Providence Mission Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital’s P&P for Assessment/Reassessment of Patients, Code Blue/Code White Response and Documentation, and Standards of Nursing Practice for two of three sampled patients (Patients 1 and 3) as evidenced by: 1. For Patient 1, the hospital failed to document cardiac rhythms/waveforms during the Rapid Response on 1/26/26 and the Code Blue event on 2/5/26, contrary to the hospital ‘s P&P for emergency response documentation. 2. For Patient 3, the hospital failed to accurate and complete documentation of the packed red blood cell (PRBC) transfusion volume, resulting in incomplete documentation of blood product administration. These failures resulted in incomplete and inaccurate clinical documentation which compromised the hospital’s ability to ensure appropriate monitoring and safe patient care. Findings: During a review of the hospital’s P&P titled “Standards of Nursing Practice,” dated 1/202, the P&P showed all nursing care shall be documented according to the hospital’s standard and designated method of documentation. This may include but not limited to the care team notes, flowsheets and or computerized documented. 1. During a review of the hospital’s P&P titled Assessment/Re-assessment of Patients dated 2/2025, the P&P showed for Critical Care Units: Cardiac Intensive Care Unit (CICU) Surgical Intensive Care Unit (SICU) ... Assessment and Documentation shall be completed per unit standard or level of care. Assessment and documentation will also include technology and continuous infusions of medications as appropriate. - Medications/infusions /blood transfusions ... - Pulse oximetry and capnography, ECG monitor-ECG rhythm and ectopy .... During a review of the hospital’s P&P titled “Code Blue /Code White Response and Location of Crash Carts,” dated 4/2026, the P&P showed: Documentation of all resuscitation interventions are placed in the Resuscitation Record. Medications ordered by the physician(s) are documented in the Resuscitation record ... Code Blue Team Roles and Responsibilities. * For Non-Critical Care Patient Care Units ... Response Team with ACLS Certification: - Rapid Response RN/Sepsis Backup or Trauma RN: Starts IV/IO and administer IV medications. Defibrillation/Cardioversion/Monitor rhythm Interpretation; Leader in the absence of a physician. - CICU Charge RN: Documentation of Code/ Obtains pertinent ECG strips; calls for CPR changes every 2 minutes .... * For CICU, SICU: response team with ACLS certification. - ICU Charge RN: takes crash cart to the room, documentation of Code/ obtains Pertinent ECG strips, calls for CPR changes every 2 minutes... - Rapid Response RN/Sepsis Backup or Trauma RN: Defibrillation/Cardioversion; monitor rhythm interpretation; IO start; leader in the absence of a physician. During a concurrent interview and medical record review on 5/14/26 at 0850 hours, with Risk Analyst RN 1 and 2, and Patient Safety Officer. The medical records showed Patient 1 was admitted to the hospital to Room A (mother-baby overflow for patients to be admitted) on 1/23/26 . During a review of the Nurse Practitioner notes of the Rapid Response for Patient 1 dated 1/26/26 at 0715 hours, the Nurse Practitioner notes showed Patient 1 had a significant event. A Rapid Response was called for suspected seizures followed by altered level of consciousness. During the event, Patient 1 was attached to a Zoll monitor and the cardiac rhythm showed rapid atrial fibrillation at a rate of 180 to 230 bmp. At 0758 hours, Patient 1’s condition was upgraded to ICU care and Patient 1 was transferred to SICU. At 0825 hours, an ECG was performed, the ECG results showed Patient 1 was having rapid atrial fibrillation. At 0850 hours the physician performed cardioversion that converted the heart rhythm to regular at a rate of 140 bpm. During a review of the Resuscitation Record, the Resuscitation Record showed Patient 1 had a respiratory arrest on 2/5/26 at 1825 hours. The Code was called on 2/5/26 at 1826 hours. Respiration was assisted by bag /mask valve. The Resuscitation Record showed at 1826 hours, the patient had palpable pulse; however, the documentation for the monitor rhythm was illegible or unreadable. At 1827 hours, the cardiac rhythm showed PEA. Patient 1 was intubated at 1833 hours; however, the respiratory rate documented had been 16 breaths per minute. The code blue ended at 1842 hours when the patient achieved ROSC. At 1844 hours, Patient 1’s monitor rhythm showed SVT rate of 183 bpm and Patient 1 received 150 joules of synchronized cardioversion. At 1845 hours, the code blue documentation showed the HR was 128 bpm with pulse and the monitor rhythm documented as ST. During a review of Patient 1’s record of the cardiac rhythm waveforms or EKG strips showed the Zoll monitor was powered on 2/5/26 at 1826 hours. At 1844 hours, rhythm of pre and post shock were recorded. And at 1858 hours, the cardiac rhythm waveform was recorded. During an interview on 5/18/26 at 1600 hours, with Risk Analyst RN 1, the Risk Analyst RN 1 stated there were no additional cardiac rhythm strips documented in the patient’s medical record for the Code Blue event on 2/5/26 at 1825 hours. During a telephone interview on 5/18/26 at 1327 hours, with the Manager of SICU/CICU, the Manager of SICU/CICU Manager stated the standard practice for ICU nurses documenting cardiac rhythm waveforms or strips. The Manager of SICU/CICU Manager stated that cardiac rhythm waveforms or strips were recorded at least once every shift and additionally when there were rhythm changes. The Manager of SICU/CICU stated the cardiac rhythm waveforms or strips should be printed from the actual Zoll printer and submitted with the resuscitation records to Medical Records. The SICU/CICU Manager stated the Medical Record was responsible for scanning all rhythm strips into the patient’s chart. The Manager of SICU/CICU stated the cardiac rhythm waveform strips were scanned after the patient was discharged and processed by Medical Record. 2. During a concurrent interview and medical record review on 5/16/26 at 0850 hours, with Risk Analyst RN 1 and 2, and Patient Safety Officer, the medical records showed Patient 3 was admitted to the hospital on 5/16/26. During a review of Patient 3’s Red Blood Cells (PRBC)-Crossmatch Order dated 5/17/26 at 0605 hours, the order question section documented “Units to crossmatch: 2.” During a review of the Single Transfusion record for Patient 3, the Single Transfusion record showed the PRBC transfusion was initiated on 5/17/26 at 0631 hours, and completed at 0900 hours. Administration Details documented initiation of a new PRBC bag at an infusion rate of 200 mL/hr at 0631 hours. The transfusion status was documented as completed at 0948 hours. The Single Transfusion Record documented a volume of 500 mL; however, the blood bank crossmatch record listed the PRBC unit volume as 300 mL for Unit # W180626716604-V. Additionally, the transfusion documentation state, “0 volume documented by night RN.” During an interview on 5/18/26 at 1533 hours, with Risk Analyst RN 1 and 2, and the Patient Safety Officer, the Risk Analyst RN 1 stated there was no documentation of the PRBC transfusion volume intake in the I/O flowsheet section. During an interview on 5/18/26 at 1533 hours with Risk Analyst RN 1, Risk Analyst RN 2, and the Patient Safety Officer, the above findings were shared with them.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure medication was administered as per the physician’s order for one of three sampled patients (Patient 1) . This failure posed an increased risk of poor health outcomes for the patient. Findings: During a concurrent interview and medical record review on 5/14/26 at 0850 hours, with Risk Analyst RN 1, Risk Analyst RN 2, and the Patient Safety Officer, Patient 1’s medical record showed Patient 1 was admitted to the hospital on 1/23/26. During a review of the physician’s order dated 2/1/26 at 1000 hours, the physician’s order showed to give valproate (medication used to treat and prevent seizures, also used as mood stabilizer for bipolar) 250 mg in 0.9% normal saline (mixture of water and salt or an intravenous solution) 50 ml IVPB, every 4 hours as needed for agitation. During a review of valproate medication administration details, the valproate medication administration details showed the medication was administered on 2/1/26 at 1429 hours. During an interview with Risk Analyst RN 1 on 5/14/26 at 0850 hours, Risk Analyst RN 1 was unable to show documentation that Patient 1 exhibited agitation behavior to support the administration of valproate for the indication of valproate administration. RN Analyst 1 could not show documentation the patient had agitation behavior for the administration of valproate. During a concurrent interview and review of the medical record on 5/14/26 at 1308 hours, with the Manager of SICU/CICU. The Manager of SICU/CICU stated the assessment for agitation was documented under RASS assessment. However, the RN’s RASS assessment for Patient 1 showed RASS score of 0 (alert and calm). The Manager of SICU/CICU stated she spoke to the RN about the RASS documentation for Patient 1 and the administration of valproate IVPB medication. The Manager of SICU/CICU stated the RN documented the RASS assessment incorrectly. During an interview on 5/14/26 at 1308 hours, with Risk Analyst 1 and 2 and Patient Safety Officer, the above findings were shared with them.”

“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: 35310 Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe environment for two of four sampled patients (Patients 1 and 2) as evidenced by: 1. For Patient 1, the nursing staff failed to perform pain assessment and reassessment as per the hospital’s P&P. The hospital’s P&P for pain management and the physician’s order for pain medication for Patient 1 were not consistent. There was no consistent documentation of meal intake for Patient 1. 2. For Patient 2, there was no documentation of education to patient/family member regarding virtual sitter as per the hospital’s P&P. These failures created the risk of substandard healthcare outcomes to the patients in the hospital. Findings: 1. During a concurrent interview and record review on 9/10/25 at 1034 hours, with the Patient Safety Officer, Patient 1’s medical record was reviewed. Patient 1’s closed medical record showed Patient 1 was admitted to the hospital on 7/29/25 and discharged on 8/1/25. Review of the physician’s order dated 7/29/25 at 1935 hours, showed an ED admit request for Patient 1. During a review of the physician’s order dated 7/29/25 at 2234 hours, the physician’s order showed to admit Patient 1 to the cardiac telemetry unit. a. Review of the hospital’s P&P titled Pain Management dated November 2024 showed patients admitted to an inpatient care setting shall receive an initial screen at the time of admission to identify the presence pain. If the screen is positive, then the patient shall receive an assessment to gather sufficient information to identify the pain. The information that may be obtained during this assessment includes, but is not limited to: - The intensity of pain using age or condition appropriate assessment tools - The location and nature of pain - The patient’s tolerance to pain and acceptable intensity of pain (pain goal) - The patient’s history of analgesic use or abuse - The patient’s respiratory risk factors During a review of the “Pain/Comfort/Sleep” dated 7/30/25 at 0140 hours, the “Pain/Comfort/Sleep” showed Patient 1 complained of pain with the pain level of three out of 10 (0 being no pain and 10 being the worst pain) to bilateral legs and lower back. Further review of Patient 1’s medical record failed to show Patient 1’s acceptable intensity of pain. b. Review of the hospital’s P&P titled Pain Management dated November 2024 showed if a treatment intervention for pain is provided, the response to that intervention should be assessed to include progress toward pain goal and side effects. Reassess the patient when drug approximately reaches peak effect: After at least 60 minutes for PO/IM/SQ/Rectal/Topical/Other Non-IV Route administration. During a review of the Pain/Comfort/Sleep dated 7/30/25 at 0426 hours, the Pain/Comfort/Sleep showed Patient 1 complained of pain with the pain level of seven out of 10 to bilateral legs and lower back. Review of the MAR showed on 7/30/25 at 0426 hours, Patient 1 received acetaminophen (a pain medication) 650 mg, PO. During a review of the Pain/Comfort/Sleep dated 7/30/25 at 0526 hours, the Pain/Comfort/Sleep showed Patient 1 was calm. Further review of Patient 1’s medical record failed to show Patient 1’s pain level progress toward the pain goal or side effects following the pain intervention. During an interview on 9/10/25 at 1034 hours, with the Patient Safety Officer, the Patient Safety Officer verified the above findings. c. Review the hospital’s P&P titled Pain Management dated November 2024, showed the Pain Management Upon Transfer from ER/Procedural Area/PACU section showing patient often presents with moderate-severe pain upon arrival to the floor despite receiving IV opioid in ER/PACU/procedure area. The goal of pain management upon patient’s arrival to the floor: - To maintain continuity of pain management from ER/Procedure area/PACU to the inpatient care area. For initial pain medication choice upon transfer, RN may choose IV opioid to provide more timely pain management if IV opioid was already administered in ER/procedure area/PACU. Review of the MAR showed on 7/29/25 at 1813 and 2136 hours, Patient 1 received hydromorphone (an opioid pain medication) 1 mg IV. Review of the MAR showed the following orders: * Acetaminophen tablet 650 mg every four hours PRN for pain, to be started on 7/29/25 at 2233 hours. * Hydrocodone-acetaminophen (Norco, an opioid pain medication) 5-325 mg per tablet, 1-2 tablets every four hours PRN, for moderate and severe pain, to be started at 7/29/25 at 2233 hours. * Hydromorphone injection 0.3 - 0.6 mg IV every two hours PRN, for moderate and severe pain, to be started on 7/29/25 at 2233 hours. The administration instructions for hydromorphone injection 0.3-0.6 mg was to give the medication if pain is not controlled with oral pain medications, or if not ordered, or if the oral route is not an option. During a concurrent interview and review of the hospital s P&P on 9/10/25 at 1034 hours, with the Patient Safety Officer, the Patient Safety Officer verified that the hospital’s P&P and the medication administration instructions were conflicting. d. Review of the Orders showed the following: * On 7/29/25 at 2331 hours, Patient 1 was on NPO. * On 7/31/25 at 0009 hours, Patient 1 was on a general diet. Review of the Flowsheets for Intake showed the following: * The Diet/Feeding Assistance section showed the tray was set up for Patient 1 on 7/30/25 at 2330 hours, 7/31/25 at 2030 hours, and 8/1/25 at 0900 hours. * The Percent Meals Eaten (%) section showed on 8/1/25 at 0900 hours, Patient 1 consumed 50% of the meal. Further review of Patient 1 ’ s medical record failed to show the percentage of the meal consumed by Patient 1 on 7/30/25 at 2330 hours and 7/31/25 at 2030 hours. During an interview on 9/10/25 at 1426 hours, with the Patient Safety Officer, the Patient Safety Officer stated there was no P&P for meal intake documentation. The Patient Safety Officer stated it was standard nursing practice to document how many percentages of meals the patient consumed. The Patient Safety Officer verified there was inconsistent meal intake documentation for Patient 1. 2. During a review of the hospital’s P&P titled, “TeleSitter: Continuous Visual Remote Patient Monitoring,” dated June 2023, the P&P indicated “...Nurse will provide patient/family education and facilitate introduction to the TeleSitter Tech.” During a tour of the unit on 9/10/25 at 1010 hours, with RN 1 in the presence of the Patient Safety Officer, the TeleSitter was observed in Patient 2’s room. The TeleSitter appeared as a tower with a camera, and Patient 2 was present in the room. During a concurrent interview and record review on 9/10/25 at 1400 hours, with the Patient Safety Officer, the medical record for Patient 2 was reviewed. Patient 2’s medical record showed the patient was admitted to the hospital on 9/4/25. Further review of Patient 2’s medical record failed to show documentation of patient/family education on TeleSitter Tech. The Patient Safety Officer verified the findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure nursing staff obtained order for the restraint for one of four sampled patients (Patient 3). This failure created a risk of unsafe care and poor clinical outcomes to the patient. Findings: Review of the hospital’s P&P titled Restraint for Non-Violent/ Non-Self-Destructive Behavior dated May 2022 showed restraints for non-violent, non-self-destructive behavior may include but are not limited to side rails x 4 when intended as restraint, i.e., used to prevent patient from voluntarily getting out of bed (two side rails are encouraged for patient safety). During a concurrent interview and record review on 9/11/25 at 1048 hours, with the Patient Safety Officer, the medical record for Patient 3 was reviewed. Patient 3’s medical record showed Patient 3 was admitted on 7/28/25 and discharged on 8/5/25. Review of the Flowsheets for the Functional Level Screening dated 7/31/25 at 0800 hours, showed Patient 3 required moderate assistance for mobility and transfers. Review of the physician’s order dated 7/31/25, showed to apply chest vest and the order expired on 8/1/25 at 1444 hours. During a review of the “Restraint Monitoring” flowsheets showed on 7/31/25 at 1445 hours, the restraint was started; and the restraint type was vest and side rails X 4. Further review of Patient 3’s medical record did not show the physician’s order for the use of side rails x 4. The Patient Safety Office verified the above findings.”

“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: 35310 Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 3) was monitored during the use of restraints as per the hospital’s P&P. This failure had the potential to result in unsafe care and adverse clinical outcomes for the patient. Findings: During a review of the hospital’s P&P titled Restraint for Non-Violent/Non-Self-Destructive Behavior dated May 2022, the P&P showed each episode of restraint will be documented in the patient’s medical record and will include the following elements: B. Individual patient reassessment by RN every two hours 1. Proper placement of restraints 2. LOC, orientation, behavior, response to restraint 3. Type of restraint with alternatives used 4. Skin and circulation assessment with ROM 5. Offer of nutrition/hydration, assistance with toileting/hygiene, comfort measures During a concurrent interview and record review on 9/11/25 at 1048 hours, with the Patient Safety Officer, the medical record for Patient 3 was reviewed. Patient 3’s medical record showed the patient was admitted on 7/28/25 and discharged on 8/5/25, was reviewed. Review of the physician’s order dated 7/31/25, showed to apply chest vest and the order expired on 8/1/25 at 1444 hours. During a review of the “Restraint Monitoring” flowsheets showed on 7/31/25 at 1445 hours, the restraints were started. Review of the Restraint Monitoring flowsheets dated 7/31/25 and 8/1/25, showed the restraint status and type, observed behavior, hydration, nutrition, elimination, ROM/repositioning, and signs of injury were assessed every two hours. Further review of Patient 3’s medical record failed to show the skin and circulation assessment as per the hospital’s P&P. The Patient Safety Officer verified the above findings.”

“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: 40483 Based on interview and record review, the hospital’s failed to ensure a safe and complete discharge process for one of four sampled patients (Patient 1). This had the potential to compromise the patient’s safety, and to result in inadequate continuity of care. Findings: Review of the hospital’s P&P titled Assessment/Re-assessment of Patients dated February 2025 showed its purpose is to comprehensively screen and document the initial assessment and reassessment of all patients admitted to the hospital. The reassessment provides ongoing data about the patient’s biophysical, psychological, spiritual and social needs. The section of Discharge Assessment showed prior to discharge identify any needs related to psychosocial, physical care, treatment and/or services needed after discharge in order to meet the patient’s needs for care services; a registered nurse is responsible for all discharge processes. Review of the hospital’s Registered Nurse Clinical Skills Checklist-Core showed the initial checklist is completed upon hire and as needed. The section of Discharge showed to provide education to the patient and family members prior to discharge using the teach-back method; validate patient understanding of discharge medications, including side effects and how to obtain medications upon discharge; and document patient personal belongings, including medications that are to be discharged with the patient. On 7/16/25, a review of Patient 1’s closed medical record was initiated. Patient 1’s medical record showed the patient was admitted to the hospital on 9/28/24 and discharged on 10/10/24. Review of the H&P examination dated 9/28/24 at 0506 hours, showed Patient 1 was admitted to the hospital for diverticulitis with contained perforation to receive IV antibiotics. Review of the Hospitalist Discharge Summary dated 10/10/24 at 1104 hours, showed Patient 1 was diagnosed with acute diverticulitis with contained perforation, and pericolonic abscess to the caecum. Patient 1 was discharged home. The patient’s discharge condition was stable. The diet was full liquid, advance diet gradually to soft. The Discharge Follow Up section showed to follow up with home infusion pharmacy. Review of the physician’s discharge order dated 10/10/24, showed to discharge Patient 1 after one dose of IV medication Invanz (antibiotic used to treat a variety of bacterial infections). The Discharge Disposition section showed home with home health. Review of Patient 1 Flowsheet dated 10/10/24, showed the last set of vitals were taken at 1635 hours. Review of Patient 1’s medical record did not show any documentation of the RN’s discharge note indicating the date or time the patient was safely discharged from the facility. There was no RN discharge note documenting that discharge education was provided to the patient regarding their medications, diet, follow-up medical appointments, or home health/home infusion pharmacy. There was no validation that the patient understood the discharge medication instructions, including side effects and how to obtain medications upon discharge. Additionally, there was no documentation showing that the patient had taken their personal belongings. On 7/17/25 at 0930 hours, an interview and concurrent record review was conducted with the Nurse Manager of 3 West MST/Oncology. The Nurse Manager of 3 West MST/Oncology verified the assessment and reassessment policy applied to Patient 1’s care and to the 3 West MST/Oncology. The Nurse Manager of 3 West MST/Oncology reviewed the Registered Nurse Clinical Skills Checklist-Core and stated it was the orientation training provided to the RNs including registry/agency RN’s (travel nurses). The Nurse Manager of 3 West MST/Oncology verified it applied to the RN providing care to the patients on 3 West MST/Oncology. The Nurse Manager of 3 West MST/Oncology reviewed Patient 1’s medical record and confirmed there was no RN discharge note indicating the date, time, or any discharge instructions regarding medication, diet, or follow-up care. The Nurse Manager of 3 West MST/Oncology verified that the nurse had received training on how to discharge patients and stated that it was the responsibility of the Registered Nurse to ensure a safe discharge by providing education on discharge medication, diet, and follow-up appointments. The Nurse Manager of 3 West MST/Oncology stated for a safe discharge, the RN was expected to provide education on discharge medication, diet, and follow-up appointments. Additionally, the RN was expected to take the patient’s vital signs before discharge to ensure the patient was stable for discharge. The Nurse Manager of 3 West MST/Oncology verified that Patient 1’s vital signs were taken at 1634 hours, but no additional vital signs were recorded closer to the discharge time from the system. The Nurse Manager 3 West MST/Oncology could not determine based on Patient 1’s medical record when or with whom the patient left the hospital but confirmed that Patient 1 was discharged from the hospital computer system on 10/10/24 at 1844 hours. The Nurse Manager 3 West MST/Oncology verified that neither the hospital’s assessment/reassessment policy nor the RN Clinical Skills Checklist Core training was followed by the discharging RN based on the documentation reviewed in Patient 1’s medical record. On 7/17/25, the Director of Risk Management, Regulatory & Patient Safety was made aware of these findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 38660 Based on observation, interview, and record review, the hospital failed to ensure the use of restraint for the management of non-violent or non-self-destructive behaviors was ordered by the physician for one of four sampled patients (Patient 2). This failure posed a risk of unnecessary restraint use and substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraint for Non-Violent Non-Self-Destructive Behavior dated April 2025 showed restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely. An episode of restraint is the period of time beginning with the application of restraint and ending with its release. Each episode requires the order of a physician/LIP/APC. Restrains may be used only when less restrictive interventions are ineffective and must be utilized, per the order of a physician/ LIP/APC. On 7/17/25 at 0950 hours, a tour of the 3 West unit was conducted with the Charge Nurse. Patient 2 was observed lying in bed, in a chest restraint. The Charge Nurse stated Patient 2 was confused, had tried to get out of bed, and pulled out an IV. Review of Patient 2’s medical record review was conducted with the Nurse Manager of 3 West MST/Oncology. Patient 2’s medical record showed Patient 2 was admitted to the hospital on 7/14/25 at 1705 hours. Review of the Restraint Flowsheets showed the chest restraint was applied to Patient 2 on 7/15/25 at 0130 hours. Review of the medical record showed the initial physician’s order for chest restraint to manage non-violent behavior was issued on 7/15/25 at 1713 hours. The Nurse Manager of 3 West MST/Oncology verified the findings and confirmed the physician’s order for restraint should be issued when the restraint was initiated for Patient 2.”

“PATIENT RIGHTS: REVIEW OF 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.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to formally process a grievance filed on behalf of one of eight sampled patients (Patient 1) as per the hospital’s P&P, increasing the risk of unresolved concerns for the complainant regarding patient safety and care. Findings: Review of the hospital’s P&P titled Complaints and Grievances, Patient dated December 2023 showed a patient grievance is a formal or informal, written or verbal, complaint that is made to the hospital by a patient or patient representative that cannot be resolved at the time of the complaint with the present caregiver, is referred to another caregiver for a later resolution, requires investigation, and/or further actions for resolution. Grievances will be entered into the Safety Event Reporting System. The designated department leader will be responsible for investigation and follow-up of the grievance. Risk management will compile the follow up information provided by the designated department leader to provide a written response to the grievance. The patient or the patient representative will receive verbal or written acknowledgement of receipt of the grievance and information regarding the process for investigating and responding to the grievance within five days of receipt. A written response is sent to the patient or patient representative within 30 calendar days of receipt of the grievance. In the event of ongoing dialogue to obtain necessary information or support a satisfactory resolution, the final response may be extended. The grievance is considered resolved when the patient is satisfied with the actions taken on their behalf. On 3/6/25 at 0910 hours, an interview and concurrent review of Patient 1’s medical record and the hospital’s documentation was conducted with the Director Risk Management, Regulatory & Patient Safety. The Director Risk Management, Regulatory & Patient Safety stated she was aware of Patient 1’s care and safety concerns brought to the attention by Patient 1’s family member. Review of the grievance tracking log failed to show Patient 1’s family member’s concerns were logged or processed according to the hospital’s grievance procedures. The Director Risk Management, Regulatory & Patient Safety stated the Director of Emergency Services, and Physician 1 immediately responded to the family member’s concern and communicated with the family member. The Director Risk Management, Regulatory & Patient Safety stated the Director of Emergency Services and Physician 1 also met with the family member and discussed the family member’s concerns and had continued discussions over the telephone. The Director Risk Management, Regulatory & Patient Safety stated Patient 1’s family member was not provided with a formal acknowledgement, extension, or resolution letters. On 3/7/25 at 1300 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety.”

“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: 35310 Based on interview and record review, the hospital failed to ensure the brochure of “If You Need Blood: A Patient’s Guide to Blood Transfusion” was provided to the patient prior to the blood transfusion for one of eight sampled patients (Patient 6). This failure created the risk of violating the patient’s rights. Findings: Review of the hospital’s P&P titled Blood Product Transfusion and Blood Warmer dated February 2025 showed the blood component therapy is considered a “complex” procedure that requires informed consent. Health and Safety code 1645 requires that patients be given the brochure “If You Need Blood: A Patient’s Guide to Blood Transfusion” (California Department of Health Services, June 2018) prior to consenting to the blood component therapy. On 3/5/25, Patient 6’s closed medical record was reviewed. Patient 6’s closed medical record showed Patient 6 was admitted to the hospital on 2/25/25 and discharged on 3/1/25. Review of the physician’s order dated 2/26/25 at 1009 hours, showed an order to transfuse one unit of red blood cell. Review of the Patient Consents to All Blood Products. Informed Consent (PARQ) Discussion Completed dated 2/26/25 at 0943 hours, showed the physician/LIP attested to having discussed the transfusion of blood products including risk, benefits, and alternatives, with the patient or surrogate. An opportunity to ask questions was provided, and detailed explanations and answers were given when necessary. The patient or surrogate stated understanding and consented to transfusion therapy. On 3/6/25 at 1400 hours, an interview was conducted with the Director Risk Management, Regulatory & Patient Safety. The Director Risk Management, Regulatory & Patient Safety stated the paper blood transfusion consent form or electric consent form could be used depending on the physician’s preference. Upon request, the Director Risk Management, Regulatory & Patient Safety provided the paper form of blood transfusion consent. Review of the Authorization for Consent to Blood Component Therapy, paper form, under Explanation of Signature, showed the following: “Your signature below indicates that: (1) you have received a copy of the brochure, “A Patient’s Guide to Blood Transfusion,”..... as your provider may order this during this hospitalization. Further review of Patient 6’s medical record failed to show documentation the brochure of “If You Need Blood: A Patient’s Guide to Blood Transfusion” was provided to Patient 6. On 3/6/25, the Director Risk Management, Regulatory & Patient Safety verified the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 36703 Based on interviews and record reviews, the hospital failed to ensure that one of eight sampled patients’ (Patient 2) care plan was updated to reflect the use of non-violent restraints during hospitalization. This failure had the potential to create a risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints for Non-Violent/Non-Self-Destructive Behavior dated May 2022 showed the patient’s plan of care will include restraint use and will be modified when restraints are applied or discontinued. The care plan is updated during the shift when restraints for non-violent/non-self-destructive behavior are initiated or discontinued, or, if close to shift change, may be included in hand-off communication, and updated the following shift. On 3/5/25, Patient 2’s closed medical record review was initiated. Patient 2 was admitted to the hospital on 1/15/25 and left AMA on 1/16/25. Review of the physician’s order dated 1/16/25 at 1031 hours, showed an order for non-violent vest restraint to the chest was ordered for Patient 2. Review of the Restraint Flowsheet dated 1/16/25 at 1030 hours, showed the vest restraint was initiated Patient 2. On 1/16/25 at 1230 hours, the Flowsheet showed the criteria for release was met and the vest restraint was discontinued. Review of Patient 2’s medical record showed no documented evidence Patient 2’s care plan was updated to address the use of non-violent restraints. On 3/6/25 at 1016 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36703 Based on interview and record review, the hospital failed to ensure the restraint monitoring assessment was conducted for one of eight sampled patients (Patient 2) as per the hospital’s P&P. This failure had the potential to create the risk of substandard outcomes for the patient. Findings: Review of the hospital’s P&P titled Restraints for Non-Violent/Non-Self-Destructive Behavior dated May 2022 showed each episode of restraint will be documented in the patient’s medical record with the following every two hours: - LOC, orientation, behavior, and response to the restraint. - Skin and circulation assessment with ROM. On 3/5/25, Patient 2’s closed medical record review was initiated. Patient 2’s closed medical record showed Patient 2 was admitted to the hospital on 1/15/25 and left AMA on 1/16/25. Review of the physician’s order dated 1/16/25 at 1031 hours, showed an order for non-violent vest restraint to the chest was ordered for Patient 2. Review of the Restraint Flowsheet dated 1/16/25 at 1030 hours, showed Patient 2’s vest restraint was initiated. On 1/16/25 at 1230 hours, the Flowsheet showed the criteria for release was met and the vest restraint was discontinued. However, there was no documentation to show Patient 2’s behavior which warranted discontinuing the restraint or if the patient had any signs of injury related to the restraint. On 3/6/25 at 1016 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety and RN 1.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nurse-to-patient ratios were maintained at all times for Telemetry unit as required. This failure had the potential for the care needs of the patients not being met when the staffing ratio were not maintained as required. Findings: Review of the hospital’s P&P titled Staffing and Scheduling dated January 2022 showed 1:4 (nurse-to-patient ratio) for the Covid Tele/PCSU/CarTel units. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217(a)(10) showed the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. 1. Review of the Assignment for Cardiac Telemetry for A Campus dated 1/15/25 for night shift (7 PM to 7 AM), showed RN 7, RN 8, and RN 9 were assigned for five telemetry patients from 0539 hours to 0700 hours on 1/16/25. 2. Review of the Assignment for Cardiac Telemetry for A Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following: * RN 9 was assigned for five telemetry patients for 12 hours shift. * RN 10 was assigned for five telemetry patients for 12 hours shift. * RN 11 was assigned for five telemetry patients from 0200 hours to 0700 hours on 2/2/25. 3. Review of the Assignment for Cardiac Telemetry for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following: * RN 11 was assigned for five telemetry patients from 0250 hours to 0700 hours on 2/8/25. * RN 12 was assigned for five telemetry patients from 2248 hours on 2/7/25 to 0700 hours on 2/8/25. * RN 13 was assigned for five telemetry patients from 0534 hours to 0700 hours on 2/8/25. 4. Review of the Assignment for PCSU for A Campus dated 1/15/25 for night shift (7 PM to 7 AM), showed the following: * RN 4 was assigned for three telemetry patients and two med/surg patients from 2221 hours on 1/15/25 to 0700 hours on 1/16/25. * RN 14 was assigned for four telemetry patients and one med/surg patient from 2157 hours on 1/15/25 to 0700 hours on 1/16/25. * RN 15 was assigned for two telemetry patients and three med/surg patients from 0229 hours to 0700 hours on 1/16/25. * RN 16 was assigned for two telemetry patients and three med/surg patients from 2113 hours on 1/15/25 to 0700 hours on 1/16/25. 5. Review of the Assignment for PCSU for A Campus dated 1/18/25 for day shift (7 AM to 7 PM), showed the following: * RN 17 was assigned for five telemetry patients from 0700 hours to 1308 hours. * RN 18 was assigned for four telemetry patients and one med/surg patient from 1101 to 1453 hours. * RN 19 was assigned for four telemetry patients and one med/surg patient from 0700 to 1538 hours. 6. Review of the Assignment for PCSU for A Campus dated 1/29/25 for night shift (7 PM to 7 AM), showed the following: * RN 23 and 24 were assigned for five telemetry patients for 12 hours shift. * RN 25 was assigned for four telemetry patients and one med/surg patient for 12 hours shift. 7. Review of the Assignment for PCSU for A Campus dated 1/31/25 for day shift (7 AM to 7 PM), showed the following: * RN 19 was assigned for four telemetry patients and one med/surg patient from 0700 to 1701 hours and five telemetry patients from 1831 to 1900 hours. * RN 20 was assigned for four telemetry patients and one med/surg patient from 0700 to 1326 hours. * RN 21 was assigned for four telemetry patients and one med/surg patient from 0700 to 1236 hours. 8. Review of the Assignment for PCSU for A Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following: * RN 4 was assigned for three telemetry patients and two med/surg patients from 2132 hours on 2/1/25 to 0700 hours on 2/2/25. * RN 16 was assigned for three telemetry patients and two med/surg patients from 2200 hours on 2/1/25 to 0700 hours on 2/2/25. * RN 26 was assigned for two telemetry patients and three med/surg patients from 2200 hours on 2/1/25 to 0700 hours on 2/2/25. * RN 27 was assigned for four telemetry patients and one med/surg patient from 2200 hours on 2/1/25 to 0700 hours on 2/2/25. 9. Review of the Assignment for PCSU for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following: * RN 15 was assigned for four telemetry patients and one med/surg patient from 1900 to 2040 hours and 0136 to 0700 hours on 2/8/25. * RN 16 was assigned for five telemetry patients from 1900 to 2045 hours. * RN 22 was assigned for five telemetry patients for 12 hours shift. 10. Review of the Assignment for Tele North for A Campus dated 1/31/25 for day shift (7 AM to 7 PM), showed the following: * RN 28 was assigned for four telemetry patients and one med/surg patient from 1900 to 2115 hours and 2200 hours to 0700 hours on 2/1/25. * RN 29 was assigned for five telemetry patients for 12 hours shift. 11. Review of the Assignment for Tele North for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following: * RN 30 was assigned for five telemetry patients from 2300 to 0700 hours on 2/8/25. * RN 28 was assigned for four telemetry patients and one med/surg patient from 2345 hours to 0700 on 2/8/25. 12. Review of the Assignment for Tele South for A Campus dated 1/15/25 for day shift (7 AM to 7 PM), showed the following: * RN 33 was assigned for four telemetry patients and one med/surg patient from 1003 to 1900 hours. * RN 34 was assigned for three telemetry patients and two med/surg patients from 1021 to 1900 hours. 13. Review of the Assignment for Tele South for A Campus dated 1/15/25 for night shift (7 PM to 7 AM), showed the following: * RN 35 was assigned for four telemetry patients and one med/surg patient from 0450 to 0700 hours on 1/16/25. * RN 36 was assigned for four telemetry patients and one med/surg patient from 0558 to 0700 hours on 1/16/25. 14. Review of the Assignment for Tele South for A Campus dated 1/18/25 for day shift (7 AM to 7 PM), showed the following: * RN 34 was assigned for five telemetry patients for 12 hours shift. * RN 37 was assigned for five telemetry patients from 0700 to 1250 hours and 1705 to 1900 hours. * RN 38 was assigned for four telemetry patients and one med/surg patient from 0700 to 1620 hours. * RN 39 was assigned for five telemetry patients for 12 hours shift. 15. Review of the Assignment for Tele South for A Campus dated 1/24/25 for day shift (7 AM to 7 PM), showed the following: * RN 40 was assigned for four telemetry patients and one med/surg patient from 0700 to 1351 hours. * RN 41 was assigned for four telemetry patients and one med/surg patient from 0700 to 1326 hours. 16. Review of the Assignment for Tele South for A Campus dated 1/29/25 for night shift (7 PM to 7 AM), showed the following: * RN 30 was assigned for five telemetry patients from 2317 to 0700 hours on 1/30/25. * RN 42 was assigned for four telemetry patients and one med/surg patient from 0008 to 0700 hours on 1/30/25. * RN 44 was assigned for four telemetry patients and one med/surg patient from 0455 to 0700 hours on 1/30/25. * RN 45 was assigned for five telemetry patients from 0530 to 0700 hours on 1/30/25. 17. Review of the Assignment for Tele South for A Campus dated 1/31/25 for day shift (7 AM to 7 PM), showed the following: * RN 39 was assigned for five telemetry patients from 0700 to 1242 hours and 1617 to 1900 hours. * RN 45 was assigned for three telemetry patients and two med/surg patients from 1350 to 1750 hours. * RN 46 was assigned for five telemetry patients for 12 hours shift. * RN 47 was assigned for five telemetry patients from 1703 to 1831 hours. 18. Review of the Assignment for Tele South for A Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following: * RN 36 was assigned for four telemetry patients and one med/surg patient from 2230 to 0700 hours on 2/2/25. * RN 48 was assigned for three telemetry patients and two med/surg patients from 2230 to 0700 hours on 2/2/25. * RN 49 was assigned for four telemetry patients and one med/surg patient from 2049 to 0700 hours on 2/2/25. * RN 50 was assigned for three telemetry patients and two med/surg patients from 2223 to 0700 hours on 2/2/25. * RN 51 was assigned for four telemetry patients and one med/surg patient from 2230 to 0700 hours on 2/2/25. 19. Review of the Assignment for Tele South for A Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed RN 43 was assigned for four telemetry patients and one med/surg patient for 12 hours shift. 20. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 1/29/25 for night shift (7 PM to 7 AM), showed the following: * RN B was assigned for five telemetry patients for 12 hours shift. * RN C was assigned for four telemetry patients and one med/surg patient for 12 hours shift. 21. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 2/1/25 for night shift (7 PM to 7 AM), showed the following: * RN D was assigned for five telemetry patients from 0206 to 0700 hours on 2/2/25. * RN E was assigned for five telemetry patients for 12 hours shift. * RN F was assigned for four med/surg patients and one telemetry patient from 2133 hours on 2/1/25 to 0700 hours on 2/2/25. 22. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 2/7/25 for night shift (7 PM to 7 AM), showed the following: * RN G was assigned for three med/surg patients and two telemetry patients from 2020 hours on 2/7/25 to 0700 hours on 2/8/25. * RN H was assigned for five telemetry patients from 2352 hours on 2/7/25 to 0700 hours on 2/8/25. 23. Review of the Assignment for Med/Surg/Telemetry for B Campus dated 3/4/25 for night shift (7 PM to 7 AM), showed the following: * RN D was assigned for five telemetry patients from 2340 hours on 3/4/25 to 0700 hours on 3/5/25. * RN F was assigned for four med/surg patients and one telemetry patients from 2325 hours on 3/4/25 to 0700 hours on 3/5/25. * RN I was assigned for five telemetry patients from 0303 hours on 3/4/25 to 0700 hours on 3/5/25. * RN J was assigned for five telemetry patients from 0302 hours on 3/4/25 to 0700 hours on 3/5/25. On 3/6/25 at 1510 hours, the Director Risk Management, Regulatory & Patient Safety verified the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on observation, interview, and record review, the hospital failed to ensure the medication was administered for one of eight sampled patients (Patient 7) as per the physician’s ordered. This failure created the risk of medication errors and poor health outcomes to the patient. Findings: On 3/5/25 at 1006 hours, RN 5 was observed administering a medication to Patient 7. RN 5 administered dexmedetomidine (a medication used to start or maintain sedation) 400 mg/100 ml at 0.6 mcg/kg/hr (10.6 ml/hr). On 3/5/25, Patient 7’s medical record was reviewed. Patient 7’s medical record showed Patient 7 was admitted to the hospital on 2/24/25. Review of the physician’s order dated 2/25/25 at 0004 hours, showed to titrate dexmedetomidine in saline 4 mcg/ml either increase or decrease the rate by 0.2 mcg/kg/hr. Review of the MAR dated 3/5/25, showed the following: * At 0054 hours, Patient 7 received the dexmedetomidine at 0.7 mcg/kg/hr. * At 1006 hours, Patient 7 received the dexmedetomidine at 0.6 mcg/kg/hr. * At 1020 hours, Patient 7 received the dexmedetomidine at 0.5 mcg/kg/hr. On 3/6/25 at 0944 hours, an interview and concurrent review of Patient 7’s medical records was conducted with Nurse Manager 1. Nurse Manager 1 verified the above findings.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff performed the blood transfusion for one of eight sampled patients (Patient 6) as per the hospital’s P&P and failed to ensure the annual competency validation for RN 6 as evidenced by: 1. For Patient 6, the blood transfusion rate for first 15 minutes was not initiated as per the hospital’s P&P. In addition, the VS was not recorded one hour after the completion of the blood transfusion for Patient 6 as per the hospital’s P&P. 2. RN 6 did not complete the required annual competency validation for blood transfusion. These failures posed the risk for potential complications, including undetected changes in the patient’s condition, delayed interventions, and overall compromised patient safety during the blood transfusion process. Findings: 1. Review of the hospital’s P&P titled Blood Product Transfusion and Blood Warmer dated February 2025 showed the following: * Initiate the blood transfusion at approximately 2 mL/min (120 ml/hr) for the first 15 minutes, remaining at the patient’s bedside to observe for transfusion reaction during this time. * Record vital signs - BP, temperature, pulse, and respirations at 15 minutes, and then hourly until transfusion complete. Take vital signs one hour post completion of the transfusion. On 3/5/25, Patient 6’s closed medical record was reviewed. Patient 6’s closed medical record showed Patient 6 was admitted to the hospital on 2/25/25 and discharged on 3/1/25. Review of the physician’s order dated 2/26/25 at 1009 hours, showed an order to transfuse one unit of Red Blood Cells (PRBC). Review of the Transfusion Record dated 2/26/25, showed the blood transfusion was initiated at 1044 hours and ended at 1156 hours. a. Review of the Transfusion Record dated 2/26/25, showed the blood was administrated at 300 ml/hr. There was no documented evidence to show the blood transfusion was initiated for the first 15 minutes as per the hospital’s P&P. b. Review of the Flowsheet dated 2/26/25, showed Patient 6’s VS was not recorded one hour after the completion of the transfusion as per the hospital’s P&P. The Flowsheet showed Patient 6’s VS was recorded at 1520 hours, three hours and 24 minutes after the transfusion was completed. On 3/7/25 at 1310 hours, the Director Risk Management, Regulatory & Patient Safety verified the above findings. 36703 2. On 3/7/25 at 1031 hours, an interview and concurrent review of RN 6’s training files was conducted with the Transition in Practice Housewide Educator, the Regulatory Assurance Analyst HR, the HR Partner, the Sr. Regulatory Analyst for HR, and the Human Resource Business Partner. Review of RN 6’s personnel file showed she was a contracted registry RN with an active contract since September 2024. Review of the registry training log showed RN 6 received the “Blood and Blood Products” training and competency validation on 11/18/23. However, further review of the log failed to show documented evidence of another training and competency validation being completed for 2024. On 3/7/25 at 1031 hours, an interview was conducted with the Transition in Practice Housewide Educator. The Transition in Practice Housewide Educator stated RN 6 was in a per diem position, which did not require annual competency. When asked if the hospital had a P&P on the competency validation requirements for the registry staff who were per diem, none was provided. The Transition in Practice Housewide Educator stated the full time RNs at the hospital were required to complete annual blood transfusion competency validation. The above findings were shared and acknowledged by the Transition in Practice Housewide Educator, the Regulatory Assurance Analyst HR, the HR Partner, the Sr. Regulatory Analyst for HR, and the Human Resource Business Partner.”

“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: 36703 Based on interview and record review, the hospital failed to ensure the hospital’s P&P related to the assessment and reassessment of patient in the ED was implemented for two of eight sampled patients (Patients 1 and 3) as evidenced by: * For Patient 1, there was no documented evidence to show the nursing staff conducted a focused assessment for the patient as per the hospital’s P&P. * For Patient 3, there was no documented evidence to show the patient’s VS was taken as per the hospital’s P&P. These failures created a risk of substandard care for patients receiving care in the ED. Findings: Review of the hospital’s P&P titled Triage and Assessment/Reassessment of Patients in the Emergency Department dated August 2023 showed the following: * Once the patient is in the treatment area, the primary RN will perform the general assessment and reassessment as necessary. * The primary assessment includes the airway, breathing, circulation and disability, review the triage assessment, and vital signs as needed. * Secondary Assessment: - The secondary assessment includes the focused assessment as it relates to the chief complaint. - Vital signs are reassessment at minimum every two hours as needed by the patient condition until placed in a treatment location. Once in a treatment location, reassessment frequency is at minimum of four hours but determined by priorities of the patient needs, condition and response to previous treatments. 1. On 3/5/25, Patient 1’s closed medical record review was initiated. Patient 1’s closed medical record showed Patient 1 arrived in the ED on 1/18/25 at 1837 hours, with an arrival complaint of head pain. Review of the Patient Care Timeline showed on 1/18/25, the following assessment and care events for Patient 1: - At 1852 hours, RN 2 started Patient 1’s triage assessment. - At 1853 hours, the vital signs and pain assessment were documented. The chief complaint was updated to show it was for a fall and head laceration. - At 1854 hours, the ED Triage Note documentation showed Patient 1 had a laceration to the left upper forehead. The patient had no loss of consciousness, no nausea/vomiting, or headache. RN 2 documented Patient 1’s bleeding was controlled with a compression dressing. - At 1856 hours, Patient 1 was screened as an ESI level 2. - At 1901 hours, Patient 1 was moved into a treatment bay and assigned to RN 52. - At 1926 hours, Patient 1 had multiple blood work studies collected. - At 1934 hours, Patient 1 had a CT imaging study started. - At 1935 hours, RN 53 was assigned to Patient 1. - At 1946 hours, the CT exam was completed. Review of the ED Provider Notes dated 1/18/25 at 2039 hours, showed Patient 1 was initially assessed as a TBI alert due to the presenting with a laceration following a ground-level fall. Patient 1 was not on any anticoagulation therapy. Patient 1 was assessed by Physician 1 as alert and oriented, with no observed neurological deficits. When Patient 1 returned from the CT study, Patient 1 became unconscious and did not respond to deep painful stimuli concerning for significant blood loss versus possible worsening intracranial bleed. Patient 1 was upgraded to a tier 1 red trauma. Patient 1 was taken to the trauma bay for resuscitation. Patient 1’s laceration was repaired by the trauma surgeon and the patient was started on a massive transfusion protocol. Review of the Trauma Patient Registry Kardex showed Patient 1 arrived in the trauma bay on 1/18/25 at 2000 hours. Review of the Patient 1’s medical records showed no documented evidence the RNs caring for Patient 1 conducted a focused assessment of the chief complaint prior to the patient becoming unconscious. On 3/6/25 at 0940 hours, an interview and concurrent review of Patient 1’s medical record was conducted with the ED Manager and the Director of Emergency Services. The ED Manager stated it was the role of the primary RN to perform the focused assessment. The ED Manager stated a focused neurological and integumentary assessment should have been documented for Patient 1 in the ED. The Director of ED Services stated Patient 1’s change of condition should have been captured by the nursing care in the medical record. The above findings were shared with and acknowledged by the ED Manager and the Director of Emergency Services. 35310 2. On 3/6/25, Patient 3’s closed medical record was reviewed. Patient 3’s closed medical record showed Patient 3 arrived to the hospital’s ED on 2/2/25 and discharged on 2/3/25. Review of the Patient Care Timeline showed on 2/2/25 at 2006 hours, Patient 3 was roomed in ED. At 2014 hours, Patient 3’s acuity was assigned as 2. Review of the Flowsheet History showed Patient 3’s VSs were measured on 2/2/25 at 2008, 2142, and 2200 hours; and on 2/3/25 at 0823 hours. On 3/6/25 at 0830 hours, an interview was conducted with the Director of Emergency Services. The Director of Emergency Services stated the VS should be measured every four hours after a patient is roomed. The Director of Emergency Services verified Patient 3’s VS was not measured as per the hospital’s P&P.”

“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: 36703 Based on interview and record review, the hospital failed to ensure one RN (RN 2) met the competency validation requirement for ESI and triage according to the hospital’s P&P. This failure increased the risk of substandard outcomes for patients in the ED. Findings: Review of the hospital’s P&P titled Triage and Assessment/Reassessment of Patient in the Emergency Department dated August 2023 showed nurses assigned as Triage Nurse Rapid Assessment Nurse, must have successfully completed the triage orientation course, training and competency. On 3/7/25 at 1031 hours, an interview and concurrent review of RN 2’s training files was conducted with the Transition in Practice Housewide Educator, the Regulatory Assurance Analyst HR, the HR Partner, the Sr. Regulatory Analyst for HR, and the Human Resource Business Partner. Review of RN 2’s personnel file showed RN 2 was hired on 1/30/23 and advanced to an acute care RN role on 1/28/24. RN 2 was an ED RN. Review of RN 2’s Triage/ESI training showed it was completed on 6/11/24. Further review of the training failed to show documented evidence of competency validation for assessing ESI or triage. On 3/7/25 at 1149 hours, an interview was conducted with the Transition in Practice Housewide Educator. The Transition in Practice Housewide Educator stated the competency validation requirements for the ESI and triage training were not incorporated into the annual competencies until the latter part of 2024. Prior to the change, the RNs received an annual training presentation and shadowed a precepting triage RN in the live ED environment. On 3/7/25 at 1300 hours, the above findings were shared and acknowledged by the Director Risk Management, Regulatory & Patient Safety, and the Regulatory Manager.”

“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: 22553 Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital’s P&Ps for one of two sampled patients (Patient 1) as evidenced by: 1. The nursing staff did not notify the physician when Patient 1’s blood glucose level was 306 ml/dL and did not develop the plan of care related to diabetes or dysglycemia for the patient. 2. The nursing staff did not complete the nutritional screening within 24 hours of admission for Patient 1. 3. The nursing staff did not complete the initial pain assessment and did not conduct the pain reassessment after administering the pain medication to Patient 1. These failures created the increased risk of poor health outcomes to the patient. Review of the hospital’s P&P tilted Assessment/Re-assessment of Patient dated September 2021 showed the following: * Re-assessment across disciplines is ongoing and occurs at regular intervals during the patient’s treatment to determine the response to and effectiveness of the plan of care and interventions. * The initial assessment on arrival to unit consists of medications, pain assessment including pain goal, a system review of the presenting symptomology and therapeutic intervention, plus any additional sections pertaining to the patient’s specific situation. Such assessments should be performed, and the findings documented in the patient’s medical record upon receipt of the patient when he/she is admitted to the unit. * Shift Assessment/Reassessment includes the following: - Assessment and Documentation shall be completed per unit standard/level of care. The full body system assessment includes a complete physiological assessment must be completed per level of care/unit standard of care at the beginning of each shift and documented by the end of the caregiver shift. - Pain assessment per Pain Management Policy. - Additional reassessments may occur for the following reasons: abnormal findings from previous assessment and physician orders. * For the Med/Surg at Laguna Beach, assessment and documentation will include lab values. On 12/12/24 at 0957 hours, Patient 1’s closed medical record was reviewed with the Nurse Manager. Patient 1’s closed medical record showed Patient 1 came to the hospital on 11/7/24, for a surgical procedure. Patient 1 was admitted to the Med/Surg Tele floor on 11/7/24 at 1430 hours, from the PACU and discharged on 11/12/24. 1. Review of the hospital’s P&P tilted Care of the Adult Patient with Diabetes or Dysglycemia (Glucose Abnormalities) dated July 2024 showed patients with diabetes or dysglycemia will receive safe, effective care that includes as assessment and a care plan for proactive glucose management to promote optimal self-care after discharge. Hyperglycemia is defined as the blood glucose greater than 180 mg/dL. Insulin therapy is defined as insulin is the preferred treatment for glycemic control in the hospital setting. Patients with diabetes should have a diagnosis clearly identified in the medical record. All patients with Type 1 Diabetes must have basal and correctional insulin with the addition of nutritional insulin if patient is eating. If a patient has persistent hyperglycemia and no insulin orders are present or patient has correction scale insulin only, notify the physician. Documentation showed to document medications, treatment, care plan in the electronic medical record. Review of the Preanesthesia Evaluation dated 11/7/24 at 0917 hours, showed Patient 1 had a medical history of Type 2 Diabetes. During the concurrent interview to the Nurse Manager, the Nurse Manager was asked for the document of the patient’s medical history. The Nurse Manager provided documents that the hospital received from the surgeon’s clinic which showed Patient 1 visited the physician’s office on 10/21/24 at 1540 hours. The document showed Patient 1 had a medical history of pancreatic insufficiency, Type 1 DM, and Type 2 DM uncontrolled. Review of the Medication Documentation Review Audit showed on 11/7/24 at 0748 hours, the pre-operating RN reviewed Patient 1’s home medications which included insulin glargine (Lantus, a long-acting insulin used to improve and maintain blood sugar level), 24 units to be injected under the skin every morning. Review of the Hospitalist Progress Note dated 11/9/24 at 1456 hours, showed the Lab Results section showing Patient 1’s blood glucose level was 306 mg/dL on 11/8/24 at 0516 hours. The “Scheduled Meds:” section showed insulin lispro (a fast-acting insulin used to lower the blood sugar level), 0-6 units subcutaneous four times daily, AC and HS. Review of the Hospitalist Progress Note dated 11/10/24 at 1452 hours, showed the Lab Results section showing Patient 1’s blood glucose level was 457 mg/dL on 11/10/24 at 1413 hours. The Assessment section showed Patient 1 had insulin dependent diabetes. Review of the POCT Glucose showed Patient 1’s blood glucose level was greater than 180 mg/dL as follows: - On 11/10/24 at 1553 hours, Patient 1’s blood glucose level was 417 mg/dL. - On 11/10/24 at 2016 hours, the patient’s blood glucose level was 390 mg/dL. - On 11/11/24 at 0617 hours, the patient’s blood glucose level was 358 mg/dL - On 11/11/24 at 1220 hours, the patient’s blood glucose level was 371 mg/dL. - On 11/11/24 at 1637 hours, the patient’s blood glucose level was 242 mg/dL. - On 11/11/24 at 1917 hours, the patient’s blood glucose level was 247 mg/dL - On 11/11/24 at 2017 hours, the patient’s blood glucose level was 234 mg/dL. - On 11/12/24 at 0736 hours, the patient’s blood glucose level was 267 mg/dL. Review of the Plan of Care from 11/7/24 to 11/12/24 showed there was no documented evidence for the plan of care for diabetes or dysglycemia. Review of the meal ’ s intake document from 11/9/24 to 11/12/24, showed the patient was on a regular diet. When asked, the Nurse Manager stated she was not able to locate documented evidence the RN notified or communicated with the providers regarding to Patient 1’s abnormal blood glucose level as of 306 on 11/8/24 at 0516 hours. 2. Review of the hospital’s P&P titled Nutrition Screening dated August 2022 showed the nursing will screen all patients within 24 hours of admission using the predetermined nutrition screening tool during the completion of the initial patient admission documentation. For adult patients, the pre-determined nutritional criteria include to use a Nutritional Risk Screening Tool 2002 (NRS-2002). Review of the hospital’s Nursing Malnutrition Risk Screen showed this helps to determine patients at nutritional risk to be prioritized for nutrition assessment. A score of 3 or signifies patient is at risk for malnutrition. The Malnutrition Risk Screen include the category of severity of disease. The Severity of Disease Reference section show “Mild Score 1” indicates the patient had chronic disease, admitted to the hospital due to complication. The example of the chronic disease is diabetes. On 12/17/24 at 1327 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 1. RN 1 stated there was no documented evidence of a nutrition screening was completed within 24 hours of admission for Patient 1. 3. Review of the hospital’s P&P tilted Pain Management dated November 2024 showed the following: * Patients have the right to pain management * Pain is assessed using approved, evidence- based validate scales appropriate for the patient’s medical condition. * Patients admitted to an inpatient care setting shall receive an initial screen at the time of admission to identify the presence pain. The information that may be obtained during this assessment includes, but is not limited to the intensity of pain, the location and nature of pain, the patient’s tolerance to pain and acceptable of pain (pain goal); the patient history of analgesic use or abuse; and the patient respiratory risk factor. * The patient will be assessed using the appropriate pain assessment tools a minimum of twice on both the day and evening shift and at least once during the night shift and PRN in the acute care area. * In general, inpatient shall receive treatment for any active pain issue when intensity exceeds their acceptable level. Treatment is to be provided in a timely manner. * If a treatment intervention for pain is provided, the response to that intervention should be assessed to include progress toward pain goal and side effects. The patient will be reassessed when drug approximately reaches peak effect as follows: after at least 30 minutes for IV administration (if the ordered frequency is less than 30 minutes, RN will perform reassessment prior to giving the next dose) * Numerical Pain Rating Tools (NRS) is a pain scale, using numbers from 0-10 in which each number refers to a different pain level such that “0” represents “No Pain” to a rating of “10” which represents “the worst possible pain.” On 12/17/24 at 1348 hours, an interview and concurrent review of Patient 1’s medical record was conducted with RN 1. Review of the initial pain assessment documented on 11/7/24 at 1215 hours, showed at the preoperative unit, Patient 1’s preferred pain scale was the numeric pain scale. The patient’s acceptable comfort level was “3.” The assessment did not include the intensity of pain, the location and nature of pain, the patient history of analgesic use of abuse, and the patient respiratory risk factors. Further review of Patient 1’s medical record showed Patient 1 admitted to med/surg unit on 11/7/24 at 1430 hours after the surgery. There was no documented evidence the med/surg unit admitting RN performed an initial pain assessment for Patient 1. Review of the nursing notes, Medication Administration Report, Flowsheet History showed the pain management was not implemented for Patient 1 as follows: * Review of the physician’s order showed to administer hydromorphone (a pain medication) 1 mg every three hours as needed for moderate pain and severe pain to be started on 11/8/24 at 0647 hours and ended on 11/9/24 at 1549 hours. The MAR showed hydromorphone 1 mg was administered to the patient on 11/8/24 at 1135, 1437, and 1737 hours; and 11/9/24 at 0425, 0836, 1212, and 1514 hours. * Review of the physician’s order showed to administer hydromorphone 2 mg every four hours as needed for moderate pain and severe pain to be started on 11/9/24 at 1551 hours and ended on 11/10/24 at 1542 hours. The MAR showed hydromorphone 2 mg was administered to the patient on 11/9/24 at 2008 hours and 11/10/24 at 0506 hours. On 12/17/24 at 1348 hours, RN 1 reviewed Patient 1’s medical record and confirmed there was no documented evidence the nursing staff completed the initial pain assessment and conducted the pain reassessment after administered the above medications to the patient.”