did not regain a pulse (heartbeat) and was pronounced dead at 8:57 p.m. ACD 1 stated the terminal heart rhythm was pulseless electrical activity (PEA, a condition where the heart has electrical activity but is not pumping blood). During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. MD 2 confirmed that the pulse oximeter and all, but one cardiac monitor lead was disconnected. MD 2 stated MD 1 checked Patient 1’s pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse. During an interview on 4/3/2025 at 10:39 a.m. with primary registered nurse (RN) 1 assigned to Patient 1, RN 1 stated that she (RN 1) did not hear Patient 1’s alarms because she was responding to an ambulance run (an ambulance arrives at the ED with a patient, and the nurse takes over the patient’s care). During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Director (MD) 7, MD 7 stated that any patient with ST elevation (a possible sign of heart attack or heart muscle damage) should be continuously monitored due to their high risk of cardiac deterioration. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (Adult),” dated 5/3/2022, the P&P indicated, “The Emergency Department shall perform cardiac monitoring as needed, according to the physician’s orders, and based on the patient’s chief complaint and condition. Documentation of cardiac rhythm, any changes in cardiac rhythm and anytime notification to the physician occurs, shall be recorded In KP Health Connect. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.).” During a review of the facility’s policy and procedure (P&P) titled, “Standardized Emergency Registered Nurse Procedures,” dated 10/21/2024, the P&P indicated the following: Requirements to be followed: Chest Pain - Consider Oxygen via nasal cannula and Pulse oximetry - Cardiac Monitor, when treatment room available”

“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: 46333 Based on interview and record review, the facility’s Quality Assurance and Performance Improvement (QAPI, a data-driven, proactive approach to improving the quality of care and services) program team failed to measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment) and establish clear expectations for safety when the facility failed to: 1. Ensure implementation of an effective process to ensure Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) telemetry alarms (alerts triggered by a heart and oxygen monitoring to notify operators or users about unusual or abnormal events or conditions within a monitored system) were audible and responded to by staff. The facility did not have a system in place to alert staff to critical telemetry alarms when they were engaged with other patients. The telemetry system was not integrated with staff communication devices, such as phones or badges in accordance with the facility’s “Cardiac Monitoring (supplies data about your heart rhythm)” policy and procedure. In addition, there were no staff assigned to continuously monitor the central telemetry (the display station showing vital signs for all monitored patients). This issue was not identified or corrected through the QAPI program before the incident involving one of 30 sampled patients (Patient 1). This deficient practice resulted in Patient 1 being found unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025 and created a risk that other ED patients might not be promptly assessed when telemetry (real-time tracking of the heart’s electrical activity through electrodes placed on the chest) alarms are not responded to by staff. 2. Ensure that the “Cardiac Monitoring” and “Code Blue (a medical emergency code signifying a cardiac [heart] or respiratory [ breathing] arrest, or other life-threatening situation) policies and procedures reflected the current Emergency Department (ED) practice. This deficient practice resulted in the QAPI program not identifying that the policy for Cardiac Monitoring and Code Blue was not implemented as written, in the ED. This misalignment between ED practice and written policy resulted in incomplete and inconsistent documentation and responses during emergency events, which may place patients at risk of delayed or inadequate care. 3. Report a serious adverse event (any unintended or undesirable occurrence, symptom, or disease that happens to a patient during medical treatment), within 5 days, to the California department of Public Health (CDPH, department that works to protect the public’s health) involving one of 30 sampled patients (Patient 1), in accordance with the facility’s “National Crosswalk of Sentinel (a serious adverse event that results in patient death, permanent harm, or severe temporary harm) Events,” policy and procedure, when Patient 1 was found on 2/10/2025 at 8:40 p.m., disconnected from supplemental oxygen and cardiopulmonary monitor, unresponsive (a patient is not reacting or responding to external stimuli, such as voice, touch, or pain), and was pronounced dead at 8:57 p.m. on 2/10/2025. The facility reported the incident to CDPH on 3/5/2025 (23 days later). This deficient practice delayed external regulatory review and the opportunity for oversight, which may affect patient safety when an investigation is not immediately undertaken to ensure corrective action plans are implemented and that the facility is taking strong enough steps to reduce the risk of a similar future event. Findings: 1. During a review of Patient 1’s “ED (Emergency Department, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) Provider Notes,” dated 2/10/2025, Patient 1’s ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with Director of Risk Management (DRM), Patient 1’s telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1’s bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate. DRM confirmed the alarms continued until Patient 1 was found unresponsive (not reacting to voice, touch, or stimulation) around 8:40 p.m. on 2/10/2025. During an observation and interview on 4/1/2025 at 2:05 p.m. with Assistant Clinical Director (ACD) 2, in the central telemetry monitor (the central screen that displays patient heart and oxygen status), the ACD 2 confirmed that at the time of the incident (2/10/2025), no staff were assigned to observe or respond to telemetry alarms at the central telemetry monitoring station. ACD 2 stated the ED did not assign staff for central telemetry monitoring because this was not their practice. During an interview on 4/1/2025 at 2:15 p.m. with Registered Nurse (RN, nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 5, RN 5 stated they were not required to print cardiac rhythm strips (test records the electrical activity of the heart) when placing patient on the monitor unless there was an event or code (a medical emergency code signifying a cardiac [heart] or respiratory arrest [stopped breathing], or other life-threatening situation). RN 5 stated the nurses do not carry phones. RN 5 also confirmed that the Emergency Department (ED) never assigned a staff for monitoring the central telemetry monitor. During an interview on 4/2/2025 at 10:15 a.m. with Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed. During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter and all, but one cardiac monitor lead was disconnected. MD 2 also confirmed that Patient 1’s oxygen was not in his nose. MD 2 stated MD 1 checked Patient 1’s pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse. During an interview on 4/3/2025 at 10:39 a.m. with primary registered nurse (RN) 1 assigned to Patient 1, RN 1 stated that she (RN 1) did not hear Patient 1’s alarms because she (RN 1) was responding to an ambulance run (an ambulance arrives at the ED with a patient, and the nurse takes over the patient’s care). During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Director (MD) 7, MD 7 stated that any patient with ST elevation (a possible sign of heart attack or heart muscle damage) should be continuously monitored due to their high risk of cardiac deterioration. During an interview with the Administrator of Quality (AQ) on 4/4/2025 at 2:19 p.m., AQ stated that the telemetry alarm monitoring was not tracked before the incident involving Patient 1. During an interview on 4/4/2025 at 4:12 p.m. with the Administrator of Quality (AQ), AQ confirmed there were no prior quality improvement projects addressing alarm response time or telemetry monitoring before the incident (incident involving Patient 1 being found disconnected from the cardiac monitor and found unresponsive). During a review of the facility’s “Hospital Quality and Patient Safety Program Description: Annual Work Plan and Evaluation,” date 2024, the plan indicated, “The purpose of this Plan is to provide the mechanism for improving hospital quality and safety and to ensure ...collaborative approach to deliver safe, effective, efficient, equitable, patient centered, and timely care within a quality assurance and performance improvement (QAPI) framework. The activities in this plan are essential to achieving the strategic plan ...This plan informs the improvement processes for patient outcomes, reducing and preventing medical errors, and applying remediation strategies in response to system or process failures ...Ensure the actual and potential hazards associated with high risk procedures, processes, and patient care populations are identified, assessed, and controlled in a way that demonstrates continuous improvement and moves the organization toward high reliability and the ultimate objective of ensuring our patients are free from unnecessary harm. Design, construct, operate, and maintain a safe environment of care as well as evaluate, purchase, and utilize equipment and products in a way that promotes the efficiency and effectiveness with which safe healthcare is provided.” During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (Adult),” dated 5/3/2022, the P&P indicated, “The Emergency Department shall perform cardiac monitoring as needed, according to the physician’s orders, and based on the patient’s chief complaint and condition. Documentation of cardiac rhythm, any changes in cardiac rhythm and anytime notification to the physician occurs, shall be recorded In KP Health Connect. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.).” 2. During an interview on 4/2/2025 at 10:15 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 stated the telemetry system in the ED was not configured to alert nurses via phones or communication badges. ACD 1 confirmed there was no staff assigned to monitor the central telemetry station where the alarms were displayed. During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director in the Emergency Department, (ACD)1, Patient 1’s electronic medical record (EMR, a digital version of the paper charts in hospitals) document titled, “Code Narrator Report (a documentation system that allows nurses to efficiently document the details during an emergency resuscitation),” dated 2/10/2025, was reviewed. ACD 1 stated Patient 1 had a pulseless electrical activity (PEA, the heart electrical signals are working but the heart is not pumping blood). ACD 1 confirmed that Patient 1’s heart rhythm was not documented in the report. During the same interview on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 further stated that during a code (Code Blue, emergency cardiac arrest [when the heart stops beating] response), each time a pulse was checked, the corresponding cardiac rhythm (the pattern and regularity of the heart’s beat, influenced by the heart’s electrical system) should be documented. ACD 1 confirmed the Code Narrator report also lacked the time chest compressions were started and stopped, and the specific roles of the code team members were not indicated. ACD 1 confirmed that these documentation elements were required as part of the code record and emphasized the importance of documenting time-stamped clinical actions during a code event. During a concurrent interview and record review on 4/4/2025 at 2:05 p.m. with Assistant Clinical Director (ACD) 2, the facility’s Code Blue policy and procedure, dated 6/21/2021, was reviewed. The policy indicated staff should document on the “Code Blue Record” form found in Appendix C. ACD2 stated the ED no longer uses the paper Code “Blue Record” form and instead documents during codes using electronic “Code Narrator” system. ACD 2 confirmed that the required documentation elements are the same in both the “Code Narrator” and the “Code Blue Record.” However, the policy does not reflect the ED’s current practice of using the “Code Narrator” instead of the paper form. During an interview on 4/4/2025 at 5:06 p.m. with the Regional Senior Director Accreditation Regulation and Licensing (RSDAR), RSDAR confirmed that while the current “Cardiac Monitoring,” policy, dated 5/3/2022, was applicable hospital-wide, including in the ED, the practice in the ED did not reflect the current policy’s requirements. Requiring printing of cardiac telemetry strips when patient was placed on the monitor (Initial Strip), when patient had telemetry discontinued (Final Strip), and use of phone to alert nurses for alarms, were not consistent with the written policy. During a review of the facility’s “Hospital Quality and Patient Safety Program Description: Annual Work Plan and Evaluation,” date 2024, the plan indicated, “The purpose of this Plan is to provide the mechanism for improving hospital quality and safety and to ensure ...collaborative approach to deliver safe, effective, efficient, equitable, patient centered, and timely care within a quality assurance and performance improvement (QAPI) framework ...Leadership is responsible for: Implementing changes in existing processes to improve the quality of the care provided ...Establishing quality of care and patient safety metrics, which can be monitored through the hospital’s ...Ensuring that staffing resources are available, trained and competent to appropriately meet the needs of the patients served ...The Patient Safety and Risk Management Committees strive to reduce risk, improve patient safety and quality outcomes in the delivery of health services across all settings of care. These two committees work in tandem to monitor the effectiveness of the corrective actions taken in response to an adverse or sentinel event to ensure that the risk reduction strategies achieve the expected results.” During a review of the facility’s emergency department policy and procedure (P&P) titled, “Standard Emergency Registered Nurse Procedures,” dated 10/21/2024, the P&P indicated, “Responsibilities: The Emergency Department is responsible for ensuring that this standardized procedure is accurate, relevant, and current. Maintenance: This policy and procedure shall be reviewed at least every three (3) years, and revised periodically, to assure continuing relevance and compliance with regulatory and accrediting standards, hospital bylaws, rules and regulations, legal statutes and current practice.” During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (Adult),” dated 5/3/2022, the P&P indicated the following: The Emergency Department shall perform cardiac monitoring as needed, according to the physician’s orders, and based on the patient’s chief complaint and condition. Monitor rhythm strip(s) will be printed when: A patient is placed on the monitor (Initial Strip),A patient has telemetry discontinued (Final Strip), there is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient, alternative monitoring equipment is used, patient is placed back on telemetry monitoring, after alternative monitoring equipment use. RN will ensure that their clinical communication device is correctly programmed. with assigned patients, and all required alarms are audible (red, yellow, and blue/inoperative). The National Paging Standard alarm configuration will be used to alert the RN by a clinical communication device (badge, smart phone, etc.) RNs will carry assigned clinical communication devices at all times except: When on breaks or meals.” During a review of the facility’s policy and procedure (P&P) titled, “Code Blue Response- Adult Medical Center Campus,” dated 6/21/2021, the P&P indicated, “Documentation: A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. Appendix C: Code Blue Record ...” 3. During a review of Patient 1’s “ED (emergency department) Provider Notes,” dated 2/10/2025, Patient 1’s ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a concurrent interview and record review on 4/1/2025 at 1:15 p.m. with the Director of Risk Management (DRM), Patient 1’s telemetry event report (a digital of monitor alerts), dated 2/10/2025, was reviewed. The telemetry event report indicated that starting at 8:01 p.m. on 2/10/2025, Patient 1’s bedside monitor generated multiple escalating alarms indicating critical deterioration including: monitor not reading oxygen level (Spo2 Probe off), unable to detect heartbeat (Pulse Search), oxygen level danger (Spo2 Alarm), and irregular respiration rate breathing patterns that deviate from the patient’s normal breathing pattern) DRM confirmed the alarms continued until Patient 1 was found unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. During an interview on 4/4/2025 at 2:42 p.m. with the Administrator of Quality (AQ), AQ confirmed the incident involving Patient 1 was reported to California Department of Public Health (CDPH, department that works to protect the public’s health) after the completion of the Corrective System Analysis (CSA, a systematic process for identifying, analyzing, and addressing system failures) was finalized. AQ confirmed that the incident involving delayed response to alarm for Patient 1 was on 2/10/2025, but the facility reported the incident to CDPH on 3/5/2025 (23 days later). During a review of the facility’s policy and procedure (P&P) titled, “National Crosswalk of Sentinel Events,” dated May 2024, the P&P indicated, “Adverse events or series of adverse events that cause/result in death or serious disability lasting > (more than) 7 days or present on discharge from an inpatient health care facility. ‘Serious disability’ is a physical or mental impairment that substantially limits one or more of the patient’s major life activities, the loss of bodily function, or the loss of a body part. Requires report to CDPH within 24 hours if urgent threat or 5 days if not urgent.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to: 1. Ensure that one of 30 sampled patients (Patient 16), received treatment for self-reported pain during their (Patient 16’s) stay in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), in accordance with the facility’s policy regarding pain assessment and management. This deficient practice had the potential for Patient 16 to experience increased pain and discomfort, worsening of Patient 15’s condition, and delayed recovery from illness. 2. Ensure one of 30 sampled patient’s (Patient 27) Columbia Suicide Severity Rating Scale (C-SSRS, an evidence-based tool used for suicide risk screening and assessment) screen, was completed in triage (the process of rapidly assessing patients to determine the severity of their condition and prioritize care), in accordance with the facility’s policy regarding suicide (when someone harms themselves with any intent to end their life) risk screening, when Patient 27 was seen in the emergency department (ED) for overdose (OD, is the ingestion of a drug or other substance in quantities much greater than are recommended). This deficient practice had the potential of failing to identify Patient 27’s level of risk for suicide which can result in patient harm or even death. Findings: 1. During a review of Patient 16’s Emergency Department (ED) Physician Progress Note,” dated 4/1/2025, the note indicated that on 4/1/2025, Patient 16 presented to the ED complaining of left lower abdominal pain for the past couple of days. During a review of Patient 16’s flowsheet (a tool used to track and document patient data over time, typically in a structured format) titled, “Pain Management-Assessment, “dated 4/1/2025, the flowsheet indicated the following pain assessment was documented on 4/1/2025: -At 9:04 a.m., Patient 16’s Pain score (self-reported) was 8/10 (8/10 on a 0-10 pain scale is considered very strong pain that is difficult to bear, making it hard to engage in normal activities; (0: No pain; 1-3: Mild pain, often described as nagging or annoying, but not significantly interfering with daily activities; 4-6: Moderate pain, which can interfere with daily activities; 7-10: Severe pain, which can be disabling and interfere with normal activities;10: The worst pain imaginable) localized in the abdomen. No acceptable level of pain, character of pain, duration, aggravating factors, alleviating factors, and pain interventions, were recorded. -At 9:47 a.m., Patient 16’s pain level was documented 7/10 (strong pain). Acceptable level of pain was documented 7/10. -At 1:31 p.m., Patient 16’s pain level was documented 9/10 (Pain that is very hard to tolerate). Acceptable level of pain was documented 5/10 During a concurrent interview and record review on 4/3/2025 at 3:05 p.m. with registered nurse (RN) 8, RN 8 reviewed Patient 16’s “Pain Management” flowsheet, dated 4/1/2025 and the “Medication Administration Record (MAR), dated 4/1/2025. RN 8 stated that Patient 16 did not receive pain relieving medication during their (Patient 16) stay in the Emergency Department (ED) on 4/1/2025 from 9:02 a.m. through 2:35 p.m. (time of Patient 16’s discharge). RN 8 also said that the expectation for the nurse was to assess the patient’s pain, address the concerns, and collaborate with the physician by requesting a pain medication order (if pain is significant and requires a medication order). During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” dated 3/21/2022, the P&P indicated that, “Acute pain - is pain of short duration and the cause is usually known (i.e. Injury or surgical intervention). It generally disappears when healing occurs. Acute pain may be associated with objective physical signs ... Most often there are NO physical signs directly related to pain. The patient’s subjective (self) report of the presence of pain is all that is needed to initiate treatment ... 4.2. Nursing will collaborate interprofessional with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. 4.3. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment and defined criteria based on patient condition, age, and ability to understand during Emergency department visit and at the time of admission to inpatient. 4.4. The patient will be reassessed as to patient’s response to pain through the following: Evaluation and documentation of response to pain interventions, including pain medication administration. The patient will be reassessed for pain scale or level of pain within 60 minutes (within one hour) of pain medication administration. Progress toward pain management goals including functional ability, i.e. ability to take deep breaths, tum in bed, walk with improved pain control ... 4.5 Patients have the right to be treated for pain and receive treatment in a timely manner. 5.2. Ongoing Pain Management: a. Assess and re-assess all patients with pain for pain intensity, quality, location precipitating factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum with routine shift assessments, operative or other procedures and prior to discharge 5.5 Documentation: Pain will be recorded as part of the initial admission patient assessment or as appropriate to the setting with every full set of vital signs ... g. The functional pain goal (patient’s acceptable level of pain) will be documented every shift. 2. During a review of Patient’s 27 “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/11/2024, the H&P indicated that Patient 27 was brought to the Emergency Department with chief complaint of overdose (OD, is the ingestion of a drug or other substance in quantities much greater than are recommended). The H&P also indicated Patient 27 was picked up from the street and brought in by ambulance for ingestion of unknown substance and bizarre behavior. Preliminary urine toxicology (a urine drug screen ) indicated Patient 27 was positive for methamphetamines (a highly addictive drug with potent central nervous system [comprise of the brain and the spinal cord- a long tube-like structure that extends downwards form the base of the brain] stimulant [speeds up the body’s functions] properties). The H&P further indicated that Ativan (a drug used to treat anxiety [a feeling of fear and uneasiness] disorders) and 2 liters of normal saline (a solution of 0.9% sodium chloride in water) was administered to Patient 27. During a concurrent interview and record review on 04/04/2025 at 11:42 a.m. with the patient safety officer (PSO), Patient 27’s medical record titled, “Patient Care Timeline,” dated 10/11/2024 at 6 :42 p.m. to 10/12/2024 at 8:17 a.m., was reviewed. The patient’s (Patient 27) Patient Care Timeline record did not indicate that a Columbia Suicide Severity Rating Scale (C-SSRS, an evidence-based tool used for suicide risk screening and assessment) screening assessment was completed during triage (the process of rapidly assessing patients to determine the severity of their condition and prioritize care). During the same interview on 4/04/2025 at 11:42 a.m. with the patient safety officer (PSO), the PSO stated that the triage nurse did not complete a C-SSRS screening assessment tool. PSO also said that Patient 27 was oriented to person and place and was seen in the ED for overdose. PSO added that patients who arrive in the ED with chief complaint of overdose must be screened for suicide (when someone harms themselves with any intent to end their life) risk. Furthermore, there was no documentation from the triage nurse as to why a C-SSRS screen was not completed. During a review of the Policy and Procedure titled “Management of Patients Who Are a Danger to Self or Others or Are Gravely Disabled (a condition where a person, due to a mental health disorder, is unable to provide for their basic needs, such as food, clothing, or shelter. This can also include an inability to seek necessary medical care or ensure their personal safety).” (Policy No.: SC.QRM.PCS.023), with revised date of 3/12/2018, the document indicated the following: Provisions and Procedures for the Emergency Department & Labor and Delivery (L&D) Triage Initial Suicide Risk Screen o During the triage and/or admitting process, the Registered Nurse (RN) shall complete a suicide risk screening using the C-SSRS on any of the following patients age ten (10) years and older. o Patients who present with a behavioral health related primary complaint. o Patients exhibiting signs/symptoms of self-harm. o Patients who are identified with risk factors for suicide; and/or whenever the nurse’s clinical judgment determines a risk screen is appropriate. o For patients age nine (9) years and under who present with suicidal thoughts and behavior, follow policy and procedures as outlined below in collaboration with parent/guardian.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 42937 Based on interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 19), a plan of care (a written document that outlines the specific healthcare needs, goals, and interventions for a patient) on Heart Failure (also known as congestive heart failure, occurs when the heart can’t pump enough blood to meet the body’s needs, leading to symptoms like shortness of breath, fatigue, and swelling), was developed and implemented upon completion of assessment (a process in healthcare that involves evaluating a patient’s condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for not addressing Patient 19’s care needs and risks, which may delay the implementation of necessary interventions resulting in complications such as kidney damage, irregular heartbeat, and cardiac arrest (when the heart stops beating). Findings: During a review of Patient’s 19 “History and Physical (H&P, a formal and complete assessment of the patient and the problem,” dated 04/02/2025, the H&P indicated that Patient 19 had a past medical history of diabetes (a condition where the body doesn’t produce enough insulin [regulates sugar levels in the bloodstream] that leads to high blood sugar levels), heart failure and asthma (a respiratory disease characterized by inflammation and narrowing of the airways, leading to difficulty breathing, wheezing, and chest tightness) and was transferred to the hospital for shortness of breath (difficulty breathing) and congestive heart failure exacerbation (occurs when the heart can’t pump enough blood to meet the body’s needs, leading to symptoms like shortness of breath, fatigue, and swelling). During a concurrent interview and record review on 04/03/2025 at 2:43 p.m. with the Quality Coordinator (QC) 1, Patient 19’s medical record titled, “Manage Plan,” undated, was reviewed. Patient 19’s Manage Plan record did not indicate heart failure as part of Patient 19’s plan of care (POC). QC 1 stated that the admitting nurse failed to identify and develop a heart failure POC. QC 1 added that the nurse should have initiated and developed the plan of care since heart failure was one of the reasons of Patient19’s hospitalization. QC 1 further said the plan of care tracks and monitors a patient’s progression and helps determine the need for intervention. During a review of the facility’s Policy and Procedure (P&P) titled, “Patient Assessment, Reassessment and Plan of Care” (Policy No.: 2120), with revised date of 10/17/2022, the P&P indicated the following: Plan of Care: -Upon completion of the assessment, a plan of care will be developed by all health care team members, in consultation with the patient/family as appropriate and possible. -Care, treatment, and services are planned to ensure that they are appropriate to the patient’s needs. -Development of a plan for care, treatment, and services is based on the data from the assessments and reassessments of patient’s needs and/or changes in condition. -The plan of care will be reviewed daily in consultation with appropriate members of the heath care team and the patient/family. The plan of care will be revised as necessary and appropriate to the patient’s condition and according to the patient’s comprehension of disease-specific information and the ongoing assessment process.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure assessment and monitoring of a patient’s condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) every 15 minutes, for one of 30 sampled patients (Patient 26), while placed on violent restraints (bilateral wrist and ankle restraints- the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient’s violent behavior poses an immediate danger to themselves or others. Example vest restraints and wrist restraints), as per facility’s policy and procedure regarding restraints use. This deficient practice had the potential for increased risk of injury (such as skin and circulatory [blood flow] impairment), psychological distress, and/or death. Findings: During a review of Patient’s 26’s “ED (Emergency Department) Provider Notes,” dated 10/14/2024, the record indicated that Patient 26 presented in the emergency department with depression (a mental disorder that can impact how you feel, think, and act) and suicidal thoughts (having abstract thoughts about ending one’s life). While waiting for the psychiatric evaluation (a comprehensive assessment conducted by a psychiatrist to evaluate a person’s mental health), Patient 26 became very combative and violent requiring sedation (the administration of a sedative drug to produce a state of calm or sleep) and restraints (the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient’s violent behavior poses an immediate danger to themselves or others). During a review of Patient’s 26’s “Order History,” dated 10/17/2024, the Order History record indicated that a medical order to place patient on bilateral (both side) wrist and ankle violent restraints (the use of physical or mechanical devices to limit patient movement, used as an intervention when a patient’s violent behavior poses an immediate danger to themselves or others. Example: vest restraints and wrist restraints), was entered on 10/17/2024 at 5:35 p.m., and was discontinued at 9:05 p.m. During a concurrent interview and record review on 04/04/2025 at 11:30 a.m. with the patient safety officer (PSO), Patient 26’s medical record titled, “Restraint Flowsheet,” dated 10/17/2024, was reviewed. The PSO stated that the Restraint Flowsheet record had no documentation of assessment and monitoring regarding Patient 26’s condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) from 7:15 p.m. to 9:00 p.m. on 10/17/2024. During the same interview on 4/04/2025 at 11:30 a.m. with the patient safety officer (PSO), PSO said that per hospital policy, patients on violent restraints should be monitored and assessed every 15 minutes. The last assessment by nurse was at 7:00 p.m. which indicated the continued use of bilateral wrist and ankle restraint. PSO further stated that the order to discontinue restraint was not until 9:00 p.m. In addition, there was missing documentation of assessment and monitoring of patient’s condition (patient behavior [example: calm, aggressive, etc.], mental status [Example: delusions- a persistent, false belief held despite evidence to the contrary], physical comfort, circulation [blood flow]) every 15 minutes from 7:15 p.m. to 9:00 p.m. on 10/17/2024. During a review of the Policy and Procedure (P&P) titled, “Restraint Use” (Policy No.: SC.QRM.PCS.024), with revised date of 3/19/2018, the document indicated the following: Assessment, monitoring, and documentation of all restraint types: -Registered Nurses (RN) are responsible for the assessment, monitoring and provision of care for patients in restraints. The use of restraint (including drugs or medication used as restraint as well as physical restraint) must be documented in the patient’s plan of care. -Patient assessment by staff who have observed, examined or interacted directly with the patient will occur every 15 minutes for violent, self-destructive restraints and every 2 hours for non-violent, non-self-destructive restraints. -Assess the patient every at least every 15 minutes and as needed to determine continued need for restraints. Assessment must include Behavior/mental status; Physical comfort; Circulation. -Assess at least every two (2) hours. Assessment must include Nutritional needs (food/meal); Hydration needs; Elimination needs; ROM (Range of Motion) Restraints released and reapplied, one limb at a time.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 15), a complete pain assessment evaluation was documented, in accordance with the facility’s policy regarding pain assessment and management. This deficient practice had the potential for Patient 15’s pain to be inadequately managed, potentially leading to prolonged discomfort and overall negative impact on Patient 15’s recovery process. In addition, incomplete pain assessment documentation had the potential to disrupt the continuity of care for Patient 15, making it difficult for other healthcare providers to understand Patient 15’s pain level, response to interventions and delays the implementation of other alternative pain management strategies. Findings: During a review of Patient 15’s “Emergency Medicine Provider Note,” dated 4/1/2025, the note indicated that Patient 15 came to the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention) complaining of tingling (a sensation like pins and needles) in the left arm for two days, and pain in the right upper shoulder and cramping in the left rib cage. During a review of Patient 15’s medical record (MR) titled, “Patient Care Timeline,” dated 4/1/2025 at 10:20 a.m. to 4/1/2025 at 3:33 p.m., the MR indicated that on 4/1/2025 at 10:23 a.m., Patient 15’s pain level was assessed to be 3/10 (a pain level of 3/10 on a 0-10 pain scale is considered mild to noticeable pain), localized at the right shoulder. The MR also indicated that the acceptable level of pain (stated by Patient 15), was not documented. During a concurrent interview and record review on 4/3/2025 at 2:40 p.m. with registered nurse (RN) 8, Patient 15’s “Pain Assessment” documentation, dated 4/1/2025, was reviewed. RN 8 reviewed Patient 15’s “Pain Assessment” documentation on 4/1/2025, and stated the following: -At 10:23 a.m.: Patient 15’s recorded pain level was documented as 3/10 (0: No pain, 1-3: Mild pain, ranging from barely noticeable to distracting but manageable. At level 3, the pain is noticeable and distracting, but you can still function, 4-6: Moderate pain, interfering with daily activities, 7-10: Severe pain, disabling and interfering with the ability to perform daily tasks), localized at right shoulder. No documentation of Patient 15’s acceptable level of pain, character (type of pain. Example: throbbing, sharp pain, dull, or aching), duration (the length of time a patient experiences pain), and pain aggravating factors (any elements that intensify or worsen pain. Example: movement), alleviating factors (things that help reduce or eliminate pain. Example: rest), and intervention was recorded. -At 12:50 p.m.: Patient 15’s pain level was documented 3/10, localized at right shoulder. No documentation of Patient 15’s acceptable level of pain, character, duration, and pain aggravating factors, alleviating factors, and intervention was recorded. -At 1:27 p.m.: Patient 15’s pain level was recorded 3/10, acceptable pain level was documented 3/3; localized at left arm, described as throbbing and aching; intermittent in duration, aggravated by activity, and alleviated by rest and medication. Documented intervention was recorded as “Care and Medication.” -At 2:42 p.m.: Patient 15’s pain level was recorded as 2/10, localized at left arm, continuous in duration. No record of acceptable pain level, character of the pain, aggravating and alleviating factors, and interventions were documented. -At 3:04 p.m.: no documentation of Patient 15’s pain level, acceptable level of pain, character, aggravating factors, alleviating factors, and intervention. During the same interview on 4/3/2025 at 2:40 p.m. with registered nurse (RN) 8, RN 8 stated that pain assessment was performed with each set of vital signs (VS, physiological measurements that indicate a person’s basic bodily functions and overall health status [typically every 2 hours, unless indicated otherwise] and as needed. During the same interview on 4/3/2025 at 2:40 p.m. with registered nurse (RN) 8, RN 8 stated that a full/complete pain assessment (which includes patient’s pain level, acceptable level of pain, aggravating factors, etc.) should be documented to ensure effective pain management. During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” dated 3/21/2022, the P&P indicated that, “Acute pain - is pain of short duration and the cause is usually known (i.e. Injury or surgical intervention). It generally disappears when healing occurs. Acute pain may be associated with objective physical signs ... Most often there are NO physical signs directly related to pain. The patient’s subjective (self) report of the presence of pain is all that is needed to initiate treatment ... 4.2. Nursing will collaborate interprofessional with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. 4.3. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment and defined criteria based on patient condition, age, and ability to understand during Emergency department visit and at the time of admission to inpatient. 4.4. The patient will be reassessed as to patient’s response to pain through the following: Evaluation and documentation of response to pain interventions, including pain medication administration. The patient will be reassessed for pain scale or level of pain within 60 minutes (within one hour) of pain medication administration. 5.2. Ongoing Pain Management: a. Assess and re-assess all patients with pain for pain intensity, quality, location precipitating factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum with routine shift assessments, operative or other procedures and prior to discharge 5.5 Documentation: Pain will be recorded as part of the initial admission patient assessment or as appropriate to the setting with every full set of vital signs ... g. The functional pain goal (patient’s acceptable level of pain) will be documented every shift.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1.a. Ensure the medical record for one of 30 sampled patients (Patient 1) contained complete documentation of a code blue event (a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation). The “Code Narrator report (a tool that helps document and track key events during a code)” for Patient 1 lacked required clinical elements including cardiac rhythm (the timing and pattern of the heart’s electrical signals, which determine how the heart beats), timing of chest compressions (push on the person’s chest in resuscitation), pulse checks (moments when medical staff checks for a heartbeat), and code team member roles, in accordance with the facility’s code blue policy. This deficient practice impeded the facility’s ability to review what actions were taken during emergency, to understand how care was provided, and to identify ways to improve future emergency responses. 1.b. Ensure that the medical record for one of 30 sampled patients (Patient 1) included a complete and authenticated documentation of care, as required by the Physician Assistant (PA, a healthcare professional licensed to practice medicine under physician supervision) 1’s practice agreement, and the facility’s medical staff rules and regulations. Specifically, the Emergency Department (ED) triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note, documented by PA 1, was not co-signed by a supervising physician, as required. This deficient practice resulted in the medical record lacking documentation required to validate that the services provided by the PA 1 were reviewed by a supervising physician. The absence of a co-signature prevented confirmation that oversight was performed in accordance with the practice agreement and facility policy, which may have an impact on patient safety. 2. Ensure that one of 30 sampled patients’ medical records (Patient 9) were complete, containing documentation of justification for the continued use of restraints (the use of physical or mechanical devices to limit patient movement. Example wrist restraints), in accordance with the facility’s policy regarding restraints use. This deficient practice had the potential to compromise Patient 9’s safety by allowing restraints to be applied without oversight and evaluation, increasing the risk of physical (example: skin breakdown [damage to the skin], circulatory issues [any condition such as tightly applied wrist restraints that impede blood flow]) and psychological harm (example: anxiety [a feeling of dread and uneasiness], trauma, etc.) to the patient (Patient 9). Findings: 1.a. During a review of Patient 1’s “ED (emergency department) Provider Notes,” dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD)1, Patient 1’s electronic medical record (EMR, a digital version of the paper charts in hospitals) document titled, “Code (Code Blue- a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation) Narrator Report (a tool that helps document and track key events during a code),” dated 2/10/2025, was reviewed. ACD 1 stated Patient 1 had a pulseless electrical activity (PEA, the heart electrical signals are working but the heart is not pumping blood). ACD 1 confirmed that Patient 1’s heart rhythm was not documented in the Code Narrator report. During the same interview on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD) 1, ACD 1 further stated that during a code, each time a pulse was checked, the corresponding cardiac rhythm (the timing and pattern of the heart’s electrical signals, which determine how the heart beats) should be documented. ACD 1 confirmed the report also lacked the documentation of the time chest compressions (the act of applying pressure to someone’s chest in order to help blood flow through the heart in an emergency situation) were started and stopped, and the specific roles of the code team members were not indicated as well. ACD 1 confirmed that these documentation elements were required as part of the code record and emphasized the importance of documenting time-stamped clinical actions during a code event. During a review of the facility’s policy and procedure (P&P) titled, “Code Blue Response- Adult Medical Center Campus,” dated 6/21/2021, the P&P indicated, “To provide guidance for the development of a standardized level of care provided to the adult patient experiencing a cardiac and/or respiratory arrest ... All those involved in the Code Blue situation respond in accordance with the American Heart Association Basic Life Support and Advanced Cardiovascular Life Support guidelines ... An accurate, chronological documentation record will be completed and submitted as part of the legal medical record for the patient in all Code Blue situations ... A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. A Code Blue Evaluation Form will be completed during the debriefing critique of the code and forwarded to the Quality Department.” During a review of the “American Heart Association (a non-profit organization dedicated to fighting heart disease and stroke through research, education, and advocacy)” Guidelines, dated 2020, the Guideline indicated providers are expected to document the patient’s condition before, during, and after a resuscitation attempt, including time of arrest, interventions (such as CPR [Cardiopulmonary Resuscitation- An emergency procedure used to restart a person’s heartbeat and breathing after one or both have stopped] and Defibrillation- a medical procedure using electrical shocks to restore a normal heart rhythm), response to treatment, and names and roles of responders. This documentation is essential for legal, clinical, and quality assurance (a proactive approach to ensure establishments consistently deliver high-quality service and amenities, meeting or exceeding established standards) purposes. During a review of the facility’s emergency department policy and procedure (P&P) titled, “Nursing initial Assessment and Re-Assessment Documentation,” dated 5/3/2023, the P&P indicated, “Nursing Interventions - will be documented on appropriate flowsheets in KPHC, as applicable, otherwise, the RN will document in the ED Notes section to ensure that interventions are documented. Patient care status updates and other general information pertaining to patient care will also be documented in the ED Notes section, unless otherwise specified.” 1.b. During a concurrent interview and record review on 4/2/2025 at 2:03 p.m. with the Patient Safety Officer (PSO, a staff member responsible for monitoring and promoting safety practices), Patient 1 ‘s medical record documented by Physician Assistant (PA 1) titled, “ED Provider Triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) Note,” dated 2/10/2025, was reviewed. The record indicated that the note had not been co-signed (formally reviewed and signed by another provider, in this case, a supervising physician). PSO confirmed that the note was not co-signed by a supervising provider. During an interview on 4/4/2025 at 10:15 a.m. with the Assistant Area Medical Director (MD) 7, MD 7 stated that the Physician Assistant (PA, a licensed healthcare professional who works under the supervision of a physician, providing medical care and performing a range of diagnostic and treatment tasks) who is working in the triage area were supervised by physicians and that the entire PA note was expected to be reviewed and co-signed by a supervising physician. During a review of Physician Assistant (PA) 1’s Practice Agreement, dated 4/27/2023, the Practice Agreement indicated: “According to California law, a PA may perform medical services if the following requirements are met: 1) The PA renders the services under the supervision of a licensed physician and surgeon. Supervising Physicians shall be available in person or by electronic communication at all times when the PA is performing medical service. The supervising physician shall review, countersign, and date within 24 hours the admitting history and physical of any hospitalized patient completed by the physician assistant.” During a review of the facility’s “Rules and Regulations of the Professional Staff,” dated 2023, the Rules and Regulation indicated, “Complete Medical Record: The attending practitioner(s) shall be responsible to assure that a complete, legible, dated and authenticated medical record is prepared for each patient accepted for care by the Hospital. This record shall be in such form and shall contain such information as the Executive Committee and Hospital Administrator shall jointly prescribe. Entries in the medical record may be electronic or hard copy.” 2. During a review of Patient 9’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 2/11/2025, the H&P indicated that Patient 9 was admitted with a chief complaint of altered mental status (AMS, a change in a person’s normal mental function, encompassing alterations in consciousness [temporary changes in a person’s awareness and perception of the world, often accompanied by shifts in behavior], cognitive function [includes ability to learn, recall events, decision-making, etc.], behavior, or alertness, ranging from mild confusion to coma [a prolonged state of unconsciousness where a person is unresponsive to their environment, unable to wake, and does not react to stimuli like pain, sound, or light]). During a review of Patient 9’s medical record (MR) titled, “Order History(a record of all the physician’s orders [instructions] for a patient’s treatment, including medications, tests, procedures, and other care directive), dated 2/10/2025, the MR indicated that on 2/10/2025 at 9:59 p.m., an order for nonviolent, bilateral (both) wrist restraints (physical restraints designed to limit a patient’s movement, typically used for medical or surgical purposes, to prevent harm to themselves or others, or to ensure the integrity of medical equipment, while not intended to address violent or aggressive behavior), was placed by the emergency department (ED) physician. During a review of Patient 9’s medical record (MR) titled, “Documentation Flowsheet (for restraints assessment),” dated 2/10/2025, the MR indicated the following: -On 2/10/2025 at 10:00 p.m., bilateral wrist restraints were applied to Patient 9. The MR also indicated that the clinical justification for restraint use was documented as the patient (Patient 9) pulling tubes and lines (which refers to the patient attempting to remove medical devices such as intravenous [IV, through the vein] lines or catheters, posing a risk to their safety or treatment efficacy]. -On 2/10/2025 at 11:00 p.m. and at 1:00 a.m., justification (the patient’s behavior that warranted the use of the restraints) for the bilateral use of wrist restraints was not documented. During an interview on 4/3/2025 at 2:06 p.m. with registered nurse (RN) 8, RN 8 stated the following: “We document the justification in the restraint assessment to indicate the reason for keeping the patient in restraints. When there is no reason to keep the patient in restraints, patient should not be in restraints.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 9/2022, the P&P indicated the following: 5.8. Assessment, monitoring, and documentation of all restraint types: 5.8.2. Patient assessment by staff who have observed, examined or interacted directly with the patient will occur every 2 hours for non-violent, non-self-destructive restraints. 5.8.4. A description of the patient’s behavior or symptom(s) that warranted the use of the restraint and the patient’s condition.”

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure that medical record for one of 30 sampled patients (Patient 1) included documentation from the physician (MD 1) who discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation). MD 1 did not record a physical assessment (a hands-on examination), clinical observations, or actions taken in response, in accordance with the facility’s policy regarding medical records content. This deficient practice resulted in an incomplete medical record and impaired the facility’s ability to evaluate the care provided, ensure continuity of care (the consistent and coordinated management of a patient’s treatment across shifts or providers), prevented a full understanding of the patient’s condition during the emergency, and made it harder for the facility to review and improve its emergency procedures. Findings: During a review of Patient 1’s “ED (emergency department) Provider Notes,” dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a review of Patient 1’s “triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note,” dated 2/10/2025, the triage note indicated Patient 1 was assigned an Emergency Severity Index (ESI, a 5-level triage system that categorizes patients based on their acuity [severity] and resource needs, from most urgent [Level 1] to least urgent [Level 5]) Level 1 (most urgent level requiring immediate life-saving intervention). During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter (a medical device that measures the amount of oxygen in a person’s blood) and all, but one cardiac monitor lead (provides different views of the heart’s electrical activity), was disconnected. MD 2 stated MD 1 checked Patient 1’s pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse. During a concurrent interview and record review on 4/2/2025 at 11:30 a.m. with Informatic staff member (IN, staff member responsible for managing the hospital’s electronic medical records system) 1, Patient 1’s physician notes, was reviewed. IN 1 confirmed that MD 1, the physician who found Patient 1 unresponsive on 2/10/2025, did not enter a note in Patient 1’s medical record (a collection of written or digital documents that contain information about a patient’s health, diagnoses, treatments, and other medical history). IN 1 confirmed that there was no documentation describing what MD 1 observed, what was assessed, or whether any actions or instructions were given to staff. During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Medical Director and Ancillary Chief of Staff (MD 7), MD 7 stated that physicians were expected to document all patient encounters before the end of their shift. MD 7 stated that when a physician discovers a patient unresponsive, the expectation was to record a note with observations and actions taken. This information was necessary to ensure other healthcare staff can understand the event and provide consistent, informed care. MD 7 confirmed that such documentation was essential for communication between medical teams and supports safe and effective care. During a review of the facility’s policy and procedure (P&P) titled, “Medical Records Content-Medical Staff,” dated 7/21/2021, the P&P indicated that attending physician (the physician responsible for overseeing the patient’s hospital care) is required to complete a medical record that includes a history of the present illness (a summary of symptoms and their development), physical examination(a hands-on evaluation of the patient ‘s condition), progress notes (written updates on clinical status), and final findings (the physician’s conclusions based on treatment and outcomes). The policy also states that current records should be completed within 24 hours.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to ensure that medical records for two of 30 sampled patients (Patient 9 and Patient 14) were complete, when: 1. Patient 9’s medical records had no documentation of physician’s order for continuous cardiac (heart)monitoring (encompasses all methods of heart rate and rhythm (the pattern and regularity of the heart’s beat) monitoring, including remote monitoring and often involves bedside displays), in accordance with the facility’s policy regarding cardiac monitoring. This deficient practice had the potential to compromise Patient 9’s safety by delaying timely placement of Patient 9 on a cardiac monitor and potentially preventing timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 9. 2. Patient 14’s medical record had no documentation of the following: 2.a. Physician’s order for continuous cardiac monitoring was not placed by the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care to patients with urgent health issues) provider, in accordance with the facility’s policy regarding cardiac monitoring and policy on Rules and Regulations for the Professional Staff. This deficient practice had the potential to compromise Patient 14’s safety by delaying timely placement of Patient 14 on a cardiac monitor and/or not continuously monitoring Patient 14’s heart rhythm potentially delaying timely detection of cardiac abnormalities, increasing the risk of serious complications for Patient 14. 2.b. No documentation of cardiac rhythm in the flowsheet assessment record despite Patient 14 being observed to be connected to a cardiac monitor, in accordance with the facility’s policy regarding cardiac monitoring and documentation. This deficient practice had the potential to compromise Patient 14’s safety by preventing other healthcare providers not to be able to promptly recognize and respond to changes in the Patient 14’s cardiac condition, leading to potential delays in necessary treatment and intervention. Findings: 1. During a review of Patient 9’s medical record (MR) titled, “Emergency Department (ED) Physician Note,” dated 2/10/2025, the MR indicated the following: Patient (Patient 9) presented to the facility’s ED with altered mental status (AMS, a change in a person’s normal mental function, encompassing alterations in consciousness [temporary changes in a person’s awareness and perception of the world, often accompanied by shifts in behavior], cognitive function [includes ability to learn, recall events, decision-making, etc.], behavior, or alertness, ranging from mild confusion to coma [a prolonged state of unconsciousness where a person is unresponsive to their environment, unable to wake, and does not react to stimuli like pain, sound, or light]) and agonal breathing (an abnormal, often labored breathing pattern characterized by shallow, gasping breaths or snorting sounds, that can occur during the early stages of cardiac arrest [when the heart stops beating] or near death). The MR further indicated that: -Patient 9 was found with acute respiratory failure (a life-threatening condition where the lungs suddenly fail to adequately oxygenate the blood or remove carbon dioxide, leading to hypoxia [low oxygen levels]) and was intubated (the medical procedure of inserting a tube into the airway to help with breathing). -Patient 9 was also found with hypoglycemia (low blood sugar, life threatening condition), requiring continuous medication administration -Patient 9 also had persistent hypotension (a condition in which blood pressure is abnormally low) requiring multiple pressors (medications or substances that raise blood pressure and increase cardiac output [how many liters of blood your heart pumps in one minute, often used to improve blood flow to vital organs]). During a review of Patient 9’s medical record (MR) titled, “Order History, a record of all the physician’s orders [instructions] for a patient’s treatment, including medications, tests, procedures, and other care directive), dated 2/10/2025, the MR indicated that on 2/10/2025, there was no order placed for continuous cardiac monitoring for Patient 9 on 2/10/2025 during Patient 9’s stay in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention). This information was verified by registered nurse (RN 8) during an interview on 4/3/2025. During concurrent interview and record review on 4/3/2025 at 1:57 a.m. with Registered Nurse (RN) 8, Patient 9’s medical record (MR) titled, “Vital Signs Flowsheet (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure), dated 2/10/2025, was reviewed. The MR indicated that Patient 9’s heart rhythm (rate) was monitored and documented in Patient 9’s Vital Signs flowsheet. RN 8 stated the following: -“In our Emergency Department (ED), placing patients on a cardiac monitor is a standard of practice and is done at the nurse’s discretion. Typically, patients classified as ESI 3 (Emergency Severity Index level 3, indicating patients who require urgent care but are not in immediate danger) and higher (ESI 2 and ESI 1, indicating more critical needs) are required to be on a cardiac monitor, especially if they are receiving certain medications that may affect cardiac function, such as antiarrhythmics or other drugs that can cause changes in heart rhythm (such as pressors, medications or substances that raise blood pressure and increase cardiac output [how many liters of blood your heart pumps in one minute, often used to improve blood flow to vital organs]).” -“I (RN 8) typically place my patients on a cardiac monitor, particularly when their clinical presentation warrants it. Regarding documentation, I do document any abnormal heart rhythms in a patient chart, but I do not typically document a normal heart rhythm.” During an interview on 4/4/2025 at 10:02 a.m. with Assistant Area Medical Director for Hospital Services (MD 7), MD 7 stated that the flow of orders should be from the doctor to the nurse. If the nurse recognized that a patient required cardiac monitoring or if the nurse had already placed a patient on a cardiac monitor, the nurse should approach the physician and notify them (the physicians) to obtain an order (for cardiac monitoring). MD 7 then said that a continuous cardiac monitoring required a physician to place an order for it. MD 7 further stated that “if a patient was to be admitted to a telemetry (a specialized ward where patients receive continuous electronic monitoring of their vital signs, particularly heart rhythm and rate, allowing healthcare providers to track and respond to any changes remotely) unit, the patient should also be monitored in the ED.” During an interview on 4/4/2025 at 11:09 a.m. with the Chief of Emergency Medicine (MD 4), MD 4 stated the following: “Typically, physicians place orders for cardiac monitoring, which requires the nurses to continuously monitor and [document] the heart rate and rhythm of the patient.” During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following regarding cardiac monitoring orders: “There are doctors that do place orders for cardiac monitoring at times, but the majority of doctors don’t.” During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (ADULT),” dated 5/2022, the P&P indicated the following: 1.1. Cardiac monitoring, when indicated by history or current illness, demonstrates the facility’s commitment to ensure patient safety through appropriate care delivery interventions. 4.1. Cardiac Telemetry Monitoring - Cardiac Telemetry monitoring is an intervention to continuously monitor the cardiac rhythm and any associated changes in rate and/or characteristics. Cardiac Telemetry monitoring is utilized throughout multiple patient care units with 24-hour visualization by competent healthcare personnel. 5.1.1 A physician’s order is required for telemetry monitoring/cardiac monitoring and discontinuation. During a review of the facility’s policy and procedure (P&P) titled, “Standardized Emergency Registered Nurse procedures,” dated 10/2024, the P&P indicated the following: 4 .... Altered Level of Consciousness (Altered Mental Status, AMS) ...Place patient on a cardiac monitor when treatment room is available ... During a review of the facility’s employee document titled, “Nursing Expectations, Norms, and Workflows,” dated 8/2023, the document indicated the following: Patients who are presenting with a cardiac, respiratory, and neurological complaint are to be placed on a cardiac monitor. During a review of the facility’s Rules and Regulations for the Professional Staff (Rules and Regs), dated 2023, the Rules and Regs indicated the following: Medical Records: 1. The attending practitioner(s) shall be responsible to assure that a complete ...medical record is prepared for each patient accepted for care by the Hospital ...xiv. Medications, assessments, and treatments are ordered ... 2.a. During a review of Patient 14’s medical record (MR) titled, “Emergency Department (ED) Patient Care Timeline,” dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), the MR indicated the following: -On 4/1/2025, at 11:38 p.m., Patient 14 arrived in the ED complaining of abdominal pain. -On 4/1/2025, at 11:43 a.m., Patient 14 was triaged (a patient has been sorted and prioritized for treatment based on the urgency of their condition), given Emergency Severity Index (ESI) level of 3 (urgent condition, but the patient is stable). -On 4/1/2025 at 11:50 a.m., Patient 14 was reassessed to ESI level of 2 (considered high-risk and should not be left unattended for any length of time). -On 4/1/2025 at 12:02 p.m., an ED provider was assigned to Patient 14. -On 4/1/2025 at 12:12 p.m., Patient 14 was moved to a room. During an observation on 4/2/2025 at 1:53 p.m., in the Emergency Department, a remote cardiac monitor (a device that enables nurses and other healthcare staff to continuously monitor the cardiac rhythms of multiple patients from a central location, providing real-time data on heart rates and rhythm abnormalities) located at the nurses’ station, was observed. The monitor displayed multiple patients’ various vital information, including the heart rhythm, heart rate, blood pressure, respirations, and SpO2 (peripheral oxygen saturation, refers to the percentage of hemoglobin in your blood that is carrying oxygen, as measured by a pulse oximeter). During the same observation on 4/2/2025 at 1:53 p.m., in the Emergency Department, Patient 14’s cardiac rhythm was observed to be irregular (as displayed on the cardiac monitor), with a heart rate ranging from 116-126 beats per minute (bmp). Not all patients were observed to be displaying cardiac rhythms on the monitor. During an interview on 4/2/2025 at 1:58 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following: “The doctor and the nurse work together to assess whether the patient needs to be connected to a cardiac monitor. If they determine that monitoring is necessary, the physician can then place an order for cardiac monitoring to ensure continuous observation of the patient’s heart rhythm and vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions). Cardiac monitoring depends on a chief complaint and the assessment of the patient.” During an observation on 4/2/2025 at 2:35 p.m., Patient 14 was observed in the room (located in the ED), lying on a gurney, connected to a cardiac monitor. During a concurrent interview and record review on 4/3/2025 at 11:02 a.m., with Registered Nurse (RN) 8, Patient 14’s “Emergency Department (ED) Patient Care Timeline,” dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), was reviewed. RN 8 stated that Patient 14s “ED Patient Care Timeline” had no documentation indicating whether Patient 14 was placed on a cardiac monitor during Patient 14’s stay in the ED. RN 8 also said that Patient 14’s medical record contained no documentation of the physician ‘s order for continuous cardiac monitoring. During a review of Patient 14’s History and Physical (H&P, a comprehensive assessment performed by a healthcare provider that includes a thorough medical history and a physical examination), dated 4/1/2025, the H&P indicated that Patient 14 had past medical history (PMH, previous illnesses, surgeries, and medication) of atrial fibrillation (AFib, a common type of arrhythmia [irregular heartbeat] where the heart’s upper chambers [atria] beat chaotically and too quickly, potentially leading to blood clots, stroke [clot in the brain], heart failure [(the heart can’t pump enough blood to meet the body’s needs, often due to a weakened or stiffened heart muscle], and other heart-related complications), heart failure and pulmonary hypertension (a condition characterized by high blood pressure in the arteries of the lungs, making the right side of the heart work harder to pump blood through the lung). The H&P also indicated that Patient 14 was admitted to the facility with a diagnosis of acute hypoxemic respiratory failure (a condition where the lungs are not effectively delivering enough oxygen to the blood, leading to low oxygen levels in the blood). During an interview on 4/3/2025 at 1:57 a.m. with Registered Nurse (RN) 8, RN 8 stated the following: -“In our Emergency Department (ED), placing patients on a cardiac monitor is a standard of practice and is done at the nurse’s discretion. Typically, patients classified as ESI 3 (Emergency Severity Index level 3, indicating patients who require urgent care but are not in immediate danger) and higher (ESI 2 and ESI 1, indicating more critical needs), are required to be on a cardiac monitor, especially if they are receiving certain medications that may affect cardiac function, such as antiarrhythmics or other drugs that can cause changes in heart rhythm [such as pressors, medications or substances that raise blood pressure and increase cardiac output [how many liters of blood your heart pumps in one minute, often used to improve blood flow to vital organs]).” -“I typically place my patients on a cardiac monitor, particularly when their clinical presentation warrants it.” During an interview on 4/4/2025 at 10:02 a.m. with the Assistant Area Medical Director for Hospital Services (MD 7), MD 7 stated that, “The flow of orders should be from the doctor to the nurse. If the nurse recognizes that a patient requires cardiac monitoring or if the nurse has already placed a patient on a cardiac monitor, the nurse should approach the physician and notify them (the physicians) to obtain an order.” MD 7 then said that a continuous cardiac monitoring requires a physician to place an order for it, “If a patient is admitted to a telemetry (a specialized ward where patients receive continuous electronic monitoring of their vital signs, particularly heart rhythm and rate, allowing healthcare providers to track and respond to any changes remotely) unit, the patient should also be monitored in the ED.” During an interview on 4/4/2025 at 11:09 a.m. with the Chief of Emergency Medicine (MD 4), MD 4 stated the following: “Typically, physicians place orders for cardiac monitoring, which requires the nurses to continuously monitor the heart rate and rhythm of the patient.” During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following regarding cardiac monitoring orders: “There are doctors that do place orders for cardiac monitoring at times, but most doctors don’t. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (ADULT),” dated 5/2022, the P&P indicated the following: 1.1. Cardiac monitoring, when indicated by history or current illness, demonstrates the facility’s commitment to ensure patient safety through appropriate care delivery interventions. 4.1. Cardiac Telemetry Monitoring - Cardiac Telemetry monitoring is an intervention to continuously monitor the cardiac rhythm and any associated changes in rate and/or characteristics. Cardiac Telemetry monitoring is utilized throughout multiple patient care units with 24-hour visualization by competent healthcare personnel. 5.1.1 A physician’s order is required for telemetry monitoring/cardiac monitoring and discontinuation. During a review of the facility’s employee document titled, “Nursing Expectations, Norms, and Workflows,” dated 8/2023, the document indicated the following: Patients who are presenting with a cardiac, respiratory, and neurological complaint are to be placed on a cardiac monitor. During a review of the facility’s the Rules and Regulations for the Professional Staff (Rules and Regs), dated 2023, the Rules and Regs indicated the following: Medical Records: 1. The attending practitioner(s) shall be responsible to assure that a complete ...medical record is prepared for each patient accepted for care by the Hospital ...xiv. Medications, assessments, and treatments are ordered ... 2.b. During a review of Patient 14’s medical record (MR) titled, “Emergency Department (ED) Patient Care Timeline,” dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), the MR indicated that Patient 14 arrived to the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care to patients with urgent health issues) on 4/1/2025 at 11:38 p.m. complaining of abdominal pain. The MR also indicated that Patient 14 was moved to a room in the ED at 12:12 p.m. on 4/1/2025. During an observation on 4/2/2025 at 1:53 p.m., in the Emergency Department, a remote cardiac monitor (a device that enables nurses and other healthcare staff to continuously monitor the cardiac rhythms of multiple patients from a central location, providing real-time data on heart rates and rhythm abnormalities) located at the nurses’ station, was observed. The monitor displayed multiple patients’ various vital information, including the heart rhythm, heart rate, blood pressure, respirations, and SpO2 (peripheral oxygen saturation, refers to the percentage of hemoglobin in your blood that is carrying oxygen, as measured by a pulse oximeter). Patient 14’s cardiac rhythm was observed to be irregular (as displayed in the cardiac monitor), with a heart rate ranging from 116-126 beats per minute (bmp). During an interview on 4/2/2025 at 1:58 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated the following: “The doctor and the nurse work together to assess whether the patient needs to be connected to a cardiac monitor. If they determine that monitoring is necessary, the physician can then place an order for cardiac monitoring to ensure continuous observation of the patient’s heart rhythm and vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions). Cardiac monitoring depends on a chief complaint and the assessment of the patient.” During an observation on 4/2/2025 at 2:35 p.m., Patient 14 was observed in the room in the ED, lying on a gurney, connected to a cardiac monitor. During a concurrent interview and record review on 4/3/2025 at 11:02 a.m. with Registered Nurse (RN) 8, Patient 14’s “Emergency Department (ED) Patient Care Timeline,” dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.), was reviewed. RN 8 stated that Patient 14’s “ED Patient Care Timeline” had no documentation indicating whether Patient 14 was placed on a cardiac monitor during Patient 14’s stay in the ED. During further review of Patient 14’s medical record (MR) titled, “Documentation Flowsheet-Vital Signs, (VS, clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions), dated 4/1/2025 (11:38 a.m.) through 4/1/2025 (9:24 p.m.),, the MR indicated that no cardiac rhythm (heart rate and pattern) was documented under the space allocated for documentation of cardiac rhythm, which is called “Monitored Cardiac Rhythm (section in the medical record where continuous heart rhythms of the patient being monitored are recorded)” and “Cardiac Rhythm Interval Monitoring (involves tracking and documentation the time intervals of different rhythms to assess for any irregularities or changes in the patients’ heart function over time).” During an interview on 4/4/2025 at 11:09 a.m. with the Chief of Emergency Medicine (MD 4), MD 4 stated the following: “Typically, physicians place orders for cardiac monitoring, which requires the nurses to continuously monitor and document the heart rate and rhythm of the patient.” During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated that current practice for cardiac monitoring documentation requirements included documentation of the patient’s cardiac rhythm on the patient’s comprehensive assessment flowsheet at least once a shift and/or when there was a change in the heart rhythm. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (ADULT),” dated 5/2022, the P&P indicated the following: 1.1. Cardiac monitoring, when indicated by history or current illness, demonstrates the facility’s commitment to ensure patient safety through appropriate care delivery interventions. 5.6. Documentation in electronic medical record: 5.6.1 Rhythm and rate, as required by unit standards”

“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: 46333 Based on interviews and record review, the facility failed to: 1. Ensure that qualified medical personnel (QMP, a healthcare provider authorized by the facility to evaluate and treat emergency patients) fulfilled responsibilities to evaluate and document emergency care for one of 30 sampled patients (Patient 1), in accordance with the facility’s policy regarding medical records content. Specifically, the physician (MD 1) who found Patient 1 unresponsive (not reacting to voice, touch, or stimulation) on 2/10/2025, did not document any clinical findings, assessments (medical evaluation of the patient’s condition), or medical interventions (steps taken to treat the patient [Patient 1]). This deficient practice resulted in the facility being unable to confirm whether timely and emergency care was provided. This omission limited the facility’s ability to verify the care rendered during the critical event and prevented staff from fully understanding and evaluating the effectiveness of the emergency care provided. 2. Ensure that emergency department staff documented in the Code Narrator (a tool that helps document and track key events during a code)” report regarding Patient 1’s cardiac rhythm (pattern of the heart’s electrical activity), time of pulse checks (moments when medical staff checks for a heartbeat), initiation of chest compressions (starting of manual pressing on the chest to restore circulation), or identification of responding team members during the code blue (a hospital-wide emergency called when patient is experiencing cardiac [heart] or respiratory arrest [stopped breathing]) on 2/10/2025. This deficient practice impeded the facility’s ability to assess the adequacy of the emergency response and limited the continuity of care (coordinated and consistent care among healthcare team members) by preventing post-event clinical evaluation, hindering quality assurance (a proactive approach to ensuring that services and amenities consistently meet or exceed established standards for excellence, guest satisfaction, and operational efficiency) processes, and restricted the facility’s ability to identify areas for improvement in resuscitation (the act of reviving a patient from apparent death) practices. Findings: 1. During a review of Patient 1’s “ED (emergency department) Provider Notes,” dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance from home with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history which included asthma (a condition that narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a review of Patient 1’s “triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) note,” dated 2/10/2025, the note indicated Patient 1 was assigned an Emergency Severity Index (ESI, a 5-level triage system that categorizes patients based on their acuity and resource needs, from most urgent [Level 1] to least urgent [Level 5]) Level 1, the most urgent level requiring immediate life-saving intervention. During an interview on 4/2/2025 at 3:46 p.m. with ED physician (MD) 2, MD 2 stated MD 1 discovered Patient 1 unresponsive (not responding to voice, touch, or other stimulation) around 8:40 p.m. on 2/10/2025. MD 2 confirmed that the pulse oximeter (a medical device that measures the amount of oxygen in a person’s blood) and all leads, but one cardiac monitor lead (provides different views of the heart’s electrical activity), was disconnected. MD 2 stated MD 1 checked Patient 1’s pulse (a rhythmical throbbing felt as blood is propelled through them) and there was no pulse. During a concurrent interview and record review on 4/2/2025 at 11:30 a.m. with the Informatic staff member (IN, staff member responsible for managing the hospital’s electronic medical records system) 1, IN 1 confirmed that MD 1, the physician who found Patient 1 unresponsive on 2/10/2025, did not enter a note in Patient 1’s medical record (a collection of written or digital documents that contain information about a patient’s health, diagnoses, treatments, and other medical history). IN 1 verified that MD 1 did not document Patient 1’s clinical condition, and physical examination (a hands-on examination of patient’s body by a healthcare provider), interventions, or the timeline of events related to the incident. During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Medical Director and Ancillary Chief of Staff (MD 7), MD 7 stated that all physicians were expected to complete documentation for any patient encounters by the end of their shift. MD 7 stated that when a physician discovers a patient unresponsive, it was standard practice to document the findings and action taken. MD 7 further stated that such documentation was necessary to ensure that care was coordinated, and that other clinical staff understand the patient’s condition. MD 7 confirmed that documentation of significant events was essential for communication among medical professionals and supports safe and effective care delivery. During a review of the facility’s policy and procedure (P&P) titled, “Medical Records Content-Medical Staff,” dated 7/21/2021, the P&P indicated that attending physician (the physician responsible for overall care of the patient during hospitalization) was required to complete a medical record that included: a history of the present illness (a summary of patient’s current symptoms and the timeline of their development), physical examination findings (a hands-on evaluation of the patient ‘s condition), progress notes (written documentation of the patient’s status and response to treatment), and final findings (a summary of diagnoses and care conclusion). The policy also indicated that current records should be completed within 24 hours. 2. During a review of Patient 1’s “ED (emergency department) Provider Notes,” dated 2/10/2025, the ED Provider Notes indicated Patient 1 was brought to the ED by ambulance, from home, with complaints of chest pain and shortness of breath (difficulty breathing). The note also indicated Patient 1 had a medical history that included asthma (a condition narrows airways and makes breathing difficult) and hepatitis C (a viral infection that affects the liver). Patient 1 was noted to be actively coughing upon arrival. During a review of Patient 1’s “Code Narrator Report (a tool that helps document and track key events during a code),” dated 2/10/2025, the Code Narrator Report indicated that a code blue (a medical emergency, typically indicating a patient is in serious condition, often requiring immediate resuscitation) was initiated at 8:40 p.m. on 2/10/2025. However, the report did not include documentation of when chest compressions (starting of manual pressing on the chest to restore circulation [blood flow]) began, Patient 1’s cardiac rhythm (the timing and pattern of the heart’s electrical signals, which determine how the heart beats) during the event, the timing of pulse checks (moments when medical staff checks for a heartbeat), or the identity and assigned roles of the team members who responded to the emergency. During a concurrent interview and record review on 4/2/2025 at 10:33 a.m. with the Assistant Clinical Director (ACD)1, ACD 1 confirmed that the Code Narrator Report lacked documentation of critical information such as the cardiac rhythm, pulse checks, and timing of chest compressions. ACD 1 sated, “This information should be part of the code documentation.” During an interview on 4/4/2025 at 10:03 a.m. with the Assistant Area Medical Director (MD 7), MD 7 validated that documentation during a code was necessary to understand what interventions were performed and when. MD 7 stated this type of documentation was expected for all code blue responses to help ensure accurate evaluation of care and support informed clinical decision-making. During a review of the facility’s policy and procedure (P&P) titled, “Medical Records Content-Medical Staff,” dated 7/21/2021, the P&P indicated that attending physician (the physician responsible for overseeing the patient’s hospital care) was required to complete a medical record that includes a history of the present illness (a summary of symptoms and their development), physical examination (a hands-on evaluation of the patient ‘s condition), progress notes (written updates on clinical status), and final findings (the physician’s conclusions based on treatment and outcomes). The policy also indicated that current records should be completed within 24 hours. During a review of the facility’s policy and procedure (P&P) titled, “Code Blue Response- Adult Medical Center Campus,” dated 6/21/2021, the P&P indicated, “To provide guidance for the development of a standardized level of care provided to the adult patient experiencing a cardiac (heart stops beating) and/or respiratory arrest (stopped breathing) ... All those involved in the Code Blue situation respond in accordance with the American Heart Association Basic Life Support and Advanced Cardiovascular Life Support guidelines ... An accurate, chronological documentation record will be completed and submitted as part of the legal medical record for the patient in all Code Blue situations ... A patient resuscitation record (Code Blue Record) will be completed during and immediately following the resuscitation efforts. A Code Blue Evaluation Form will be completed during the debriefing critique of the code and forwarded to the Quality Department.” During a review of the “American Heart Association (AHA, a non-profit organization dedicated to fighting heart disease and stroke through research, education, and advocacy)” Guideline, dated 2020, the AHA Guideline indicated providers are expected to document the patient’s condition before, during, and after a resuscitation attempt, including time of arrest (cardiac/respiratory arrest), interventions (such as CPR [Cardiopulmonary Resuscitation- An emergency procedure used to restart a person’s heartbeat and breathing after one or both have stopped] and Defibrillation a medical procedure using electrical shocks to restore a normal heart rhythm), response to treatment, and names and roles of responders. This documentation is essential for legal, clinical, and quality assurance purposes.”

“EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b) Personnel This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure the annual educational requirements (the mandated training and continuing education that employees must complete each year to maintain their knowledge skills and compliance with regulatory standards) for three of 10 sampled Emergency Department (ED)employees (E2, E5 and E7) were completed, in accordance with the facility’s annual educational requirements for employees and regulatory standards. This deficient practice had the potential to compromise quality of patient care delivered by employees who may lack current knowledge and training necessary to provide effective treatment. 2. Ensure Annual competencies (assessments and evaluations to determine if employees possess the necessary skills and abilities required for their positions) for one of 10 sampled Emergency Department staff member (E5), were completed as indicated by the facility’s procedures regarding annual competency trainings. This deficient practice had the potential to result in compromised patient safety and quality of care when healthcare professionals may not be equipped with the knowledge to provide safe, effective, and high-quality care to patients. Findings: 1.a. During a concurrent interview and record review on 4/4/2025 at 3:45 p.m. with the Assistant Clinical Director (ACD 1), Employee 2’s (E2) annual education requirements for the emergency department (ED) nursing personnel, were reviewed. ACD 1 stated that E 2’s file was missing a completed rhythm recognition web-based (involves using the internet and online platforms to deliver educational content and training programs) training for 2024 (the process of identifying and interpreting various heart rhythms which is essential for effective patient care in emergency settings) that was required for ED nursing staff to be completed annually. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (Adult),” dated 5/2022, the P&P indicated that: 5.4. Registered Nurses’ (RN) education and Competency: ...Newly hired and/or transferring RNs ...be accountable for completing annual competency validation on rhythm strip (test records the electrical activity of the heart) recognition and proper use of monitoring equipment ... During a review of the facility’s policy and procedure (P&P) titled, “Emergency Department (ED) Scope of Service,” dated 5/2023, the P&P indicated the following: “Inservice/Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ...” 1.b. During a concurrent interview and record review on 4/4/2025 at 4:20 p.m. with the Assistant Clinical Director (ACD 1), Employee 5’s (E5) annual education requirements for the emergency department (ED) nursing personnel, were reviewed. E5’s file contained no record of rhythm recognition web-based training completed in 2024 and was also missing EMTALA (the Emergency Medical Treatment and Labor act, a federal law that requires hospitals to provide emergency medical treatment to patients regardless of their ability to pay or insurance status) training for 2024. ACD 1 stated that these two educational trainings (Rhythm Recognition and EMTALA) were required for the emergency staff to be completed annually to demonstrate staff competencies as required by the facility. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Department (ED) Scope of Service,” dated 5/2023, the P&P indicated the following: “Inservice/Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ...” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA),” dated 5/15/2023, the P&P indicated the following: 5.17.2 Training and education on EMTALA requirements will be provided to ED staff during new employee orientation and annually. During a review of the facility’s policy and procedure (P&P) titled, “Cardiac Monitoring (Adult),” dated 5/2022, the P&P indicated that: 5.4. RN education and Competency: ...Newly hired and/or transferring RNs ...be accountable for completing annual competency validation on rhythm strip recognition and proper use of monitoring equipment ... 1.c. During a concurrent interview and record review on 4/4/2025 at 4:26 p.m. with the Assistant Clinical Director (ACD 1), Employee 7’s (E7) annual mandatory education requirements for the emergency department (ED) nursing personnel, were reviewed. E7’s file indicated that 2023-2024 Abuse (any intentional or unintentional harm caused to a patient by a caregiver, whether through physical, emotional, or financial means) Assessment and Reporting (to prohibit and be free from all forms of abuse which includes verbal, mental, physical, sexual, exploitation, neglect and harassment during any episode of patient care) web-based training, was missing. The ACD 1 stated that Abuse Assessment and Reporting training should be done every 2 years and was a mandatory educational requirement for the ED nursing staff. During a concurrent interview and record review on 4/4/2025 at 4:27 p.m. with the Assistant Clinical Director (ACD 1), Employee 7’s (E7) annual education requirements for the emergency department (ED) nursing personnel, were reviewed. E7’s file contained no record of EMTALA (the Emergency Medical Treatment and Labor Act, a federal law that requires hospitals to provide emergency medical treatment to patients regardless of their ability to pay or insurance status) web-based training for 2024. ACD 1 stated that EMTALA educational training was a required annual education for the emergency staff to be completed every year to demonstrate staff competencies as required by the facility Emergency Department unit. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights: Protection from Abuse, Exploitation, Neglect, and Harassment,” dated 11/2023, the P&P indicated the following: “Train: All employees receive abuse training upon hire and ongoing training by the end of the second calendar year from when the employee last completed training. The training/education provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.” During a review of the facility’s policy and procedure (P&P) titled, “Emergency Medical Screening Examination, Treatment, and Transfer (EMTALA),” dated 5/15/2023, the P&P indicated the following: 5.17.2 Training and education on EMTALA requirements will be provided to ED staff during new employee orientation and annually. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Department (ED) Scope of Service,” dated 5/2023, the P&P indicated the following: “ ...Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ...” 2. During a concurrent interview and record review on 4/4/2025 at 4:20 p.m. with the Assistant Clinical Director (ACD 1), Employee 5’s (E5) annual competencies (refer to the measurable knowledge, skills, abilities, and behaviors that employees need to perform their jobs successfully, assessed and verified on an annual basis) for 2024, were reviewed. E5’s file lacked E5’s annual competency check-off list and skills validation for the year 2024. The ACD 1 stated that E5 was a traveler nurse, (registered nurse [RN] who accepts temporary nursing assignments in various locations and typically, traveler nurses come through an agency [contracted services] and do not stay longer than a year). The ACD 1 then said that competencies and skill checks, as well as annual performance evaluations, were not conducted for traveler nurses in the Emergency Department (ED). During the same interview on 4/4/2025 at 4:21 p.m. with the Assistant Clinical Director (ACD 1), the ACD 1 said that Employee 5’s (E5) start date at the facility was 8/23/2023 (this indicated that E5 Had been working as a travel nurse at the facility for more than one year since 2023). During an interview on 4/4/2025 at 5:23 p.m. with the Director of Clinical Education (DCE), the DCE stated that a traveler nurse that extends their assignment beyond one year must go through the unit’s regular annual competency check-off list and skills validation to ensure that they are up to date with the latest practices and protocols relevant to their role. The DCE also said that additionally, all traveler nurses were expected to complete any mandated web-based learning modules, which provide important training and updates on policies, procedures, and clinical practices. During a review of the facility’s policy and procedures (P&P) titled, “Emergency Department (ED) Scope of Service,” dated 5/2023, the P&P indicated the following: “ ...Continuing education to maintain and increase staff competency is completed on the following basis: annual skills assessment and validation; annual mandatory education ...The Emergency Department is responsible for ensuring that this scope is accurate, relevant, and current ...””

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that four of four sampled registered nurses (E2, E4, E6, and E8), working in the Emergency Department (ED, a hospital department staffed and equipped to provide immediate medical care to patients with sudden, serious illnesses or injuries, requiring immediate attention), fully met the written standardized emergency procedure (established protocols that define the actions, responsibilities, and practices that registered nurses must initiate based on patients’ chief complaints and presenting symptoms prior to an evaluation of the Emergency Department physician [when no triage -the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) physician was available to perform a rapid medical exam [RME, a process in emergency departments that initiates testing and evaluation of patients while they are still in the waiting room, aiming to improve patient flow and reduce wait times]) requirements and competencies needed, to be authorized to perform standardized procedures in the facility’s ED. This deficient practice had the potential to compromise patient care and safety by increasing the risk of inadequate responses to emergency situations, leading to delays in treatment and ultimately adverse patient outcomes when employees do not possess the necessary competencies in accordance with the facility’s policy regarding Standardized Emergency Registered Nurse procedures. Findings: During an interview on 4/4/2025 at 12:39 p.m. with the Assistant Clinical Director (ACD 2), the ACD 2 stated that standardized emergency procedures (pre-defined, consistent protocols and guidelines designed to ensure a coordinated and effective response to a variety of emergencies) allowed registered nurses in triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) to place orders to initiate pre-established, presenting chief complaint-based physician orders for patients waiting for an Emergency Department (ED) physician evaluation. The ACD 2 then stated that ED Registered Nurses must pass the testing scenarios and pass the ESI (Emergency Severity Index) triage test, which was a five-level algorithm used to categorize patients based on the severity of their condition and urgency of their need for medical care. The ACD 2 also said that regarding annual competency testing for the standardized procedures, no specific frequency had been assigned to it. During a concurrent interview and record review on 4/4/2025 at 3:31 p.m. with the Assistant Clinical Director (ACD 1), the facility’s current roster of registered nurses (RNs) authorized to perform standardized procedures (effective as of 2/2/2024), was reviewed. The ACD 1 stated that the list of registered nurses (dated 2/2/2024) contained a few names of registered nurses who no longer work at the facility. During the same interview on 4/4/2025 at 3:31 p.m. with the Assistant Clinical Director (ACD 1), the ACD 1 stated that competencies for standardized procedures were included among the annual mandatory competencies and demonstrated Employee 2’s (E2) 2024 competency summary, where the ACD pointed to the Standardized Nursing Protocol policy, documented to be verbally validated by the Assistant Clinical Director (ACD 2). The ACD 1 also said that no initial competency scenario-based testing (which demonstrates understanding of the goals, scope and limitations of utilizing Emergency RN Standardized Procedures) was found in E 2’s file. During an interview on 4/4/2025 at 3:40 p.m. with the Assistant Clinical Director (ACD 1), the ACD 1 then demonstrated Employee 2’s (E2) annual scenario-based testing competency with a perfect score, dated 4/12/2024. The ACD 1 verified that E2’s testing competency results contained no record of being reviewed and approved by one the following: 1. Rapid Medical Exam provider 2. Full-time physician on shift for that day 3. Chief of Emergency medicine During a concurrent interview and review on 4/4/2025 at 3:50 p.m. with the Assistant Clinical Director (ACD 1), Employee 4’s (E4) personnel file, was reviewed. The E4’s file contained no initial competency (scenario-based testing with results, which should be reviewed and approved by the Director of the Emergency Department). The E4’s file contained 2024 scenario-based testing with results, but had no record of the reviewer (annual testing competency results should be reviewed and approved by one the following): 1. Rapid Medical Exam provider 2. Full-time physician on shift for that day 3. Chief of Emergency medicine. During a review of Employee 6’s (E6) personnel file, no initial and annual (for year 2024) scenario-based testing with results (reviewed and approved), were found in E6’s personnel file. This information was confirmed by the Assistant Clinical Director (ACD 1) on 4/4/2025 at 3:55 p.m. During a concurrent interview and record review on 4/4/2025 at 4:15 p.m. with the Assistant Clinical Director (ACD 1), Employee 8’s (E8) personnel file, was reviewed. E8’s personnel file contained no initial and annual (for year 2024) scenario-based testing with results reviewed and approved, in accordance with the facility’s policy. ACD 1 stated that E8 was an Assistant Clinical Director (ACD) and has held this position since 2022; therefore, E8 did not require any competency testing based on the employment position. During an interview on 4/4/2025 at 4:25 p.m. with the Assistant Clinical Director (ACD 1), the ACD reviewed the facility’s current roster of registered nurses (RNs) authorized to perform standardized procedures (effective as of 2/2/2024), and stated that all four employees (E2, E4, E6, and E8) were listed on the roster as RNs currently authorized to perform standardized procedures in the Emergency Department. During an interview on 4/4/2025 at 5:05 p.m. with the Administrator of Quality (AQ), the AQ stated that the Emergency Department leadership was ultimately responsible for the implementation of policies and procedures related to Standardized Procedures for the Emergency Department Registered Nurse. During a review of the facility’s policy and procedure (P&P) titled, “STANDARDIZED EMERGENCY REGISTERED NURSE PROCEDURES,” dated 10/21/2024, the P&P indicated the following: 1.1. Emergency Department Registered Nurses who have demonstrated competency in the use of standardized orders may initiate standardized orders based on patients’ chief complaints and presenting symptoms prior to an evaluation of the Emergency Department physician. 2.1. Emergency Department Registered Nurses who are functioning independently and demonstrated successful completion of the following education, training and experience: ... a. An initial competency of scenario-based testing which demonstrates understanding of the goals, scope and limitations of utilizing Emergency Registered Nurse Standardized Procedures. The results of every Registered Nurse’s competency testing shall be reviewed and approved by the Director of the Emergency Department. b. Annual competency testing shall demonstrate the Emergency Registered Nurses understanding of the goals, scope and limitations of utilizing Emergency Registered Nurse Standardized Procedures. The results of every Registered Nurse’s competency testing shall be reviewed and approved by the following: 1. Rapid Medical Exam provider 2. Full time physician on shift for that day 3. Chief of Emergency medicine 2.4. Access to list of nurses who are approved to use Standardized Procedures: A current roster of Registered Nurses who have been competency validated to perform presenting complaint based standardized procedures will be available for review. 2.6. Validation and management of Registered Nurses authorized to perform Standardized Procedures: A written record of initial and on-going competency will be maintained in the employee personnel file in the Emergency Department. 2.7. Situations to remove authorization to perform Standardized Procedures: a. Quality and judgment concerns will be reviewed with the Registered Nurse as needed and on an annual basis. b. Expiration of Annual competency c. Failure of competency testing. If a nurse has his or her authorization to perform Standardized Procedures revoked, their name will be promptly removed from the approved list in the department and with the Nurse Director.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to address and document the grievance (a formal complaint) for one of 30 sampled patients (Patient 1) concerning abnormal test results. These concerns were reported to the nursing staff by Patient 1’s surrogate (a person legally authorized to make healthcare decisions for the patient) on 11/6/2024 at 10:00 p.m. but were not promptly addressed, in accordance with the facility’s “Hospital Patient Grievance Policy.” This deficient practice caused emotional distress for Patient 1’s surrogate, dissatisfaction with the care provided, and a loss of trust in the healthcare team. By not addressing and escalating the reported concerns, the facility missed the opportunity to ensure timely review and resolution of the patient’s condition, potentially compromising the quality and safety of care. (Refer to A-0118) 2. The facility failed to ensure its physician and nursing staff followed the informed consent process (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for one of 30 sampled patients (Patient 18), in accordance with the facility’s policy and procedure regarding informed consent when: 2.a. Physician (MD 3) did not discuss and provide Patient 18’s family member (FM 1) with the information including risks, benefits, and alternatives of tracheostomy (a surgical procedure to create an artificial opening through the neck usually for the relief of difficulty in breathing). This deficient practice had the potential to result in Patient 18’s family member (FM 1) to not fully understand the risks and benefits in order to make an informed decision and not giving opportunities for FM 1 to ask questions when signing the informed consent form for the procedure. (Refer to A-0131) 2.b. Nursing staff failed to provide and document Spanish translation use when witnessing three of seven informed consent forms (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment) signed by Patient 18’s family member (FM1). This deficient practice had the potential to result in Patient 18’s family member (FM 1) to not fully understand the risks and benefits in order to make an informed decision and not giving opportunities for FM 1 to ask questions when signing the informed consent form for the procedure. (Refer to A-0131) 3. The facility failed to ensure its nursing staff performed assessment and document restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every 2 hours, for 13 hours (from 6 a.m. to 7 p.m.) for one of 30 sampled patients (Patient 18), in accordance with the facility’s policy and procedure regarding restraints. The facility also failed to ensure its nursing staff assessed Patient 18’s condition including skin assessment when restraints were removed. This deficient practice had the potential to put Patient 18 at risk for skin break down (damage to the skin) and other injury due to lack of assessment and monitoring with restraint use. (Refer to A-0175) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“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: 46333 Based on interviews and record reviews, the facility failed to address and document the grievance (a formal complaint) for one of 30 sampled patients (Patient 1) concerning abnormal test results. These concerns were reported to the nursing staff by Patient 1’s surrogate (a person legally authorized to make healthcare decisions for the patient) on 11/6/2024 at 10:00 p.m. but were not promptly addressed, in accordance with the facility’s “Hospital Patient Grievance Policy.” This deficient practice caused emotional distress for Patient 1’s surrogate, dissatisfaction with the care provided, and a loss of trust in the healthcare team. By not addressing and escalating the reported concerns, the facility missed the opportunity to ensure timely review and resolution of the patient’s condition, potentially compromising the quality and safety of care. Findings: During a review of Patient 1’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/26/2024, the “H&P” indicated, Patient 1’s past medical history included a liver and kidney transplant (surgeries to replace diseased organs with healthy ones), anoxic encephalopathy (brain damage caused by a lack of oxygen) from cardiac arrest (when the heart stops beating), and the use of a chronic Foley catheter (a tube inserted into the bladder to drain urine) with recurrent urinary tract infections (UTIs, infections in the bladder or urinary system). The H&P also indicated Patient 1 was transferred from a nursing home to the facility with complaints of mild confusion, high blood pressure and hyperglycemia (high blood sugar). During a review of Patient 1’s “Multi-Discipline Progress Note: Registered Nurse,” documented by Registered Nurse (RN, nurse who has graduated from a college’s nursing program or from a school of nursing and has passed a national licensing exam) 5, dated 11/7/2024, the note indicated: - At 10:00 p.m., Patient 1’s son (Patient 1’s surrogate) approached the nurses’ station appearing erratic. He requested to speak with charge nurse (the lead nurse for that shift) and primary doctor. He stated that the day-shift nurse misdiagnosed his mother and wanted to file a complaint. He also requested to speak with the Chief Nursing Officer (CNO, the head of nursing staff) and the Director of Nursing (DON, and administrator overseeing the nursing team). RN 1’s notes indicated, “I told him they are off the campus that he can follow up next day that all the administration will be available.” -Patient 1’s son expressed frustration about the lack of transparency regarding his mother’s care and showed lab results from his phone (hemoglobin [a protein in the blood that carries oxygen from the lungs to the body’s tissues and organs; Normal for females is 12-16 grams per deciliter- unit of measurement] 6.2, potassium [a mineral in the body that helps regulate fluid balance, muscle contractions, and nerve signals; Normal is 3.6 to 5.2 millimoles per liter- unit of measurement] 3.1, sodium [salt; Normal is between 135 to 145 milliequivalents per liter- unit of measurement] 132) claiming no action had been taken since the morning. RN 1’s notes indicated, “MOD (Medical Physician on Duty) was notify (notified) but will order given. I spoke to him at lent (length), encourage him to address this tomorrow that nothing can be done tonight. He agreed to address the issue tomorrow. Pt (Patient 1’s) son remain in the room and bedside with pt (Patient 1).” During an interview on 1/7/2025 at 11:30 a.m. with the ICU (intensive care unit, a ward in the hospital that provides critical care and life support for acutely ill and injured patients) Manager (MN 3), MN 3 stated that grievances unresolved at the unit level should be escalated to Membership Services department. MN 3 stated that grievances must be addressed immediately, even during off-hours, by contacting the tele-physician (telemedicine physician, a licensed medical doctor who provides healthcare services to patients remotely using telecommunications technology, essentially allowing patients to consult with a doctor virtually through video calls, phone calls, or secure messaging platforms, instead of visiting them in person). MN 3 further stated if patient or patient’s family grievances cannot be resolved at the unit level, they are to be escalated to supervisor and Membership Services for resolution. MN 3 also stated that grievances should be escalated immediately to ensure timely resolution. During an interview on 1/10/2025 at 11:15 a.m. with the Charge Nurse (CN) 3, CN 3 stated that during after-hours, patient grievances during after-hours should be escalated to the Nurse Manager or MOD (Medical Physician on Duty). If they cannot be reached, the nurse must notify the supervisor or use alternative contact methods like the hospital operator. CN 3 confirmed that documentation in the Electronic Medical Record (EMR, digital version of paper chart) regarding details of the family’s concerns and resolution, including the name of the physician contacted and the outcome of that communication, if an order or instructions were placed, was mandatory. During a concurrent interview and record review on 1/10/2025 at 12:07 p.m. with the Quality Coordinator (QC 1), Patient 1’ EMR titled, “Multi-Discipline Progress Note: Registered Nurse,” and related areas, were reviewed. These records, dated from 11/6/2024 through 11/7/2024 contained no documentation indicating that Patient 1’s son’s concerns had been escalated to a physician, a manager, or a supervisor. Additionally, QC 1 confirmed there was no documentation of any physician’s name to indicate that the lab (laboratory) results had been reported or discussed. QC 1 verified this lack of documentation and stated that the grievance should have been escalated and recorded as required by facility policy. During a review of the facility’s policy and procedure (P&P) titled, “Hospital Patient Grievance Policy,” dated 7/27/2022, the P&P indicated, “A hospital patient and/or their representative have the right, without fear of recrimination, to voice concerns or complaints regarding any aspect of the care and/or service in connection with hospital licensed services. The hospital patient or their representative can use the hospital grievance process as a means to raise concerns or complaints immediately at the point of care and/or through a formal process ...This policy applies to all employees who are employed by the following entities ... Process for immediate resolutions of grievances while a patient is still hospitalized. When a patient and/or patient’s representative expresses a grievance while still hospitalized about care and/or service, a member of the patient’s health care team attempts to resolve the issue in the best interest of the patient. If the health care team member is unable to resolve a grievance, a health care team member brings the concern to the attention of their manager for assistance in resolving the grievance. If the manager is unable to provide assistance in resolving the grievance, the manager refers the grievance to the Member Services Department and informs the patient or the patient’s representative of such referral. A grievance is considered “resolved” when the patient or patient representative is reasonably satisfied with the actions taken by the Hospital or the Hospital has taken all reasonable measures to resolve the matter and the patient or patient representative has not responded thereto.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibility,” dated 10/17/2022, the P&P indicated, “receive information about your health status diagnosis prognosis course of treatment prospective for recovery and outcome of care parentheses including unanticipated eating unanticipated outcomes closed, in terms you can understand. You have the right to effective community location and to participate in the development and implementation of your plan of care you have the right to participate in ethical questions that arise in the course of your care. Including issue of conflict resolution withholding resuscitation services and forgoing or withdrawing life sustaining treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Care Communication Process-Chain of Command/Escalation of Concern,” dated 4/18/2022, the P&P indicated, “To provide guidelines for patient caregivers when communicating about patient conditions and to provide a mechanism for a higher level of discussion regarding the medical care being rendered to a patient. To establish a standard method of communication process and provide a mechanism to address issues regarding patient care and workplace safety concerns or interdisciplinary disputes at a higher level of command. To ensure safe, timely and appropriate quality and safe care for the patient when any aspect of patient care is in question or when conflict arises between health care team members. Every member of the health care team is responsible for delivering the most effective care and treatment to all patients at the appropriate time. All employees/staff are required to take action when there is a question or concern about the quality of care and or patient safety. Employees shall elevate communication to the next level of responsibility by utilizing the SBAR (Situation, Background, Assessment, and Recommendation, a communication tool for sharing information about a patient’s health condition) process of communication ...Patient care concerns shall be resolved through communication between the members of the patient care team that includes the medical, nursing, and/or ancillary staff. The first line of communication to discuss any aspect of patient care shall be between the ordering practitioner or designee and the nursing or ancillary staff providing the care. a. Each practitioner shall provide a designee for coverage whenever he or she is unavailable and inform the appropriate person responsible for tracking the providers’ duty schedules and the designated “charge” nurse or person as appropriate. b. The most current list of the names of designees for coverage for all unavailable physicians is accessible through (name of the facility’s) Telecommunications/Operator. c. Unresolved concerns shall be brought up to the next level of the chain of command for discussion and appropriate resolution. If a higher level of care or staff is unavailable, proceed with the next level chain of command ... Decision Making/Other Avenues for Consultation: If in the first line of communication, the matter is not resolved, the unit/department supervisor and the physician in charge or physician on-call shall be included in the discussion for a quick negotiable resolution. If in the first line of communication a decision or conclusion is not reached, the department nursing leader and/or the next higher- or highest-level professional practice leader and the Medical Director or Chief of Service shall be the final deciding authorities.””

“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: 48212 Based on observation, interview and record review, the facility failed to ensure its physician and nursing staff followed the informed consent process (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for one of 30 sampled patients (Patient 18), in accordance with the facility’s policy and procedure regarding informed consent when: 1. Physician (MD 3) did not discuss and provide Patient 18’s family member (FM 1) with the information including risks, benefits, and alternatives of tracheostomy (a surgical procedure to create an artificial opening through the neck usually for the relief of difficulty in breathing). 2. Nursing staff failed to provide and document Spanish translation use when witnessing three of seven informed consent forms (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment) signed by Patient 18’s family member (FM1). These deficient practices had the potential to result in Patient 18’s family member (FM 1) to not fully understand the risks and benefits in order to make an informed decision and not giving opportunities for FM 1 to ask questions when signing the informed consent form for the procedure. Findings: 1. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/7/2024, the H&P indicated, Patient 18 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body’s overwhelming and life-threatening response to infection) with acute (new onset) organ dysfunction (when an organ is not working properly), community acquired pneumonia (lung infection), and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During a review of Patient 18’s “Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” form, dated 11/7/2024, the COA form indicated, Patient 18’s family member (FM 1) signed the COA form for Patient 18. The COA form also indicated translation was used via phone/video remote interpreting with Spanish interpreter needed. During a concurrent observation and interview on 1/7/2025 at 11:52 a.m. with Charge Nurse (CN) 2, at Patient 18’s room, FM 1 was sitting in Patient 18’s room. CN 2 stated FM 1 required Spanish interpretation. Observed CN 2 using the facility’s phone to connect to a Spanish speaking interpreter and started to talk to FM 1. During a concurrent interview and record review on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4, Patient 18’s “Consent to Operation, Administration of Anesthetics, and the Rendering of other medical services” form (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment), dated 11/24/2024, was reviewed. The consent form was in Spanish and indicated procedure of tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe [trachea]). The consent form indicated FM 1 signed the consent form on 11/24/2024 at 10:53 a.m. witnessed by RN 6 with the section of interpreter’s name and identification number left blank. During the same interview on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4 , RN 4 stated translator use should be documented on the consent form to indicate the use of translator. RN 4 stated it was important for nursing staff to utilize translation service (ensures that all patients receive the information they need in a language they understand) for non-English speaking patients and family when witnessing signature on consent form so that they would know what they were signing and would allow them to ask questions before signing the consent form. RN 4 stated if patient or family member still had questions, nursing staff should contact the physician and not to let them (Patient and/or designated patient representative/family member) sign the consent form. During a concurrent interview and record review on 1/10/2025 at 2:08 p.m. with Registered Nurse (RN) 4, Patient 18’s Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) Progress Notes (physician notes indicating patient’s health condition, progress and treatment plan), dated from 11/23/2024 to 11/25/2024, was reviewed. The ICU Progress Notes indicated the following: -On 11/23/2024, physician (MD 3)’s plans for today: “ventilator (an appliance for artificial respiration) support: will again try weaning (a process of transitioning patient from ventilator use to breathing on his own)” noted palliative (a medical approach that helps people with serious illness live with more comfort and dignity) conversation and if needed, patient’s (Patient 18’s) [family member] (FM 1) is willing to have patient (Patient 18) undergo tracheostomy;” -On 11/24/2024, MD 3’s plans for today: “ventilator support: patient (Patient 18) unable to wean: will pursue tracheostomy, likely tomorrow (11/25/2024);” -On 11/25/2024, MD 3’s plans for today: “tracheostomy today ... updated [family member] (FM 1) at bedside this morning via interpreter.” During the same interview on 1/10/2025 at 2:08 p.m. with Registered Nurse (RN) 4, RN 4 stated MD 3’s progress notes did not show MD 3 had discussed any risks, benefits, and alternatives of tracheostomy with FM 1 prior to tracheostomy (procedure performed on 11/25/2024). During a concurrent interview and record review on 1/10/2025 at 4:17 p.m. with the Chief of Staff (COS), Patient 18’s Procedure Notes (operative notes), dated 11/25/2024, was reviewed. The operative notes indicated, Patient 18 had a placement of percutaneous (made through the skin) tracheostomy tube. The operative notes also indicated, “consent: consent was informed, signed by the patient’s (Patient 18’s) designee - [family member] (FM 1) and on the chart.” COS stated there was no documentation of risks and benefits of the procedure and informed consent discussion with FM 1 by MD 3. COS stated during the informed consent process, the physician was responsible to explain the diagnosis, risks and benefits and provide alternatives with translation if needed for non-English speaking patient or patient’s representative. COS stated the physician needed to document the informed consent discussion in their notes, typically in the operative notes. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent, Written Consent and Refusal of Consent,” dated 3/2023, the P&P indicated, “Prior to consenting to any treatment or procedure, patients have the right to know the relevant risks of the treatment or procedure, expected or hoped for benefits of the treatment or procedure, treatment alternatives and potential problems that might occur during recuperation. Patient also have the right to receive information in a manner he or she understands. Based on patient’s preferred language, interpreter and translation services are offered ... it is the physician/allied health practitioner (AHP, a category of health professionals)’s obligation to assure that the elements of informed consent have been discussed with and explained to the patient/legally recognized health care decision maker (LRHCDM) ... a critical part of the informed consent process is the discussion between the patient/LRHCDM and physician/AHP, which shall include an explanation of the risks, benefits, and alternatives to the recommended treatment or procedure, as well as potential problems that may occur during recuperation ... after the discussion, the physician/AHP must document in the patient’s medical record that the physician discussed the proposed procedure with the patient/LRHCDM and obtained informed consent.” During a review of the facility’s medical staff rules and regulation (rules and regulations) titled, “Rules and Regulations of the Professional Staff,” dated 12/2023, the rules and regulations indicated, “Consent. The competent patient is entitled to be informed about the nature of the proposed diagnostic and therapeutic procedures, possible benefits, risks, reasonable alternatives to the proposed care or treatment, side effects related to the alternatives, risks of not receiving the proposed care, and potential complications. It is the Professional Staff’s responsibility to convey the necessary information appropriate to the patient, and the circumstances, in language that the patient is likely to understand, and to document this discussion in a separately entry in the medical record. Except in emergencies, no patient shall be subjected to any surgical, diagnostic, or therapeutic procedure that involves a significant risk of bodily harm unless informed consent if obtained from the patient or his or her legally recognized representative and all other persons, if any, from whom consent is required by law.” 2. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/7/2024, the H&P indicated, Patient 18 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body’s overwhelming and life-threatening response to infection) with acute (new onset) organ dysfunction, community acquired pneumonia (lung infection), and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During a review of Patient 18’s “Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” form, dated 11/7/2024, the COA form indicated, Patient 18’s family member (FM 1) signed the COA form for Patient 18. The COA form also indicated translation was used via phone/video remote interpreting with Spanish interpreter needed. During a concurrent observation and interview on 1/7/2025 at 11:52 a.m. with Charge Nurse (CN) 2, at Patient 18’s room, FM 1 was sitting in Patient 18’s room. CN 2 stated FM 1 required Spanish interpretation. Observed CN 2 using the facility’s phone to connect to a Spanish speaking interpreter and started to talk to FM 1. During a concurrent interview and record review on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4, seven of Patient 18’s “Consent to Operation, Administration of Anesthetics, and the Rendering of other medical services” forms (consent form, document signed by the patient or legally recognized health care decision maker [LRHCDM] to consent to the procedure or treatment), dated from 11/7/2024 to 12/24/2024, were reviewed. Three of the consent forms were in Spanish and indicated the following: -Consent form with procedure for Central line (CVC or Central Venous Catheter- a thin, flexible tube that is inserted into a large vein near the heart to give fluids, blood and medications) placement signed by Patient 18’s family member (FM 1) on 11/7/2024 at 6:42 p.m. witnessed by RN 7 with no documentation of interpreter’s name and identification number; -Consent form with procedure for tracheostomy (a surgical procedure to create an artificial opening through the neck usually for the relief of difficulty in breathing) signed by FM 1 on 11/24/2024 at 10:53 a.m. witnessed by RN 6 with no documentation of interpreter’s name and identification number; -Consent form with procedure for placement of chest tube (a flexible tube that drains fluid, air or blood from the chest cavity) on left, signed by FM 1 on 12/16/2024 at 11:58 a.m. witnessed by RN 8 with no documentation of interpreter’s name and identification number. During the same interview on 1/10/2025 at 1:36 p.m. with Registered Nurse (RN) 4, RN 4 stated translator use should be documented on the consent form to indicate the use of translator. RN 4 stated it was important for nursing staff to utilize translation service for non-English speaking patients and family when witnessing signature on consent form so that they (Patient and/or designated family representative) would know what they were signing and would allow them to ask questions before signing the consent form. RN 4 stated if patient or family member still had questions, nursing staff should contact the physician and not to let them sign the consent form. During a review of the facility’s policy and procedure (P&P) titled, “Informed Consent, Written Consent and Refusal of Consent,” dated 3/2023, the P&P indicated, “General principle: patients and legally recognized health care decision maker (LRHCDM) must be able to understand what they are being asked to authorize. The hospital must arrange for communication in a language or mode that can be understood by the patient or LRHCDM. Documentation of interpreter: when an interpreter is required, the name of the interpreter and date/time of if the universal language telephone line or video remote interpreting used, their interpreter identification number must be documented.””

“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: 48212 Based on observation, interview and record review, the facility failed to ensure its nursing staff performed assessment and document restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every 2 hours, for 13 hours (from 6 a.m. to 7 p.m.) for one of 30 sampled patients (Patient 18), in accordance with the facility’s policy and procedure regarding restraints. The facility also failed to ensure its nursing staff assessed Patient 18’s condition including skin assessment when restraints were removed. This deficient practice had the potential to put Patient 18 at risk for skin break down (damage to the skin) and other injury due to lack of assessment and monitoring with restraints use. Findings: During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/7/2024, the H&P indicated, Patient 18 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body’s overwhelming and life-threatening response to infection) with acute (new onset) organ dysfunction (when an organ is not working properly), community acquired pneumonia (lung infection), and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During a concurrent observation and interview on 1/7/2025 at 11:52 a.m. with Charge Nurse (CN) 2, at Patient 18’s room, Patient 18 was in bed with bilateral (both) soft wrists restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on. CN 2 stated Patient 18 was on bilateral soft wrist restraints due to pulling lines. During a review of Patient 18’s “physician order (orders written by physicians to direct care and treatment),” dated 12/23/2024, the physician order indicated, there was need for bilateral wrists restraints due to pulling tube/lines and interfering with dressing, wounds, or devices. During a concurrent interview and record review on 1/10/2025 at 2:27 p.m. with Registered Nurse (RN) 4, Patient 18’s “restraints flowsheet (documentation of restraints use and assessment),” dated 12/24/2024, was reviewed. The restraint flowsheet indicated Patient 18 was on bilateral soft wrists restraints. The restraint flowsheet indicated an entry of assessment was completed on 12/24/2024 at 6 a.m. by RN 9. The next entry was on 12/24/2024 at 7 p.m. which indicated “discontinued. Not present on assessment,” by RN 9. During the same interview on 1/10/2025 at 2:27 p.m. with the Registered Nurse (RN) 4, RN 4 stated the following: Patient 18’s restraints were removed sometime from 6 a.m. to 7 p.m. on 12/24/2024, but the day shift nurse did not document anything. There should be restraints assessment done every two hours by nursing staff to check for skin for any injury, circulation (blood flow), range of motion (ROM, the full movement potential of a joint, usually its range of flexion and extension), discoloration, and swelling while Patient 18 was on restraints. Nursing staff should document time of restraints removal along with post (after) restraints assessment to assess skin for any injury. There was no assessment done from 6 a.m. to 7 p.m. (13 hours). Patient 18 could be at risk for skin breakdown and injury due to lack of proper monitoring. During a review of the facility’s policy and procedure (P&P) titled, “Restraint Use,” dated 9/2022, the P&P indicated, “Assessment, monitoring, and documentation of all restraint type: Registered Nurses (RN) are responsible for the assessment, monitoring and provision of care for patients in restraints ... Patient assessment by staff who have observed, examined or interacted directly with the patient will occur ... every two (2) hours for non-violent, non self-destructive restraints ... Patients in non-behavioral restraints are monitored and assessed at least every two (2) hours or sooner, as indicated by the condition of the patient and type of restraint. The assessment will be documented in the medical record. Assessment at least every two (2) hours include: behavior/mental status; circulation; nutritional needs (food/meal); hydration needs; elimination needs; range of motion (ROM); restraints released and reapplied, one limb at a time ...The patient shall be continually assessed to determine the patient’s condition and whether restraint can be discontinued. The physician or nurse responsible for the patient’s care has the authority to discontinue restraints based on patient assessment.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure one of 30 sampled patients (Patient 27), was provided a copy of the “Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” in Patient 27’s and/or their representative’s preferred language, in accordance with the facility’s policy and procedure regarding Patient Rights (a subset of human rights). This deficient practice resulted in Patient 27 and/or Patient 27’s representative not being able to fully understand and exercise his rights as patient, which may lead to Patient 27’s inability to effectively make decisions regarding own care and treatment in the facility. (Refer to A-0117) 2. The facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30 and Patient 30’s family member, was involved in the patient’s plan of care when, Patient 30’s education regarding Enoxaparin (blood thinner medication), given by Registered Nurse 1 (RN 1), was not in Patient 30’s preferred language (Spanish). This deficient practice resulted in Patient 30 not being able to fully understand the benefits and use of the medication which may result in Patient 30 to not comply with taking the medication. In addition, this deficient practice resulted in Patient 30 not understanding the possible adverse side effect of the medication which could cause negative effect on the patient’s health condition. (Refer to A-0130) 3. The facility failed to ensure that appropriate consent for transfer was obtained and documented for one of 30 sampled patients (Patient 1) and/or Patient 1’s representative that would indicate that the patient (Patient 1) and/or their representative was provided, both verbally and in writing, a complete explanation of the reason for transfer, the risks, benefits, and any alternatives to the transfer, in accordance with the facility’s policy and procedure regarding patient transfers. This deficient practice had the potential to compromise Patient 1 and/or Patient 1’s representative to make informed decisions (a choice made after gathering all relevant information and analyzing the potential outcomes, benefits, and risks of each option) regarding his care and be able to request or refuse treatment. (Refer to A-0131) 4. The facility failed to ensure that for one out of 30 sampled patients (Patient 1), the process of transfer to another facility was implemented in accordance with the facility’s policies and procedures regarding patient transfers when, the facility failed to ensure that the “Notification of Intent to Transfer” form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient’s appeal rights-was completed and signed by Patient 1 and/or Patient 1’s representative on the day of the transfer. In addition, the facility failed to document (in Patient 1’s medical chart) the determination that Patient 1 was “Medically Fit to Transfer,” that would indicate that the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient). This deficient practice had the potential to place Patient 1’s life and safety at risk due to inappropriate transfer or potential deterioration of Patient 1’s condition during transfer. (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure that for one of 30 sampled patients (Patient 4), reported pain was addressed in a timely manner. In addition, nursing staff did not document a complete pain assessment to evaluate the effectiveness of the pain management intervention, as required by the facility’s policy and procedure regarding pain assessment and management. This deficient practice had the potential to leave Patient 4 in prolonged discomfort, which may worsen Patient 4’s pain and may also result in psychological distress due to inadequately managed pain. (Refer to A-0395) 2. The facility failed to re-assess one of 30 sampled patient’s (Patient 6) temperature after administering acetaminophen (an over-the-counter fever reducer and pain reliever) for fever, in accordance with the facility’s policy and procedure regarding assessment and reassessment of interventions. This deficient practice had the potential for inability to determine the medication’s effectiveness in resolving Patient 6’s fever, which can delay additional treatment if needed that may result in complications such as seizure (a sudden, abnormal burst of electrical activity in the brain). (Refer to A-0395) 3. The facility failed to re-assess one of 30 sampled patient’s (Patient 7) pain level after administering acetaminophen and ibuprofen (medications that reduces fever, pain, and inflammation) for pain. This deficient practice had the potential for inability to determine the medication’s effectiveness in resolving Patient 7’s pain, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain. (A-0395) 4. The facility failed to ensure the following for one of 30 sampled patients (Patient 20): 4.a. Patient 20’s high blood pressure (BP, blood pressure is the pressure of circulating blood against the walls of blood vessels, a normal blood pressure measurement is 120/90) reading of 191/90 mmHg (millimeters of Mercury, a unit of measurement) was addressed in accordance with the physician’s order. 4.b. Patient 20’s vital signs (VS, measurement data of the body’s essential functions, such as body temperature, BP, rate of breathing, heart rate and level of pain) was checked in accordance with the facilities policy and procedure. These deficient practices had the potential to result in Patient 20’s delay in treatment and may result in further health complications for Patient 20 due to untreated high BP such as heart attack and/or death. (Refer to A-0395) 5. The facility failed to ensure for three of 30 sampled patients (Patients 12, 17, and 19), Patients 12, 17, and 19’s individualized nursing care plan (provides a means of communication among health care providers) was initiated in accordance with the facility’s policy and procedure regarding developing and implementing care plans. This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 12, 17, and 19’s needs and risks. (Refer to A-0396) 6. The facility failed to validate one of five registered nurses (RN 8) annual skills competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and education. This deficient practice had the potential for RN 8 to be carrying out nursing duties in which RN 8 may not be competent of performing, thus placing patients at risk for harm. (Refer to A-0397) 7. The facility failed to provide a unit orientation for one of five sampled RNs (RN 9) prior to working in the Intensive Care Unit (provides critical care and life support to patients who are very ill). This deficient practice had the potential for RN 9 to be unfamiliar with the unit process, locations of medical supplies, etc. And, therefore, placing patients at risk for harm. (Refer to A-0397) 8. The facility failed to ensure that for two of 30 sampled patients (Patient 3 and Patient 4), a call light (a system device used by the patient to call for help) was provided to Patient 3 and Patient 4. This deficient practice had the potential for Patients 3 and 4’s needs to not be met since both patients (Patient 3 and Patient 4) were unable to call for help with no nurse call system provided, which may result in a significant safety risk, as patients may be unable to promptly alert staff in emergencies, leading to delays in receiving necessary care and worsening of their conditions. (Refer to A-0398) 9. The facility failed to ensure that for one of 30 sampled patients (Patient 4), a complete pain assessment was conducted and documented in accordance with the facility’s policy and procedure regarding nursing pain assessment and management. This deficient practice had the potential to result in delayed provision of appropriate pain management strategies for Patient 4, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain. (Refer to A-0398) 10. The facility failed to ensure one of 30 sampled patient’s (Patient 8) pain level was assessed upon arrival to the Emergency Department (provides immediate care to patients with conditions that require urgent attention), when Patient 8’s vital signs (includes temperature, heart rate, respiratory rate, blood pressure, and pain level) was assessed, in accordance with the facility’s policy and procedure regarding initial pain assessment. This deficient practice resulted in an incomplete nursing assessment and had the potential to affect Patient 8’s treatment plan and Patient 8’s pain not to be addressed, which can lead to prolonged discomfort and worsening of pain. (Refer to A-0398) 11. The facility failed to ensure for one of 30 sampled patients (Patient 17), Patient 17’s neutropenic precautions (precautions for a condition characterized by low white blood cell count to avoid infections) were followed, in accordance with the facility’s policy and procedure regarding neutropenic precautions when, two of Patient 17’s family member did not wear a mask while inside the patient’s room. This deficient practice had the potential for Patient 17 to be exposed from infection that may worsen Patient 17’s health condition, including prolonged hospitalization, and/or death. (A-0398) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility’s governing body (responsible for guiding the hospital’s long-term goals and policies and assisting with strategic planning and decision-making) failed to ensure oversight in ensuring that all facility employees followed the established policies governing safe patient transfers for one of 30 sampled patients (Patient 1) when: 1. The notification of intent to transfer form was not completed by the facility and signed by the patient representative. 2. The Inter-facility transfer summary form was not filled out by the transferring physician and added into the medical record of Patient 1. 3. The Consent for transfer was not obtained from patient representative nor was it documented including any explanation provided regarding the risks, benefits, and alternatives for the transfer 4. There was no documentation by the transferring physician (MD 1) that Patient 1 was stable for transfer. 5. Staff were not aware of the facility’s policy regarding the use of the notification of intent transfer form and the inter-facility transfer summary form These deficient practices had the potential to place Patient 1 at risk for harm due to inappropriate transfer, potential deterioration of Patient 1’s condition during transfer, insufficient communication regarding the patient’s status and transfer risks. Findings: During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, Patient 1 had past medical history (PMH, a record of medical, personal, and family history that may be relevant to their current illness) of liver cirrhosis (a chronic liver disease characterized by the extensive replacement of healthy liver tissue with scar tissue), End-Stage Renal Disease (ESRD, a permanent condition that occurs when the kidneys stop functioning) with peritoneal dialysis (PD) catheter (a soft plastic tube that is surgically inserted into the abdomen to allow for the treatment of kidney failure) and was admitted to the facility on 11/20/2023 with a diagnosis of small bowel obstruction (SBO, a blockage in the small intestine [gut] that prevents the normal flow of intestinal contents). During a review of Patient 1’s Medical Record (MR) titled, “Progress Note-General Surgery,” dated 12/22/2023, the MR indicated that the course was complicated by intraabdominal sepsis [a severe abdominal infection, because of intestinal fluid leakage], which also led to contamination (the introduction of pathogens or infectious material) of the PD tube (later removed). The MR indicated, Patient 1 also experienced ileus, a temporary blockage in the intestines [when something prevents food, liquid, stool, or gas from moving through the intestines normally] that has since resolved, but there have been recurring episodes of possible bleeding in the small intestines, four times so far, and still ongoing, and a fistula (an abnormal connection between an organ) in the digestive tract (a series of hollow organs that food and liquids pass through as they are digested and absorbed, and leaves the body) that was first detected on 12/9/2023. During a review of Patient 1’s medical record (MR) titled, “Intensive Care Unit (ICU, a hospital ward that provides specialized care and monitoring for patients who are seriously ill or injured) Progress Note,” dated, 12/21/2023, the MR indicated, on 12/21/2023, Patient 1 required full ventilatory support (a life support system that uses a machine to help a patient breathe when they are unable to do so on their own), was on pressors (medications that increase blood pressure), was on antibiotics (medications to treat bacterial infection), was on TPN (total parenteral nutrition, a method of feeding that provides nutrients directly into the bloodstream through a vein), and continued to experience ongoing GI (Gastrointestinal- stomach and the intestines) bleeding requiring ongoing multiple blood transfusions (provides blood or blood components if you’ve lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components). The MR also indicated that Patient 1 had to be transferred to another facility to receive a required procedure called double balloon enteroscopy (DBE, a nonsurgical procedure used to diagnose and treat problems deep within the small bowel) but on 12/21/2023 Patient 1 was deemed unstable for transfer. During a review of Patient 1’s Medical Record (MR) titled, “ICU Update Note,” dated 12/22/2023 at 2:12 p.m., the MR indicated, on 12/22/2023, Patient 1 was accepted by the receiving facility for transfer. During a review of Patient 1’s medical record (MR) titled, “Nurse Progress Note,” dated 12/22/2023, the MR indicated, “Patient 1’s primary nurse gave a report to the transport Registered Nurse (RN), and all drips were transferred to the transport pump. Upon transferring the patient to the stretcher, the patient became bradycardic (heart rate that’s too slow), and blood pressure could not be obtained. A Code Blue (hospital emergency code indicating that a patient is in cardiac or respiratory arrest and requires immediate resuscitation efforts) was activated. During further review of Patient 1’s medical chart, dated 12/22/2023, there was no documentation indicating that appropriate transfer consent from Patient 1’s representative had been obtained and recorded in the medical record on the day of the transfer, on 12/22/2023. Additionally, the medical record contained no documentation showing that the patient (Patient 1) or their legal representative were notified, both verbally and in writing, that they had been given a complete explanation of the reason for the transfer, as well as the associated risks, benefits, and any alternatives. The MR contained no “Notification of Intent to Transfer” form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient’s appeal rights- that was completed and signed by Patient 1 and/or their representative. In addition, there was no physician documentation of the determination that Patient 1 was “Medically Fit to Transfer,” that would indicate the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient) at the time of transfer on 12/22/2024. This record review was verified with the Charge Nurse (CN 4) and the Informatics Nurse (IN 1) on 10/16/2024 at 9:49 a.m. During an interview on 10/16/2024 at 1:06 p.m. with ICU charge nurse (CN 6) regarding the transfer forms and consents that were required prior to a transfer from the ICU, the CN 6 stated “The physicians are the ones who give us the approval for transfer. Typically, no forms or consents are filled out prior to transfers.” CN 6 also stated that they were not fully familiar with the content of the facility’s current policy regarding transfers, titled “Patient Transfer General Guidelines,” dated 9/2020. During the same interview on 10/16/2024 at 1:24 p.m. with the house supervisor (Sup 1), the Sup 1 said, “The physician decides on the patient’s condition. In the inpatient unit, we don’t have any specific forms to sign; everything must be documented in the notes. The sending physician should complete the transfer summary before the patient is transferred. In the inpatient setting, the patient or their family should provide consent, and the physician should document this in their notes. It is important to determine whether the patient is stable or unstable, and we need to ensure that the family consents and understands where and why the patient is being transferred. All of this should be documented by the transferring physician. We want to ensure transfers are safe before they occur to avoid compromising the patient’s recovery.” During an interview on 10/17/2024 at 10:22 a.m. with ICU charge nurse (CN 5), CN 5 stated, “The transfer order should be placed by the physician, specifying how, where, and when the transfer will occur. The physician should also include an order for transport, detailing what is required during the transfer and what type of transport is necessary. The transport hub is not staffed by an RN; it’s a call center. During the same interview on 10/17/2024 at 10:22 a.m. with CN 5, CN 5 said the charge nurses are responsible for calling the transport hub. I’ve been working here for 24 years, and sometimes the hub takes a very long time to answer. I document everything, including how many drips and the ventilator settings (the parameters that control how a ventilator [a machine that helps people breathe when unable to breath on their own] delivers air to a patient). The physician’s order should outline all of this information.” During an interview on 10/17/2024 at 12:18 p.m. with the critical care physician (MD 1) regarding the transfer procedures and required forms that need to be completed prior to a transfer from the ICU, MD 1 stated, “Typically, we don’t fill out any forms when the transfer is within the same organization.” MD 1 further said, “At the time I saw the patient, the patient was pretty sick and was bleeding from an unknown source. The patient (Patient 1) needed a procedure that required transfer to another facility. The patient’s representative was aware of the transfer. On the day of the transfer, during my shift, the patient (Patient 1) was stable.” During the same interview on 10/17/2024 at 12:18 p.m. with the critical care physician (MD 1), MD 1 stated, “I ordered to discharge Patient 1 with ACLS (Advanced Cardiac Life Support- a set of clinical guidelines for the urgent and emergent treatment of life-threatening conditions that could lead to cardiac arrest [when the heart stops beating], etc.) transport. Since the patient (Patient 1) was on a ventilator, the Respiratory Therapist should have likely accompanied the patient for transport as well.” MD 1 also stated, “At the time of transfer, if the patient had not been stable, I would not have approved the transfer. Stability can change, and I don’t know what happened after I left the hospital. The telecritical care (TCC) physicians (tele-ICU physicians, are healthcare providers who remotely monitor and manage critically ill patients in intensive care units (ICUs) using telemedicine technology) take over at 7:00 p.m.” During the same interview on 10/17/2024 at 12:18 p.m. with MD 1, the MD 1 stated, “We sign out to the TCC doctor, and once they receive the sign-out, they review the chart and round with the nurses. If there are any issues with the patient, they address them. If there were signs of instability and the patient was decompensating, the nurses would likely notify them.” During an interview on 10/18/2024 at 9:25 a.m. with the Accreditation, Regulatory, and Licensing Director (ARLD) the ARLD stated, “Our facility follows both regional [Organization] and local (specific to one facility) policies. If a regional policy is sent to the hospital, it must be implemented. If we have a local policy, we will have to archive it and adopt the regional one. However, if the local policy is more stringent than the regional one, the more stringent policy is typically implemented. Our facility has a more stringent transfer policy than the regional one which means we have to follow it.” During an interview on 10/18/2024 at 9:25 a.m. with the ARDL (who is a member of the local governing body structure at the facility and a member of the Quality Oversight Committee [QOC]), regarding the facility’s local organizational structure and responsibilities for policy reviews, approval, and implementation process, the ARDL stated that the owner of the local transfer policy titled, “Patient Transfer General Guidelines” (dated September 2020), was the Nursing Service Director (NSD). The NSD was responsible for reviewing, approving, and ensuring the implementation of the policy, as well as overseeing that staff follow it. When the policy is due for review, the NSD is tasked with revising and approving the policy before forwarding it to the Quality Oversight Committee for further review and approval. During the same interview on 10/18/2024 at 9:25 a.m. with the Accreditation, Regulatory, and Licensing Director (ARLD), regarding the local facility’s policy and procedure (P&P) titled, “Patient Transfer General Guidelines,” dated 9/2020, the ARLD stated, “There is no local policy committee. We are in the process of doing a major overhaul of the policy portal. The policy was due for review in 2023 but it has not come up for a review yet. I have oversight over policies. We had a policy portal, and we are working on uploading all the policies. We have identified the need for some cleanup. The system will notify us when policies are due for review and will update the policy owners. It will highlight which policies are up for review.” During an interview on 10/18/2024 at 10:28 a.m. with the ICU department administrator (DA 1) regarding transport and transfer arrangements for ICU patients, DA 1 stated, “From a nursing perspective, we call the transport hub (a call center that coordinates with contracted ambulance services for transport), provide the patient’s status, including drips (a method of delivering fluids, nutrients, or medicine directly into a patient’s bloodstream through a vein), and give the necessary information. The transportation hub then decides on the appropriate transport based on that information. When transport team arrives, the primary nurse would give report, and she/he doesn’t necessarily need to remain with the patient for the entire process. It may take about 45 minutes for the transport team to check vital signs and complete the transfer. Sometimes, the transport RN may decide not to take the patient and refuse the transfer based on established criteria.” During the same interview on 10/18/2024 at 10:28 a.m. with DA 1, the DA 1 stated, “The nurse is responsible for assessing whether the patient is deteriorating and for communicating that to the physician to determine if the patient is stable or unstable. As far as I know, we don’t have any transfer forms signed by the physician that indicate if the patient is stable or unstable, and I have been working here for 10 years.” During an interview on 10/18/2024 at 12:54 p.m. with the Regional Director for Medical Transportation Services (RDMT), [a title held in 2023], the RDMT stated, “The transportation hub serves as the point of contact for medical centers when a [Organization] member needs a transfer. We coordinate non-emergency medical transportation. Our job is to maintain a network of contracted providers/suppliers to meet [Organization] demand. We receive reports regarding patient status from the medical facility either via phone or digitally. We are essentially a call center that processes the request to ensure the level of service the clinician has requested is fulfilled. The transport supplier then dispatches the appropriate team based on the information provided. They follow their own guidelines, policies, and procedures, as each county may have different requirements for transport.” During an interview on 10/18/2024 at 11:00 a.m. with the Vice President and General Manager of Operations for the contracted transport company (VPGM), the VPGM stated, “We typically receive a patient care report from the transportation hub. We ask if the patient is stable or unstable. We review the transport request, such as whether ACLS (Advanced Cardiovascular Life Support Transport, equipped to handle patients with critical cardiac conditions or other emergencies that may need immediate intervention, such as defibrillation, advanced airway management, and administration of specific medications) or CCT (Critical Care Transport, highly specialized service designed for critically ill or injured patients who need continuous monitoring and treatment during transport. During the same interview on 10/18/2024 at 11:00 a.m., the VPGM also said “it involves a higher level of care than ACLS transport, including ventilator support, multiple intravenous drips, and complex monitoring. CCT is often staffed by a critical care team, which may include a critical care nurse, respiratory therapist, and sometimes a physician, depending on the patient’s needs) is needed, we decide if we agree with the request or if additional staff are required. We follow our own policies and procedures that are based on county’s guidelines, and we are not required to check for any forms when we pick up a patient for transport. For example, if the patient is on multiple devices, receiving an excessive number of drips, or on a ventilator, we may send another staff member for monitoring.” During the same interview on 10/18/2024 at 11:00 a.m., the VPGM stated “For patient (Patient 1), we determined that one RN and two EMTs (Emergency Medical Technicians, trained to respond to emergency situations and are skilled in basic life-saving techniques, such as CPR, airway management, wound care, and patient stabilization. EMTs typically work alongside paramedics and other medical personnel during medical emergencies and in transport situations, but they do not perform the more advanced procedures handled by paramedics or critical care teams) were sufficient based on the report we received from the hub. The report indicated that the patient was stable.” During a review of the document provided by the facility titled, “Transport Request,” dated 10/22/2023 at 9:21 p.m., the record indicated that the request for the level of service was for Critical Care Transport (CCT) due to Patient 1 being on multiple drips and requiring ventilator support. During a review of the facility’s policy and procedure (P&P) titled, “Patient Transfer General Guidelines,” dated 9/2020, the P&P indicated that it applies to all employees of the organization to ensure the continuity of safe and high-quality medical and nursing care for patients being transferred to another facility of equal or higher care level. The P&P indicated the following: ... 5. Before a patient is transferred, both the transferring and receiving facilities must ensure that appropriate consent has been obtained and documented. 1. Steps in the Transfer Process: Transferring physician obtains informed consent from patient and documents on “Notification of Intent to Transfer.” ... 7.4. The patient or their legal representative must be notified both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives. 7.4. The patient or their legal representative must be notified (of transfer) both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives. 8. If the patient has an unstable emergency medical condition but requires transfer for their medical benefit, they must sign a “Notification of Intent to Transfer” form. ... 8.1 The responsible practitioner shall explain and document in the progress notes, the risks and alternatives of the recommended therapeutic course to the patient, including the risks of transfer, and obtain consent. ... 8.8. The “Inter-Hospital Transfer Summary” form must be completed at the time of transfer. In determining that it is to the patient’s medical benefit to affect a transfer, the responsible practitioner shall determine that the medical benefits expected from the provision of appropriate medical treatment at the receiving medical facility outweigh any increased risks caused by such transfer. The practitioner shall list such risks and benefits of the transfer as a part of a dictated transfer summary or transfer progress note and on “Inter-hospital Transfer Summary.” ... 10. Except as provided in this policy, or unless otherwise agreed upon by both facilities and documented in the patient’s medical record, responsibility for the patient during transport shall remain with the facility from which patient is being transferred. Such responsibility shall include: 10.1 The determination of the mode of transportation to be used 10.2 The provision of all equipment, supplies, drugs, and personnel which may be required during the transport; and 10.3 The instruction of transporting attendants relative to the patient’s diagnosis, medications, possible untoward reactions and monitoring requirements. ... 12. The transferring physician and facility have specific responsibilities: a. The transferring physician must determine whether the patient is “Medically Fit to Transfer.” This decision should follow facility protocols to ensure that the transfer does not pose a medical risk to the patient. The physician must document this determination in the patient’s medical record. c. The patient must be informed about the need for the transfer, any alternatives, the proposed transportation plans, and the benefits and risks associated with the transfer. This explanation should focus on risks and benefits specifically related to the patient’s condition and the procedure requiring the transfer. The transferring physician must document this discussion in the patient’s medical record. 13. Admitting/ED/Nursing Services are responsible for ensuring that this policy and procedure is accurate, relevant, and current. 14. The policy and procedure shall be reviewed at least every three years, and revised periodically, to assure continuing relevance and compliance with regulatory and accrediting standards, hospital bylaws, rules and regulations, legal statues, and current practice.”

“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: 50515 Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 27), was provided a copy of the “Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)” in Patient 27’s and/or their representative’s preferred language, in accordance with the facility’s policy and procedure regarding Patient Rights (a subset of human rights). This deficient practice resulted in Patient 27 and/or Patient 27’s representative not being able to fully understand and exercise his rights as patient, which may lead to Patient 27’s inability to effectively make decisions regarding own care and treatment in the facility. Findings: During a review of Patient 27’s “Face Sheet (a document containing a patient’s medical and demographic information),” (undated), the Face Sheet indicated Patient 27 was admitted to the facility on 10/2/2024, with a medical diagnosis of pneumonia (an infection/inflammation in the lungs). The Face Sheet further indicated that Patient 27’s preferred language was Spanish. During a concurrent interview and record review on 10/16/2024 at 10:20 a.m. with Charge Nurse 1 (CN 1), Patient 27’s “Hospital Conditions of Admission - COA (a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.),” dated 10/2/2024, was reviewed. Patient 27’s COA was written in English and was signed by Patient 27’s representative. Patient 27’s signed COA did not indicate an interpreter (helps the patient and the provider fully understand each other to reduce the risks associated with misunderstanding a diagnosis or treatment plan) was used. During the same interview on 10/16/2024 at 10:20 a.m., CN 1 stated Patient 27’s preferred language was Spanish, and he (CN 1) was not aware if Patient 27’s representative understands English. CN 1 further said, it was important for the patient and their representative to receive legal documents in their preferred language, so they know what they are signing. During a phone interview on 10/16/2024 at 10:28 a.m., with Patient 27’s representative, Patient 27’s representative stated Patient 27 and herself do not speak and/or understand English. Patient 27’s representative stated she (Patient 27’s interpreter) signed Patient 27’s COA, given in English, and was not offered a written Spanish COA or use an interpreter prior to signing the COA written in English. During review of the facility’s Policy and Procedure (P&P) titled, “Patient Rights and Responsibilities,” revised 10/2022, the P&P indicated, “Patient Rights, you have the right to...Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. 5. Make decisions regarding medical care and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment.” During a review of the facility’s policy and procedure (P&P) titled, “Qualified Interpreter Services for limited English Proficient persons,” revised 11/2023, the P&P indicated, “Qualified interpreter services are provided during all hours of operation at no cost to members/patients, their medical decision makers, and their companions ...Language assistance is provided 24 hours a day, 7 days a week.””

“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: 50515 Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30 and Patient 30’s family member, was involved in the patient’s plan of care when, Patient 30’s education regarding Enoxaparin (blood thinner medication), given by Registered Nurse 1 (RN 1), was not in Patient 30’s preferred language (Spanish). This deficient practice resulted in Patient 30 not being able to fully understand the benefits and use of the medication which may result in Patient 30 to not comply with taking the medication. In addition, this deficient practice resulted in Patient 30 not understanding the possible adverse side effect of the medication which could cause negative effect on the patient’s health condition. Findings: During a review of Patient 30’s “Face Sheet (front page of the chart that contains a summary of basic information about the resident),” (undated), the face sheet indicated, Patient 30 was admitted to the facility on 10/14/2024, with a medical diagnosis of Acute (severe and sudden) on chronic (persisting for a long time) hypoxemic (low levels of oxygen in blood) respiratory failure (when lungs cannot exchange oxygen). The face sheet further indicated, Patient 30’s spoken, and written language was Spanish. During a review of Patient’s 30’s “Medication Detail,” dated 10/14/2024, the record indicated, a physician’s order of Enoxaparin injection 40 mg every 24 hours SQ (Subcutaneous injection, beneath the skin or under all the layers of the skin). During an observation on 10/15/2024 at 12:38 p.m. with the Quality Coordinator (QCRN), RN 1 was observed inside Patient 30’s room, RN 1 was in the process of administering Enoxaparin 40 milligram (mg, metric unit of measurement, used for medication dosage and/or amount) subcutaneous injection to the patient (Patient 30). Patient 30’s family member, who was at the bedside, spoke in Spanish and inquired about Patient 30’s medication. RN 1 responded in English and told Patient 30’s family member, “it’s a blood thinner,” no interpreter was observed used. During the same observation on 10/15/24 at 12:38 a.m., Patient 30 and the patient’s family member stated, they did not understand English very well and would like to know what medication was given to Patient 30. Patient 30’s family member stated she had a lot of questions regarding the medication. During an interview on 10/15/24 at 12:50 p.m., with RN 1, RN 1 stated Patient 30’s family member can sometimes understand English. RN 1 said she used the language line (a company that provides language services for facilities for interpretation and translation) when she needs to establish line of communication with the patient that do not speak or understand English. RN 1 further stated it was important to use the language line with patients that do not speak or understand English when administrating medication, so the patient could understand what medication was being administered. During an interview on 10/15/2024 at 1:00 p.m. with the Department Administrator (FDA), the FDA stated the nurses should use the language line if the patient’s preferred language was not English. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” revised 10/2018, indicated, “Patient (and/or authorized family members) has the right to be informed of the medication being administered, purpose, action and potential side effects.” During a review of the facility’s policy and procedure (P&P) titled, “Qualified Interpreter Services for limited English Proficient persons,” revised 11/2023, indicated, “Any member/patient who expresses a preference for a non-English language, including Sign language or demonstrates a need for interpreter services is offered the use of qualified Interpreter Services at all administrative and clinical points of contact during all hours of operation at no charge to the member/patient.””

“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: 46238 Based on interview and record review, the facility failed to ensure that appropriate consent for transfer was obtained and documented for one of 30 sampled patients (Patient 1) and/or Patient 1’s representative that would indicate that the patient (Patient 1) and/or their representative was provided, both verbally and in writing, a complete explanation of the reason for transfer, the risks, benefits, and any alternatives to the transfer, in accordance with the facility’s policy and procedure regarding patient transfers. This deficient practice had the potential to compromise Patient 1 and/or Patient 1’s representative to make informed decisions (a choice made after gathering all relevant information and analyzing the potential outcomes, benefits, and risks of each option) regarding his care and be able to request or refuse treatment. Findings: During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, Patient 1 had past medical history (PMH, a record of medical, personal, and family history that may be relevant to their current illness) of liver cirrhosis (a chronic liver disease characterized by the extensive replacement of healthy liver tissue with scar tissue), End-Stage Renal Disease (ESRD, a permanent condition that occurs when the kidneys stop functioning) with peritoneal dialysis (PD) catheter (a soft plastic tube that is surgically inserted into the abdomen to allow for the treatment of kidney failure) and was admitted to the facility on 11/20/2023 with a diagnosis of small bowel obstruction (SBO, a blockage in the small intestine [gut] that prevents the normal flow of intestinal contents). During a review of Patient 1’s medical record (MR) titled, “Progress Note-General Surgery,” dated 12/22/2023, the MR indicated, during the course of admission (11/20/2023 through 12/22/2023), Patient 1 underwent exploratory laparotomy (ex-lap, a major surgical procedure that involves making a large incision in the abdomen), three (3) repairs of enterotomies (a surgical procedure that involves repairing an incision into the intestine), debridement of midline and port site wounds (removing dead skin and foreign material from a wound), removal of PD catheter, then esophagogastroduodenoscopy (EGD, a diagnostic procedure that allows a doctor to examine the upper gastrointestinal [GI, gastrointestinal- made up of the stomach and the intestines] tract) and colonoscopy (a procedure in which a flexible fiber-optic instrument is inserted through the anus in order to examine the colon) complicated by (c/b) evisceration (protrusion of internal organs through a surgical wound or incision) and laceration by fascial sutures (that the sutures placed in the fascia [the connective tissue layer just below the skin and fat] were either torn or cut, causing a disruption of the wound’s closure) of small bowel loop (refers to a segment or loop of the small intestine). The MR indicated, Patient 1 then required another surgery to remove part of the intestine and reconnect it, with the wound being closed only at the skin level. During further review of Patient 1’s MR titled, “Progress Note-General Surgery,” dated 12/22/2023, the MR indicated that the course was complicated by intraabdominal sepsis [a severe abdominal infection, because of intestinal fluid leakage, which also led to contamination (the introduction of pathogens or infectious material)] of the PD tube (later removed). The MR indicated, Patient 1 also experienced ileus, a temporary blockage in the intestines that has since resolved, but there have been recurring episodes of possible bleeding in the small intestines, four times so far, and still ongoing, and a fistula (an abnormal connection between an organ) in the digestive tract that was first detected on 12/9/2023. During a review of Patient 1’s medical record (MR) titled, “Intensive Care Unit (ICU, a hospital ward that provides specialized care and monitoring for patients who are seriously ill or injured) Progress Note,” dated, 12/21/2023, the MR indicated, on 12/21/2023, Patient 1 required full ventilatory support (a life support system that uses a machine to help a patient breathe when they are unable to do so on their own), was on pressors (medications that increase blood pressure), was on antibiotics (medications to treat bacterial infection), was on TPN (total parenteral nutrition, a method of feeding that provides nutrients directly into the bloodstream through a vein), and continued to experience ongoing GI bleeding requiring ongoing multiple blood transfusions (provides blood or blood components if you’ve lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components). The MR also indicated that Patient 1 had to be transferred to another facility to receive a required procedure called double balloon enteroscopy (DBE, a nonsurgical procedure used to diagnose and treat problems deep within the small bowel) but on 12/21/2023 Patient 1 was deemed unstable for transfer. During a review of Patient 1’s medical record (MR) titled, “ICU Progress Note,” dated, 12/22/2023 at 8:00 a.m., the MR indicated, Patient 1’s possible transfer was still pending. During a review of Patient 1’s MR titled, “ICU Update Note,” dated 12/22/203 at 2:12 p.m., the MR indicated, on 12/22/2023, Patient 1 was accepted by the receiving facility for transfer. During further review of Patient 1’s medical chart, dated 12/22/2023, there was no documentation indicating that appropriate transfer consent from Patient 1 or Patient 1’s representative had been obtained and recorded in the medical record on the day of the transfer, on 12/22/2023. Additionally, the medical record contained no documentation showing that the patient (Patient 1) or their legal representative were notified, both verbally and in writing, that they had been given a complete explanation of the reason for the transfer, as well as the associated risks, benefits, and any alternatives. This record review was verified on 10/16/2024 at 9:49 a.m. with the Charge Nurse (CN 4) and the Informatics Nurse (IN 1). During an interview on 10/16/2024 at 1:06 p.m. with ICU charge nurse (CN 6) regarding the transfer forms and consents that were required prior to a transfer in the ICU, the CN 6 stated “The physicians are the ones who give us the approval for transfer. Typically, no forms or consents are filled out prior to transfers.” CN 6 also stated that they were not fully familiar with the content of the facility’s current policy regarding transfers titled, “Patient Transfer General Guidelines,” dated 9/2020. During an interview on 10/17/2024 at 10:22 a.m. with ICU charge nurse (CN 5) regarding the transfer forms and consents that were required prior to a transfer from the ICU, the CN 5 stated that the facility does not have a flowsheet or specific form that must be completed prior to a patient’s transfer to another facility. CN 5 stated that all consents were typically documented in the physician’s notes, but it depends on what the physician chooses to document. During an interview on 10/17/2024 at 12:18 p.m. with the ICU physician (MD 1) regarding the transfer procedures, forms, and consents required prior to a transfer from the ICU, MD 1 stated that typically physicians do not fill out any forms or obtain official consents before a transfer. During the same interview, when discussing Patient 1’s transfer process on 12/22/2024, MD 1 stated that no consent for the transfer was obtained from Patient 1 or Patient 1’s representative. However, MD 1 said that Patient 1’s representative was aware of the transfer and understood that it was necessary because the required procedure could only be performed at a different facility, as Patient 1 continued to experience bleeding from an unknown source. MD 1 also stated that they were not fully familiar with the content of the facility’s policy regarding patient transfers titled, “Patient Transfer General Guidelines,” dated 9/2020. During an interview on 10/18/2024 at 10:28 a.m. with the ICU department administrator (DA 1) regarding the transfer procedures, forms, and consents required prior to a transfer in the ICU, the DA 1 stated, “Prior to any patient transfer, nurses should ensure that the physician’s documentation reflects whether the physician obtained acceptance from the receiving facility, secured a bed, and communicated with the patient or family regarding the transfer. This conversation should take place on the day of the transfer or discharge.” The DA also added, “As far as I know, we don’t have any transfer forms or consent for transfer that are signed by the physician, and I have been working here for some time.” The DA 1 also stated that they were not fully familiar with the content of the facility’s policy regarding patient transfers titled, “Patient Transfer General Guidelines,” dated 9/2020. During a review of the facility’s policy and procedure (P&P) titled, “Patient Transfer General Guidelines,” dated 9/2020, the P&P indicated that it applies to all employees of the organization to ensure the continuity of safe and high-quality medical and nursing care for patients being transferred to another facility of equal or higher care level. The P&P indicated the following: ... 5. Before a patient is transferred, both the transferring and receiving facilities must ensure that appropriate consent has been obtained and documented. ... 7.4. The patient or their legal representative must be notified both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives.”

“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: 46238 Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 1), the process of transfer to another facility was implemented in accordance with the facility’s policies and procedures regarding patient transfers when, the facility failed to ensure that the “Notification of Intent to Transfer” form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient’s appeal rights-was completed and signed by Patient 1 and/or Patient 1’s representative on the day of the transfer. In addition, the facility failed to document (in Patient 1’s medical chart) the determination that Patient 1 was “Medically Fit to Transfer,” that would indicate that the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient). This deficient practice had the potential to place Patient 1’s life and safety at risk due to inappropriate transfer or potential deterioration of Patient 1’s condition during transfer. Findings: During a review of Patient 1’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, Patient 1 had past medical history (PMH, a record of medical, personal, and family history that may be relevant to their current illness) of liver cirrhosis (a chronic liver disease characterized by the extensive replacement of healthy liver tissue with scar tissue), End-Stage Renal Disease (ESRD, a permanent condition that occurs when the kidneys stop functioning) with peritoneal dialysis (PD) catheter (a soft plastic tube that is surgically inserted into the abdomen to allow for the treatment of kidney failure) and was admitted to the facility on 11/20/2023 with a diagnosis of small bowel obstruction (SBO, a blockage in the small intestine [gut] that prevents the normal flow of intestinal contents). During a review of Patient 1’s medical record (MR) titled, “Progress Note-General Surgery,” dated 12/22/2023, the MR indicated, during the course of admission (11/20/2023 through 12/22/2023), Patient 1 underwent exploratory laparotomy (ex-lap, a major surgical procedure that involves making a large incision in the abdomen), three (3) repairs of enterotomies (a surgical procedure that involves repairing an incision into the intestine), debridement of midline and port site wounds (removing dead skin and foreign material from a wound), removal of PD catheter, then esophagogastroduodenoscopy (EGD, a diagnostic procedure that allows a doctor to examine the upper gastrointestinal [GI- Gastrointestinal, includes the stomach and the intestines] tract) and colonoscopy (a procedure in which a flexible fiber-optic instrument is inserted through the anus in order to examine the colon) complicated by (c/b) evisceration (protrusion of internal organs through a surgical wound or incision) and laceration by fascial sutures (that the sutures placed in the fascia [the connective tissue layer just below the skin and fat] were either torn or cut, causing a disruption of the wound’s closure) of small bowel loop (refers to a segment or loop of the small intestine). The MR indicated, Patient 1 then required another surgery to remove part of the intestine and reconnect it, with the wound being closed only at the skin level. During further review of Patient 1’s Medical Record titled, “Progress Note-General Surgery,” dated 12/22/2023, the MR indicated that the course was complicated by intraabdominal sepsis, a severe abdominal infection, because of intestinal fluid leakage, which also led to contamination (the introduction of pathogens or infectious material) of the PD tube (later removed). The MR indicated, Patient 1 also experienced ileus, a temporary blockage in the intestines that has since resolved, but there have been recurring episodes of possible bleeding in the small intestines, four times so far, and still ongoing, and a fistula (an abnormal connection between an organ) in the digestive tract that was first detected on 12/9/2023. During a review of Patient 1’s medical record (MR) titled, “Intensive Care Unit (ICU, a hospital ward that provides specialized care and monitoring for patients who are seriously ill or injured) Progress Note,” dated 12/21/2023, the MR indicated, on 12/21/2023, Patient 1 required full ventilatory support (a life support system that uses a machine to help a patient breathe when they are unable to do so on their own), was on pressors (medications that increase blood pressure), was on antibiotics (medications to treat bacterial infection), was on TPN (total parenteral nutrition, a method of feeding that provides nutrients directly into the bloodstream through a vein), and continued to experience ongoing GI bleeding requiring ongoing multiple blood transfusions (provides blood or blood components if you’ve lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components). The MR also indicated that Patient 1 had to be transferred to another facility to receive a required procedure called double balloon enteroscopy (DBE), a nonsurgical procedure used to diagnose and treat problems deep within the small bowel) but on 12/21/2023 Patient 1 was deemed unstable for transfer. During a review of Patient 1’s medical record (MR) titled, “Progress Note-General Surgery,” dated 12/22/2023, the MR indicated that on 12/22/2023 Patient 1 was stable for transfer when accepted by the receiving facility. During a review of Patient 1’s medical record (MR) titled, “ICU Progress Note,” dated 12/22/2023 at 8:00 a.m., the MR indicated, Patient 1’s possible transfer was still pending. During a review of Patient 1’s Medical Record titled, “ICU Update Note,” dated 12/22/203 at 2:12 p.m., the MR indicated, Patient 1 was accepted by the receiving facility for transfer. During further review of Patient 1’s medical record (MR), dated 12/22/2023, the medical record contained no documentation showing that the patient (Patient 1) or their legal representative were notified, both verbally and in writing, that they had been given a complete explanation of the reason for the transfer, as well as the associated risks, benefits, and any alternatives. The MR contained no “Notification of Intent to Transfer” form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient’s appeal rights- that was completed and signed by Patient 1 and/or their representative on the day of the transfer. In addition, there was no physician documentation of the determination that Patient 1 was “Medically Fit to Transfer,” that would indicate that the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient) at the time of transfer on 12/22/2024. This record review was verified with the Charge Nurse (CN 4) and the Informatics Nurse (IN 1) on 10/16/2024 at 9:49 a.m. During an interview on 10/16/2024 at 1:06 p.m. with ICU charge nurse (CN 6) regarding the transfer forms and consents that are required prior to a transfer in the ICU, the CN 6 stated “The physicians are the ones who give us the approval for transfer. Typically, no forms or consents are filled out prior to transfers.” CN 6 also stated that they were not familiar with the content of the facility’s current policy regarding transfers. During the same interview on 10/16/2024 at 1:24 p.m. with Sup 1, the Sup 1 said, “The physician decides on the patient’s condition. In the inpatient unit, we don’t have any specific forms to sign; everything must be documented in the notes. The sending physician should complete the transfer summary before the patient is transferred. In the inpatient setting, the patient or their family should provide consent, and the physician should document this in their notes. It is important to determine whether the patient is stable or unstable, and we need to ensure that the family consents and understands where and why the patient is being transferred. All of this should be documented by the transferring physician. We want to ensure transfers are safe before they occur to avoid compromising the patient’s recovery.” During an interview on 10/17/2024 at 10:22 a.m. with ICU charge nurse (CN 5) regarding the transfer forms and consents that were required prior to a transfer from the ICU, the CN 5 stated, “All our patients are very critical in the ICU. The transfer order should be placed by the physician, specifying how, where, and when the transfer will occur. For the ICU, we don’t have a flowsheet or specific forms. The consent for transfer is documented by the doctor in their notes, and it depends on the physician what gets documented. We print out the Interfacility Transfer form, and everything must be printed out, including the History & Physical (H&P), the summary, and the entire packet. For interfacility transfers between [Organization] locations, they can access the patient’s chart and see everything. Some clerks tell me the patient is going to the same organization, and we remind them that we need to prepare the discharge entire packet in case the patient has to be diverted to another facility.” During an interview on 10/17/2024 at 12:18 p.m. with the ICU physician (MD 1) regarding the transfer procedures and required forms that need to be completed prior to a transfer from the ICU, MD 1 stated, “Typically, we don’t fill out any forms when the transfer is within the same organization.” MD 1 further said, “At the time I saw the patient, the patient was pretty sick and was bleeding from an unknown source. The patient (Patient 1) needed a procedure that required transfer to another facility. The patient’s representative was aware of the transfer. On the day of the transfer, during my shift, the patient (Patient 1) was stable. At the time of transfer, if the patient had not been stable, I would not have approved the transfer. Stability can change, and I don’t know what happened after I left the hospital. The telecritical care (TCC) physicians (tele-ICU physicians, are healthcare providers who remotely monitor and manage critically ill patients in intensive care units (ICUs) using telemedicine technology) take over at 7:00 p.m.” During the same interview on 10/17/2024 at 12:18 p.m. with MD 1, the MD 1 stated, “We sign out to the TCC doctor, and once they receive the sign-out, they review the chart and round with the nurses. If there are any issues with the patient, they address them. If there were signs of instability and the patient was decompensating, the nurses would likely notify them.” During an interview on 10/18/2024 at 10:28 a.m. with the ICU department administrator (DA 1) regarding the transfer procedures, forms, and consents required prior to a transfer from the ICU, the DA 1 stated, “Prior to any patient transfer, nurses should ensure that the physician’s documentation reflects whether the physician obtained acceptance from the receiving facility, secured a bed, and communicated with the patient or family regarding the transfer. This conversation should take place on the day of the transfer or discharge.” During the same interview on 10/18/2024 at 10:28 a.m. with DA 1, the DA stated, “The nurse is responsible for assessing whether the patient is deteriorating and for communicating that to the physician to determine if the patient is stable or unstable. As far as I know, we don’t have any transfer forms signed by the physician that indicate if the patient is stable or unstable, and I have been working here for 10 years.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Transfer General Guidelines,” dated 9/2020, the P&P indicated that it applies to all employees of the organization to ensure the continuity of safe and high-quality medical and nursing care for patients being transferred to another facility of equal or higher care level. The P&P indicated the following: ... 7.4. The patient or their legal representative must be notified (of transfer) both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives. ... 8. If the patient has an unstable emergency medical condition but requires transfer for their medical benefit, they must sign a “Notification of Intent to Transfer” form. 8.1 The responsible practitioner shall explain and document in the progress notes, the risks and alternatives of the recommended therapeutic course to the patient, including the risks of transfer, an obtain consent. 8.8. The “Inter-Hospital Transfer Summary” form must be completed at the time of transfer. In determining that it is to the patient’s medical benefit to affect a transfer, the responsible practitioner shall determine that the medical benefits expected from the provision of appropriate medical treatment at the receiving medical facility outweigh any increased risks caused by such transfer. The practitioner shall list such risks and benefits of the transfer as a part of a dictated transfer summary or transfer progress note and on “Inter-hospital Transfer Summary.” ... 12. The transferring physician and facility have specific responsibilities: a. The transferring physician must determine whether the patient is “Medically Fit to Transfer.” This decision should follow facility protocols to ensure that the transfer does not pose a medical risk to the patient. The physician must document this determination in the patient’s medical record. c. The patient must be informed about the need for the transfer, any alternatives, the proposed transportation plans, and the benefits and risks associated with the transfer. This explanation should focus on risks and benefits specifically related to the patient’s condition and the procedure requiring the transfer. The transferring physician must document this discussion in the patient’s medical record.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50521 Based on interview and record review, the failed to: 1. Ensure that for one of 30 sampled patients (Patient 4), reported pain was addressed in a timely manner. In addition, nursing staff did not document a complete pain assessment to evaluate the effectiveness of the pain management intervention, as required by the facility’s policy and procedure regarding pain assessment and management. This deficient practice had the potential to leave Patient 4 in prolonged discomfort, which may worsen Patient 4’s pain and may also result in psychological distress due to inadequately managed pain. 2. Re-assess one of 30 sampled patient’s (Patient 6) temperature after administering acetaminophen (an over-the-counter fever reducer and pain reliever) for fever, in accordance with the facility’s policy and procedure regarding assessment and reassessment of interventions. This deficient practice had the potential for inability to determine the medication’s effectiveness in resolving Patient 6’s fever, which can delay additional treatment if needed that may result in complications such as seizure (a sudden, abnormal burst of electrical activity in the brain). 3. Re-assess one of 30 sampled patient’s (Patient 7) pain level after administering acetaminophen and ibuprofen (medications that reduces fever, pain, and inflammation) for pain. This deficient practice had the potential for inability to determine the medication’s effectiveness in resolving Patient 7’s pain, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain. 4. Ensure the following for one of 30 sampled patients (Patient 20): 4.a. Patient 20’s high blood pressure (BP, blood pressure is the pressure of circulating blood against the walls of blood vessels, a normal blood pressure measurement is 120/90) reading of 191/90 mmHg (millimeters of Mercury, a unit of measurement) was addressed in accordance with the physician’s order. 4.b. Patient 20’s vital signs (VS, measurement data of the body’s essential functions, such as body temperature, BP, rate of breathing, heart rate and level of pain) was checked in accordance with the facilities policy and procedure. These deficient practices had the potential to result in Patient 20’s delay in treatment and may result in further health complications for Patient 20 due to untreated high BP such as heart attack and/or death. Findings: 1. During a review of Patient 4’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, on 10/15/2024, Patient 4 was transferred from outside facility to the facility’s Emergency Department (ED, provides medical and surgical to patients arriving in the ED n need of immediate care) for further evaluation and treatment of right ankle fracture (one or more of the bones that make up the ankle joint are broken). The H&P further indicated that Patient 4 had right ankle pain with each movement. During a review of Patient 4’s medical record (MR) titled, “Pain Assessment,” dated 10/16/2024, the MR indicated, on 10/16/2024 at 9:00 a.m. Patient 4’s pain level was documented as 6 out of 10 (6/10) using the numeric pain scale, a tool used to rate patients’ pain on a scale from 0 to 10 (0-no pain, 1-3 - mild pain, 4-6 - moderate pain, 7-10 - severe pain). The record also indicated that there was no documentation of the assessment of Patient 4’s acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided. During a review of Patient 4’s Medication Administration Record (MAR), dated 10/16/2024, the MAR indicated, Patient 4 had an order for Norco 5-325 milligrams (mg, measuring unit) (Norco 5-325 mg is a prescription pain medication that combines two active ingredients: Hydrocodone Bitartrate [5 mg, an opioid pain reliever that helps to reduce moderate to severe pain by acting on specific receptors in the brain and spinal cord] and Acetaminophen [325 mg, a non-opioid pain reliever that enhances the pain-relieving effects of hydrocodone]). The MAR indicated, Norco 5-325 mg can be administered every 4 hours as needed for moderate (4-6) or severe (7-10) pain. The MAR also indicated that on 10/16/2024 Patient 4 was given 1 tablet (tab) Norco 5-325 at 12:29 p.m. During a review of Patient 4’s medical record (MR), titled “Pain Assessment,” dated 10/16/2024, the MR indicated that on 10/16/2024 at 1:00 p.m., Patient 4’s pain level was recorded as 4 out of 10 (4/10). The assessment was incomplete, as it lacked documentation of Patient 4’s acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided. During a concurrent interview and record review on 10/17/2024 at 11:56 a.m. with the Assistant Clinical Director (ACD), after reviewing Patient 4’s MR titled, “Pain Assessment,” dated 10/16/2024 at 9:00 a.m., and Patient 4’s Medication Administration Record (MAR), dated 10/16/2024, the ACD stated that, based on the reviewed records, no pain medication was provided to the patient (Patient 4) when Patient 4 reported a pain level of 6/10 on 10/16/2024 at 9:00 a.m. The ACD further said that the administration of 1 tablet of Norco 5-325 mg, recorded in the MAR on 10/16/2024 at 12:29 p.m., was likely in response to the pain level of 6/10 reported earlier that day at 9:00 a.m. The ACD also said that the pain assessment recorded on 10/16/2024 at 1:00 p.m. must have been a re-assessment following the administration of Norco 5-325 mg at 12:29 p.m. During an interview on 10/17/2024 at 11:56 a.m. with the Assistant Clinical Director (ACD), the ACD stated that nurses should document a complete pain assessment in the patient’s medical records, including pain location, the patient’s pain goal, and the intervention provided. The ACD said that pain should be promptly addressed when patients report it, and reassessment should be conducted within sixty (60) minutes after administering any pain medication to ensure the intervention was effective, in accordance with the facility’s policy and procedure. During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” dated 3/2022, the P&P indicated that patients are to be screened, assessed, and re-assessed for pain using a comprehensive pain assessment based on the patient’s condition, age, and ability to understand during their Emergency Department visit. Ongoing pain management includes the assessment and re-assessment of all patients with pain, addressing pain intensity, quality, location, precipitating factors, and responses to interventions. The patient’s subjective report of pain is sufficient to initiate treatment, and patients will be re-assessed for their response to pain through evaluation and documentation of the response to pain intervention, including pain medication administration. Reassessment should be conducted within 60 minutes of administering pain medication. Patients have the right to be believed when they report pain, to be treated for pain, and to receive timely treatment. 2. During a review of Patient 6’s “Patient Care Time,” dated 9/9/2024, the Patient Care Timeline indicated the following: Patient 6 arrived at the Emergency Department (provides immediate care to patients with conditions that require urgent attention) at 5:34 a.m., for complaints of a fever (elevated body temperature). Patient 6’s temperature was 101 degrees Fahrenheit (F, [38.3 degrees Celsius] over 100.4 degrees F indicates a fever). During a review of Patient 6’s “ED (Emergency Department) Provider Notes,” dated 9/9/2024 at 7:57 a.m., the ED Provider Notes indicated the following: Patient (6) presents with fever. During a review of Patient 6’s “Vital Signs (temperature, blood pressure, pulse, respiratory rate),” dated 9/9/202, the Vital Signs indicated the following: At 5:43 a.m., Patient 6’s temperature was 101 degrees F. At 10 a.m., Patient 6’s temperature was 98.6 degrees F (normal). At 1:40 p.m., Patient 6’s temperature was 99.6 degrees F (normal). During a review of Patient 6’s “Physician’s Order,” dated 9/9/2024 at 7:07 a.m., the order indicated to give acetaminophen 1000 milligrams (mg - weight unit of measurement) IV (in the vein), one time. During a review of Patient 6’s “Medication Administration Record (MAR),” dated 9/9/2024, the MAR indicated Patient 6 received acetaminophen 1000 mg IV at 7:36 a.m. During a concurrent interview and record review on 10/15/2024 at 10:22 a.m. with the Associate Clinical Director (ACD) 2, the ACD 2 stated the following: Patient 6 arrived at the Emergency Department on 9/9/2024 at 5:46 a.m., for a fever and feeling dehydrated (loss of body fluids). Patient 6’s temperature was 101 degrees F (high, fever) at 5:43 a.m. Patient 6 received acetaminophen 1000 mg for fever at 7:36 a.m. Patient 6’s temperature was not re-assessed between 30 to 60 minutes after giving acetaminophen. Patient 6’s temperature should have been re-assessed to determine the medication’s effectiveness. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Initial Assessment and Re-assessment Documentation Guidelines,” dated 8/23/2024, the P&P indicated the following: “Re-assessments are performed to evaluate the effectiveness of health care interventions.” 3. During a review of Patient 7’s “Flow sheet (a structured and organized method for documenting aspects of patient care),” dated 10/15/2024 at 12:13 p.m., the Flowsheet indicated Patient 7 had pain to the left ear rated at a 10 out of 10 (10, highest level of pain). No further pain assessments /reassessments were documented on the Flowsheet. During a review of Patient 7’s “ED (Emergency Department) Notes,” dated 10/15/2024 at 1:13 p.m., the ED Notes indicated the following: Patient 7 “ ...presents with left ear pain for one day ...crying 200/10 pain (pain scale 0 - 10, 0 indicates no pain, 10 indicated worst pain).” During a review of Patient 7’s, “Medication Detail,” dated 10/15/2024 at 1:13 p.m., indicated to give Acetaminophen oral solution (Tylenol) 293.8 milligrams (mg - weight unit of measurement), one time by mouth. During a review of Patient 7’s, “Medication Detail,” dated 10/15/2024 at 1:15 p.m., indicated to give ibuprofen oral suspension 196 mg, one time, by mouth. During a review of Patient 7’s “Medication Administration Record (MAR),” dated 10/15/2024, the MAR indicated Patient 7 received acetaminophen 293.8 mg and ibuprofen 196 mg on 10/15/2024 at 1:26 p.m. During a review of Patient 7’s “Patient Care Time,” dated 10/15/2024, the Patient Care Timeline indicated at 1:30 p.m., Patient 7 was discharged home “ ... At 1:31 p.m., Patient discharge instructions provided to the parents, verbalized understanding ...” During a concurrent interview and record review on 10/15/2024 at 10 a.m. with the Associate Clinical Director (ACD) 2, the ACD 2 stated the following: Patient 7 arrived at the Emergency Department for ear pain at 11:48 a.m. Patient 7’s pain level was rated at a 10/10 (worst pain) at 12:13 p.m. Patient 7 received acetaminophen 293.8 mg and ibuprofen 196 mg at 1:26 p.m., for ear pain. Patient 7’s pain level should have been re-assessed between 30 to 60 minutes after administering the medication to evaluate for effectiveness. Patient 7 was discharged at 1:31 p.m. without having pain re-assessment. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Initial Assessment and Re-assessment Documentation Guidelines,” dated 8/23/2024, the P&P indicated the following: “Reassessment of pain will be completed and documented between 30 and 60 minutes of medication administration ...” 4. During a review of Patient 20’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/14/2024, the H&P indicated Patient 20 was admitted to the facility with a diagnosis of acute respiratory failure (results from inadequate gas exchange by the respiratory system). Patient 20’s medical history included Hypertension (high blood pressure [BP]). 4.a. During a concurrent interview and record review on 10/17/2024 at 11:45 a.m. with Charge Nurse 4 (CN 4), Patient 20’s physician’s order, dated 10/14/2024, indicated, “Notify physician for Systolic Blood Pressure (the pressure in arteries when the heart contracts and pumps blood out) greater than 180 or less than 90 and Diastolic Blood Pressure (the pressure in arteries when the heart is at rest between heart beats) greater than 120.” During the same interview and record review on 10/17/2024 at 11:45 a.m., CN 4 stated Patient 20’s “Vital Signs Documentation Flowsheet” indicated Patient 20’s BP on 10/16/2024 at 7:27 a.m. was 191/90 mmHg (millimeters of mercury, a unit of measurement). CN 4 verified Patient 20’s record did not have documentation that Patient 20’s BP of 191/90 was addressed/treated, nor the physician was notified. Furthermore, on 10/17/2024 at 11:45 a.m., CN 4 stated that the importance of assessing the BP was to make sure the patient’s BP was under control to avoid the patient suffering from a stroke (loss of blood flow to a part of the brain) or heart attack (when the heart stops beating). CN 4 stated Patient 20’s BP of 191/90 should have been reported to the physician as ordered During a review of the facility’s policy and procedure (P&P) titled, “Standard of Care,” revised in 10/18/ 2021, the P&P indicated, “Within two hours of beginning the shift, the nurse should: Review the doctor’s orders ...The nurse will communicate to physician when the doctor is needed to come to the floor to assess a patient. Physician will be notified of changes in condition, abnormal lab results, abnormal findings or for clarification of the medical plan of care.” 4.b. During a concurrent interview and record review on 10/17/2024 at 9:50 a.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN verified Patient 20’s “Vital Signs Documentation Flowsheet,” indicated on the following dates and times: - On 10/16/2024 at 4:00 a.m., Patient 20’s VS was not checked. - On 10/16/2024 at 11:00 p.m., Patient 20’s VS was not checked. During a concurrent interview and record review on 10/17/2024 at 10:58 a.m. with Charge Nurse 4 (CN 4), CN 4 stated the patient’s VS in the Step-Down Unit (provides an intermediate level an intermediate level of care between an intensive care unit and general medical surgical ward) were checked every 4 hours. CN 4 stated the Registered Nurse (RN) was responsible in taking the patient’s VS. During the same interview and record review on 10/17/2024 at 10:58 a.m., CN 4 stated it was important for the patient’s VS to be checked for accurate record of the patient status and to provide interventions if needed. CN 4 stated Patient 20’s VS was not taken every 4 hours per the facility’s policy and procedure (P&P). During a review of the facility’s policy and procedure (P&P) titled, “Standard of Care,” revised on 10/18/ 2021, the P&P indicated, “Vital signs must be taken every four hours or as ordered.” During a review of the facility’s policy and procedure (P&P) titled, “Vital Signs Routine,” revised on 10/18/ 2021, the P&P indicated, “Temperature, pulse, blood pressure, and respiration are to be taken every 4 hours for patients who have a cardiac monitoring (continuous monitoring of the heart activity) order ...””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50521 Based on observation, interview and record review, the facility failed to ensure for three of 30 sampled patients (Patients 12, 17, and 19), Patients 12, 17, and 19’s individualized nursing care plan (provides a means of communication among health care providers) was initiated in accordance with the facility’s policy and procedure regarding developing and implementing care plans. . This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 12, 17, and 19’s needs and risks. Findings: 1. During a review of Patient 12’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/6/2024, the H&P indicated Patient 12 was admitted to the facility for facial asymmetry (occurs when the features on one side of the face does not reflect the other side in size, shape or position). The H&P further indicated, Patient 12’s active hospital problem list included Stroke (a critical condition caused by lack of oxygen to the brain by a clot or bursts that causes permanent damage or death). During a concurrent observation and interview on 10/15/2024 at 12:52 p.m. with Registered Nurse 3 (RN 3), Patient 12 was observed lying in bed with a percutaneous endoscopic gastrotomy (PEG, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). Patient 12 was receiving enteral tube feeding (method of delivering nutrients and fluids into the stomach to support a person’s nutritional needs) at 55 milliliter per hour (ml/hr) via PEG. During a concurrent interview and record review on 10/15/2024 at 12:55 p.m. with Registered Nurse 3 (RN 3), RN 3 stated Patient 12’s record indicated the patient (Patient 12) had difficulty of swallowing and poor oral intake (not consuming enough food or drinks to meet physiological needs) on 10/8/2024, and a nasogastric tube (a thin, flexible tube inserted through the nose and into the stomach to deliver food or fluids for people with swallowing problems) was inserted. RN 3 stated on 10/14/2024, Patient 12’s PEG was inserted. During the same interview and record review on 10/15/2024 at 12:55 p.m., RN 3 verified Patient 12’s “care plan (provides a means of communication among health care providers)” did not include a care plan that addressed Patient 12’s enteral tube feeding nutrition that started on 10/8/2024. RN 3 stated the nurses were responsible in developing a personalized care plan that meets the patient’s needs. During a concurrent interview and record review on 10/16/2024 at 10:26 a.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN verified Patient 12 had a care plan for enteral nutrition and it was developed on 10/15/2024 at 5:51 p.m. (7 days after Patient 12’s enteral tube feeding started). During a review of the facility’s policy and procedure (P&P) titled, “Patient Assessment and Re-assessment and Plan of Care,” revised in 10/2022, the P&P indicated, “All patients admitted to the facility will receive a complete initial assessment and reassessments by a qualified staff or licensed independent practitioners to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient ...the patient’s plan of care/treatment/services will be based on needs identified by the patient’s assessment, reassessment and results of diagnostic testing. The plan and goals for care, treatment and services will be revised based on patient’s needs, patient goals, timeframes, settings, and services required to meet those goals.” During a review of the facility’s policy and procedure (P&P) titled, “Regional Care Plan Guideline,” dated 8/19/21, the P&P indicated, “Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission ...A template includes problems, associated goals, potential interventions, documentation rows/individualization opportunities, and Care Plan Guide (CPGs) as applicable ...Include templates for problems actively treated during the hospitalization.” 2. During a review of Patient 17’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/24/2024, the H&P indicated Patient 17 was admitted to the facility with a chief complaint of vomiting. The H&P further indicated Patient 17 had a medical history of AML (Acute Myeloid Leukemia, a type of cancer that affects the blood and bone marrow [a soft, spongy tissue in the center of most bones]). During a concurrent observation, interview, and record review on 10/15/2024 at 2:39 p.m. with Registered Nurse (RN) 4, Patient 17’s room door was observed to have a neutropenic precaution (precautions for a condition characterized by low white blood cell count to avoid infections) signage that indicated “please wear a face mask, strict hand hygiene, no fresh-cut flowers or plants.” RN 4 stated patient was on neutropenic precautions due to Acute Myeloid Leukemia medication. During the same interview and record review on 10/15/2024 at 2:39 p.m., RN 4 stated Patient 17’s “Care Plan” did not include a plan that addresses the patient’s neutropenic condition. RN 4 stated Patient 17 should have a care plan for nursing guidance on how to protect Patient 17 from getting an infection. During a concurrent interview and record review on 10/16/2024 at 3:20 p.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN verified Patient 17 had an order on 9/24/2024 for “Implement Neutropenic Isolation Precautions.” The QCRN verified Patient 17 had a neutropenic precautions care plan that was developed on 10/16/2024 at 3:01 p.m. (22 days after Patient 17’s admission and neutropenic precaution was in place). During a review of the facility’s policy and procedure (P&P) titled, “Patient Assessment and Re-assessment and Plan of Care,” revised in 10/2022, the P&P indicated, “All patients admitted to the facility will receive a complete initial assessment and reassessments by a qualified staff or licensed independent practitioners to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient ...the patient’s plan of care/treatment/services will be based on needs identified by the patient’s assessment, reassessment and results of diagnostic testing. The plan and goals for care, treatment and services will be revised based on patient’s needs, patient goals, timeframes, settings, and services required to meet those goals.” During a review of the facility’s policy and procedure (P&P) titled, “Regional Care Plan Guideline,” dated 8/19/21, the P&P indicated, “Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission ...A template includes problems, associated goals, potential interventions, documentation rows/individualization opportunities, and Care Plan Guide (CPGs) as applicable ...Include templates for problems actively treated during the hospitalization.” 3. During a review of Patient 19’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/12/2024, the H&P indicated Patient 19 was admitted to the facility for weakness. The H&P further indicated, Patient 19’s active hospital problem list included Urinary tract infection (UTI, an infection in the bladder [a muscular, hollow organ that stores urine]/urinary tract [the body’s drainage system for removing urine). During a concurrent interview and record review on 10/15/2024 at 2:53 p.m., RN 5 verified Patient 19’s “Care Plan” did not include a plan that addresses Patient 19’s UTI. RN 5 stated the patient’s care plan for UTI was important to know the plan and interventions for nursing care guidance. During a concurrent interview and record review on 10/16/2024 at 3:33 p.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN stated the development of the patient’s care plan was part of the admission process. The QCRN stated Patient 19 had a care plan on UTI that was developed on 10/15/2024 at 2:57 p.m. (3 days after Patient 19 was admitted for UTI). During a review of the facility’s policy and procedure (P&P) titled, “Patient Assessment and Re-assessment and Plan of Care,” revised in 10/2022, the P&P indicated, “All patients admitted to the facility will receive a complete initial assessment and reassessments by a qualified staff or licensed independent practitioners to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient ...the patient’s plan of care/treatment/services will be based on needs identified by the patient’s assessment, reassessment and results of diagnostic testing. The plan and goals for care, treatment and services will be revised based on patient’s needs, patient goals, timeframes, settings, and services required to meet those goals.” During a review of the facility’s policy and procedure (P&P) titled, “Regional Care Plan Guideline,” dated 8/19/21, the P&P indicated, “Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission ...A template includes problems, associated goals, potential interventions, documentation rows/individualization opportunities, and Care Plan Guide (CPGs) as applicable ...Include templates for problems actively treated during the hospitalization.””

“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: 36206 Based on interview and record review, the facility failed to: 1. Validate one of 5 registered nurses (RN 8) annual skills competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and education. This deficient practice had the potential for RN 8 to be carrying out nursing duties in which RN 8 may not be competent of performing, thus placing patients at risk for harm. 2. Provide a unit orientation for one of five sampled RNs (RN 9) prior to working in the Intensive Care Unit (provides critical care and life support to patients who are very ill). This deficient practice had the potential for RN 9 to be unfamiliar with the unit process, locations of medical supplies, etc. And, therefore, placing patients at risk for harm. Findings: 1. During a concurrent interview and personnel file review on 10/17/2024 at 2:48 p.m. with the Director of Operations (DOP), Department Administrator (DA), Program Manager for Human Resources (PMHR), Clinical Director of Education (CDED), and the Staff Educator (SED), the DOP, DA, PMHR, CDED, and SED stated the following: Registered Nurse (RN 8)’s Competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and Education Summary dated 10/3/2024 was missing a validator’s signature. The validator should have signed the competency to validate that RN 8 was proficient in her (RN 8) nursing duties. The PMHR stated the facility did not have policy indicating that a validator’s signature was required for the annual competencies validation, however, it was part of the Human Resources Department process to check and ensure the validator’s signatures were present on the documents. During a review of RN 8’s personnel file, the personnel file indicated the following: RN 8 was hired on 2/18/2024. RN 8’s “2023 Annual Mandatory Competency and Education Validation Summary in Emergency Department,” dated 10/3/2024, indicated competencies required to work in the Emergency Department. Competencies included knowledge of medical equipment, skills demonstration ...safe patient handling ...care of a behavior health patient, care of a stroke patient, care of sepsis patient ... RN 8’s and a validators initials were documented on 11/8/2028. The page titled “Validator,” was blank. It did not contain the name, signature, initials of the validator, or the date validation. 2. During a concurrent interview and personnel file review on 10/17/2024 at 3:02 p.m., with the Director of Operations (DOP) and the Department Administrator (DA), the DOP and DA reviewed RN 9’s file and stated the following: RN 9 worked in the Intensive Care Unit (provides critical care and life support to patients who are very ill) from 11/1/2023 to 2/3/2024. RN 9 was “contingent,” or working under a contract. The DA stated that contracted nurses should receive an orientation to the unit the nurse was assigned to. The orientation should be done before the nurse works on the unit, on her own or solo. The DA stated she (DA) could not locate evidence in RN 9’s personnel file, that RN 9 received an orientation to the ICU prior to working by herself on the unit. The unit orientation consists of a tour, location of medical equipment, supplies, hospital processes (nursing practice, patient safety, policies and procedures, skills validation (a process that ensures nurses have the knowledge and skills to perform their tasks), and charting frequency. The DA stated that the unit orientation was necessary to orient new nurses on hospital process, patient safety, etc. During a review of RN 9’s Personnel file, RN 9’s personnel file indicated the following: RN 9 was a contracted (not a permanent employee, an individual hired by a company to complete a specific project or assignment for a defined period) staff. There was no documentation that an orientation to ICU was provided by the facility. During a review of the facility’s policies and procedure (P&P) titled, “Orientation of New Employees (Medical Center Orientation and Department),” dated 8/23/2024, the P&P indicated the following: “The organization provides an individual who is new to the organization ...with an orientation of sufficient scope and duration to inform the individual about the organization’s promise, mission, goals ... patient safety and other pertinent topics.””

“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: 46238 Based on observation, interview and record review, the facility failed to adhere to the facility’s policies and procedures when: 1.The facility failed to ensure that for two of 30 sampled patients (Patient 3 and Patient 4), a call light (a system device used by the patient to call for help) was provided to Patient 3 and Patient 4. This deficient practice had the potential for Patients 3 and 4’s needs to not be met since both patients (Patient 3 and Patient 4) were unable to call for help with no nurse call system provided, which may result in a significant safety risk, as patients may be unable to promptly alert staff in emergencies, leading to delays in receiving necessary care and worsening of their conditions. 2. The facility failed to ensure that for one of 30 sampled patients (Patient 4), a complete pain assessment was conducted and documented in accordance with the facility’s policy and procedure regarding nursing pain assessment and management. This deficient practice had the potential to result in delayed provision of appropriate pain management strategies for Patient 4, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain. 3. The facility failed to ensure one of 30 sampled patient’s (Patient 8) pain level was assessed upon arrival to the Emergency Department (provides immediate care to patients with conditions that require urgent attention), when Patient 8’s vital signs (includes temperature, heart rate, respiratory rate, blood pressure, and pain level) was assessed, in accordance with the facility’s policy and procedure regarding initial pain assessment. This deficient practice resulted in an incomplete nursing assessment and had the potential to affect Patient 8’s treatment plan and Patient 8’s pain not to be addressed, which can lead to prolonged discomfort and worsening of pain. 4. The facility failed to ensure for one of 30 sampled patients (Patient 17), Patient 17’s neutropenic precautions (precautions for a condition characterized by low white blood cell count to avoid infections) were followed, in accordance with the facility’s policy and procedure regarding neutropenic precautions when, two of Patient 17’s family member did not wear a mask while inside the patient’s room. This deficient practice had the potential for Patient 17 to be exposed from infection that may worsen Patient 17’s health condition, including prolonged hospitalization, and/or death. Findings: 1.a. During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, Patient 3 had past medical history of hypertension (HTN, when the pressure in your blood vessels is too high [140/90 mmHg or higher]) and dementia (a range of neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes with daily life) and was diagnosed with altered mental status (AMS, a significant change from a person’s baseline level of consciousness, awareness, cognitive function (anything related to thinking, learning and understanding), and behavior). During a concurrent observation and interview on 10/15/2024 at 12:48 p.m. with the Assistant Clinical Director (ACD) in the Emergency Department (ED, a hospital area that provides immediate care to patients with urgent conditions), Patient 3 was observed in the patient’s room. Patient 3’s monitor was alarming (an automatic warning that sounds when a patient’s vital signs, such as heart rate, blood pressure, or oxygen levels, fall or rise outside of a healthy range), and a family member (FM) was standing at the bedside. The FM stated that the monitor had been alarming for some time and that they wanted to notify the nurse. The ACD confirmed that all patient rooms should have a call light available to call for help when needed, but there was no call light observed attached to the wall in Patient 3’s room. During an interview on 10/15/2024 at 12:50 p.m., the Assistant Clinical Director (ACD) stated that the facility admits many psychiatric (patients with mental, emotional, and behavioral disorders) patients throughout the day, and the rooms are often stripped of equipment, such as call light cords, that may pose a safety risk for psychiatric patients. The ACD explained that Patient 3’s room was likely used for a psychiatric patient previously, and the staff must have forgotten to return the call light when Patient 3 was admitted. The ACD further stated that the call light should have been provided for Patient 3 upon admission, but the ED staff likely forgot. During a review of the facility’s policy and procedure (P&P) titled, “Activities of Daily Living,” dated 8/19/2021, the P&P indicated that to ensure a safe environment for patients, visitors, and employees, each patient must have a properly functioning and easily accessible nurse call system. 1.b. During a review of Patient 3’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, on 10/15/2024, Patient 4 was transferred from outside facility to the facility’s Emergency Department for further evaluation and treatment of right ankle fracture (one or more of the bones that make up the ankle joint are broken). During a concurrent observation and interview on 10/15/2024 at 12:55 p.m. with the Assistant Clinical Director (ACD) in the Emergency Department (ED), Patient 4 was observed sleeping in their (Patient 4’s room) room. There was no call light attached to the wall and placed within Patient 4’s reach. The ACD confirmed that Patient 4’s room had no call light available for the patient to use to call for help if needed and stated that the ED staff should have provided the call light system when Patient 4 was admitted to the room. During a review of the facility’s policy and procedure (P&P) titled, “Activities of Daily Living,” dated 8/19/2021, the P&P indicated that to ensure a safe environment for patients, visitors, and employees, each patient must have a properly functioning and easily accessible nurse call system. 2. During a review of Patient 4’s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, on 10/15/2024, Patient 4 was transferred from outside facility to the facility’s Emergency Department for further evaluation and treatment of right ankle fracture (one or more of the bones that make up the ankle joint are broken). The H&P further indicated that Patient 4 had right ankle pain with each movement. During a review of Patient 4’s medical record (MR) titled, “Pain Assessment,” dated 10/15/2024 and 10/16/2024, the MR indicated the following: On 10/15/2024 at 4:00 p.m., Patient 4’s pain level was documented as 2 out of 10 (2/10) using the numeric pain scale, a tool used to rate patients’ pain on a scale from 0 to 10 (0-no pain, 1-3 - mild pain, 4-6 - moderate pain, 7-10 - severe pain). The record also indicated that the patient’s (Patient 4) acceptable pain level was documented as 2, but there was no documentation of the pain’s location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided. On 10/16/2024 at 9:00 a.m., Patient 4’s pain level was recorded as 6 out of 10. The record also indicated that there was no documentation of the assessment of Patient 4’s acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided. On 10/16/2024 at 1:00 p.m., Patient 4’s pain level was recorded as 4 out of 10 (4/10). The record also indicated that there was no documentation of the assessment of Patient 4’s acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided. On 10/16/2024 at 5:00 p.m., Patient 4’s pain level was recorded as 3 out of 10 (3/10). The record also indicated that there was no documentation of the assessment of Patient 4’s acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided. During an interview on 10/17/2024 at 11:56 a.m. with the Assistant Clinical Director (ACD) in the Emergency Department (ED), after reviewing Patient 4’s medical record (MR) titled, “Pain Assessment,” dated 10/15/2024 and 10/16/2024, the ACD stated that the patient’s (Patient 4) acceptable pain level, pain location, and the patient’s pain goal should have been documented. The ACD further stated that nurses should have completed a thorough pain assessment, as a complete assessment is essential for determining the appropriate intervention. During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” dated 3/2022, the P&P indicated that patients are to be screened, assessed, and re-assessed for pain utilizing a comprehensive pain assessment based on the patient’s condition, age, and ability to understand during their Emergency Department visit. Ongoing pain management includes the assessment and re-assessment of all patients with pain, addressing pain intensity, quality, location, precipitating factors, and responses to interventions. 3. During a review of Patient 8’s “Patient Care Timeline,” dated 10/9/2024, the Patient Care Timeline indicated the following: On 10/9/2024 at 7:39 p.m., Patient 8 arrived at the Emergency Department for seizures (a sudden, uncontrolled burse of electrical activity in the brain). At 7:52 p.m., Patient 8’s Vital Signs (temperature, blood pressure, pulse, Respiratory Rate) were as follows: Temperature 97.6 (normal), pulse: 115 (high, normal range is 60-100 beats per minute), blood pressure: 225/151 (high, normal range is 20/90), Respiratory Rate: 26 (high, normal range is 12-20 breaths per minute), Oxygen saturation (measures the amount of oxygen in the blood): 99 % (normal) on Room air. Patient 8’s pain level was not documented. At 9:17 p.m., Patient 8’s pain level was assessed at 3 (indicated mild discomfort) on a FLACC (Face, Legs, Activity, Cry, Consolability- a behavior scale for scoring pain, used on non-verbal patients) scale. During a concurrent interview and record review on 10/16/2024 at 1:15 p.m. with the Associate Clinical Director (ACD) 2, the ACD 2 reviewed Patient 8’s “Patient Care Timeline, dated 10/9/2024, and stated the following: Patient 8 arrived at the Emergency Department at 7:39 p.m., for seizures. Patient 8’s pain level was not assessed initially at 7:52 p.m., when Patient 8’s vital signs were checked. Patient 8 was unresponsive (not reacting normally to touch, sound, or other stimulation) upon arriving at the ED. Nursing staff could have assessed the pain level by using a FLACC scale for Patient 8. All patients should be assessed for pain upon arrival to the Emergency Department (ED) to ensure a complete assessment of patients. During a review of the facility’s policies and procedures (P&P) titled, “Nursing Initial Assessment and Re-Assessment Documentation Guidelines,” dated 8/23/2024. The P&P indicated the following. Initial pain assessment should include: the Pain Scale Type used as appropriate to the patient’s status and developmental age ...” 4. During a record review of Patient 17’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/24/2024, the H&P indicated Patient 17 was admitted to the facility with a chief complaint of vomiting. The H&P further indicated Patient 17 had a medical history of Acute Myeloid Leukemia (AML, a type of cancer that affects the blood and bone marrow). During a concurrent observation and interview on 10/15/2024 at 2:39 p.m. with Registered Nurse (RN) 4, Patient 17’s room door was observed to have a neutropenic precautions signage that indicated, “please wear a face mask, strict hand hygiene, no fresh-cut flowers or plants.” RN 4 stated patient (Patient 17) was on neutropenic precautions (precautions for a condition characterized by low white blood cell count to avoid infections) due to immunocompromised (a condition in which the immune system ability to fight infectious disease is compromised) condition due to AML medication. RN 4 verified that Patient 17’s two family members (FM 1 and FM 2), who were inside Patient 17’s room, were not wearing a face mask. During the same interview on 10/15/2024 at 2:39 p.m., RN 4 stated there was no documented evidence Patient 17’s family members were given education regarding the patient’s neutropenic precaution. RN 4 stated it was important to follow the neutropenic precaution like the wearing of face mask in Patient 17’s room to prevent the patient from getting an infection. During an interview on 10/16/2024 at 3:02 p.m. with Patient 17’s family members (FM 1 and FM 2), FM 1 stated she (FM 1) spends the entire day with Patient 17 at the bedside and she was not sure of the neutropenic precaution measures, its risk and consequences. FM 2 stated, he (FM 2) was not aware of the risk of not wearing the mask when with Patient 17. During a review of the facility’s policy and procedure (P&P) titled, “Neutropenic Precautions,” revised on 8/19/2021, the P&P indicated, “Strict adherence to infection prevention and control is important due to patients with compromised immunological systems resulting in neutropenia. When a patient’s absolute neutrophil count (ANC) falls below 500 or the WBC falls below 1,000, the patient will be placed on Neutropenic Precautions ...Patients and families will be instructed about neutropenic precautions by nursing staff upon implementation and will reinforce as necessary. Patient/family teaching will include instruction on good hand hygiene guidelines and prophylactic oral hygiene.””