Eisenhower Medical Center

“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: 50433 Based on interview and record review, the facility failed to ensure care in a safe setting was provided, for one of 21 sampled patients (Patient 21), when Patient 21, who stated she was suicidal (having thoughts of, or a desire to, end one’s own life) at triage (the process of sorting and prioritizing patients based on the urgency and severity of their medical conditions), was returned to the Emergency Department (ED, a unit where patients with sudden, severe illnesses and life-threatening injuries are evaluated and treated) lobby where she stayed for 1 hour and 27 minutes without being continuously monitored. This failure had the potential to result in Patient 21 being able to commit suicide. Findings: On June 15, 2026, at 3:40 p.m., Patient 21’s record was reviewed with the Director of Emergency Services (DES). A facility document titled, “ED Provider [physician] Notes,” dated May 19, 2026, at 6:10 p.m., was reviewed. The document indicated, “...Chief Complaint Patient presents with Suicidal [thoughts]...patient has started feeling suicidal since yesterday...Patient states she would take excess of her pills...” A facility document titled “Provider In Triage Note,” dated May 19, 2026, at 2:46 p.m., was reviewed. The document indicated, “...c/o [complaint of] suicidal thoughts since yesterday...Patient advised to stay for the completion of the medical screening examination. Patient...advised to report to ED staff if symptoms worsen...” A facility document titled, “Social Service Consult,” dated May 19, 2026, at 5:47 p.m., was reviewed. The document indicated, “...Pt was placed on DTS [danger to self] hold [5150 hold]...Patient arrived to the emergency room reporting suicidal ideation [SI, thoughts, contemplations, or a preoccupation with ending one’s own life] with plan to take her medications until they [the pills] were gone...” A facility document titled, “ED Care Timeline,” dated May 19, 2026, from 2:12 p.m. to May 20, 2026, at 8:37 a.m., was reviewed. The document indicated the following: - At 2:18 p.m., “...triage started...Chief Complaints...Suicidal...Patient states she would take excess of pills...”; - At 2:20 p.m., “...Triage Completed...Patient Acuity [severity and urgency of a patients illness or condition]: 2 [on the emergency severity index (ESI), a triage tool which sorts patients from most urgent (Level 1) to least urgent (Level 5) based on acuity and resources needed, with a Level 2 meaning emergent with the patients in a high-risk situation or experiencing severe symptoms and is likely to deteriorate but is not in an immediate or life-threatening danger]...”; - At 2:42 p.m., “...Roomed in PIT [Physician in Triage, an assessment area in the ED where a physician performs an emergency medical screening (a mandatory evaluation provided by the ED provider (a licensed individual who delivers medical care or treatment to patients) to determine if a patient has a life-threatening or emergency medical condition (the presence of acute, severe symptoms where a reasonable person would expect the lack of immediate medical care to result in serious health risks)]...”; - At 2:43 p.m., “...First Provider Evaluation of Patient...”; - At 2:49 p.m., “...Social Work [healthcare professionals who provide emotional support, non-medical counseling, and practical assistance to patients] Consult Ordered...”; - At 2:55 p.m., “...Patient [Patient 21] transferred From...PIT...to...Lobby [ED lobby] Post [after] PIT...”; - At 4:22 p.m., “...Patient transferred From Lobby Post PIT to room [in the ED]...”; - At 5 p.m., “...pt [Patient 21] going through her purse and pulled out a medicine bottle with “clonipine [sic, Klonopin, a prescription medication which slows down brain activity]”...Thin [sic, then] nurse stopped pt from taking home medications...Pt appears drowsy...”; - At 5:25 p.m., “...Suicide Risk Screening [a brief, simple set of questions used to identify if a person is having thoughts of committing suicide]...Suicide and Safety Check [an evaluation to determine if a patient is at risk of hurting themselves]...” (Three hours and seven minutes after Patient 21 told the triage RN she was suicidal.); and - At 5:46 p.m., “...Placed on 5150 Hold [an involuntarily detention of a person who is determined to be a danger to himself or others or who is gravely disabled (when a person is unable to provide for his own basic needs) for a 72-hour evaluation and treatment...” (Three hours and 28 minutes after Patient 21 told the triage RN she was suicidal). During the review of Patient 21’s record, on June 15, 2026, conducted with the DES, there was no documented evidence Patient 21 was continuously observed and monitored while in the ED lobby on May 19, 2026, from 2:55 p.m. to 4:22 p.m. (one hour and 27 minutes), in accordance with the facility’s policy and procedure (P&P). There was no documented evidence SW consult was completed timely after it was ordered by the physician on May 19, 2026, at 2:49 p.m. (SW consult was conducted two hours and 58 minutes from the time the physician placed an order for it.) There was no documented evidence an environmental check was conducted for the ED lobby before Patient 21 was placed back in the ED lobby, in accordance with the facility’s P&P. There was no documented evidence Patient 21’s Klonopin pills were removed from her possession when she was placed back in the ED lobby, in accordance with the facility’s P&P. On June 16, 2026, at 1:35 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when a patient presents to triage with suicidal ideation, he assesses the patient for a plan on how the patient would commit suicide, obtains vital signs [measurements of the body’s basic, life-sustaining functions including heart rate (number of heart beats per minute), temperature, respiratory rate (number of breaths per minute), and blood pressure (the force of the blood pushing against the walls of the arteries as the heart pumps it through the body)], and takes the patient to PIT right away. RN 1 stated, if a patient informs him the plan to commit suicide is to take pills, he would ask what type of pills, and if the patient had the pills on them. RN 1 stated, if the patient stated they did have pills with them, he would have the facility security personnel log the pills and remove the pill’s from the patient’s possession and would get social worker (a healthcare professional who supports patients and their families, addressing the emotional, social, and practical impacts of their illnesses, helping individuals cope with their diagnoses, and coordinating care plans, counseling, and discharge transitions) involved because there is a potential for patients to harm themselves if they have pills in their possession. On June 16, 2026, at 2:07 p.m., an interview was conducted with Physician (MD) 1. MD 1 stated a patient with suicidal ideation would be brought back to a room in the ED as soon as possible. MD 1 stated, if the patient could not be brought to an ED room immediately, the patient should be kept in an area while being closely monitored. On June16, 2026, at 4:40 p.m., an interview was conducted with the DES. The DES stated, ideally, a patient with suicidal ideation should be in the staff’s “line of sight [a method of patient monitoring where a healthcare provider must maintain an unobstructed, direct visual on a patient at all times]” with staff keeping an eye on the patient. On June16, 2026, at 4:50 p.m., an interview was conducted with RN 4. RN 4 stated a transporter (a healthcare worker responsible for safely moving patients throughout the facility) brought Patient 21 from the ED lobby to the ED room. RN 4 stated Patient 21 was lethargic (a state of being extremely sluggish, tired, and lacking energy) and when she reentered Patient 21’s room, she observed that Patient 21 had retrieved a bottle of medication labeled as Klonopin and Patient 21 stated she was going to take her medication. RN 4 stated Patient 21 seemed confused and “out of it,” and “was clearly altered.” An undated facility P&P titled, “Patients’ Rights and Responsibilities,” was reviewed. The document indicated, “...Patients’ Rights...You have the right to...Receive care in a safe setting...” An undated facility P&P titled, “Emergency Care of the Behavioral Health Patient,” was reviewed. The P&P indicated, “...This policy outlines the requirements for managing behavioral health patients presenting to the [name of facility] Emergency Department (ED) in a manner that protects the patient’s health and safety...Triage: the patient presenting with psychiatric emergency medical condition or behavioral health chief complaint...Required nursing assessments - At minimum, conduct and document the following...screen for suicidal ideation all patients who are being evaluated or treated for a behavior health condition...Risk assessment of the patient’s room...Ensure all objects that pose for harm to self or others are removed...Place the patient in a designated quiet room with minimal traffic in and out of room...” An undated facility P&P titled, “Suicide Screening, Assessment, and Precautions,” was reviewed. The P&P indicated, “[Name of the facility] utilizes consistent and evidence-based tools for screening and assessing the severity of risk for suicide and for protecting patients with potential for self-harm...All patients...being admitted to the Emergency Department...will be screened for suicidal ideation...Suicide BPA [best practice alert, automated clinical decision support notifications in an electronic health record designed to guide medical staff]...any positive screen will trigger the BPA for the orders below...Consult to Social Services [non-medical support for patients and their families]...Clear room for behavioral health evaluation...Safey attendant at bedside...Suicide precautions...Environment of care checklist...The patient room is checked to ensure removal of all potentially dangerous items that are not needed for medical treatment...The patient’s personal belongings should be sent home with family...If no family member is present to take the patient’s personal belongings home, the personal belongings will be sequestered and secured until the patient is discharged...Safety attendant at beside...A safety attendant or designee will provide direct observation...The patient will be kept in full view of the safety attendant at all times...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to ensure the patient’s right to be free from inappropriate restraint (any physical, mechanical, or chemical method used to restrict a patient’s movement, freedom, or normal access to their own body) use was promoted, for one of 21 sampled patients (Patient 17), when Patient 17 was assessed to have a severe neurological dysfunction [the brain, spinal cord, or nerves are severely damaged or failing to work] with no purposeful movement [unable to make conscious, deliberate, or intentional physical actions] and was placed on restraint. This failure resulted on Patient 17 being put on continuous restraint and had the potential to increase the risk of injury to Patient 17. Findings: On June 16, 2026, at 10:21 a.m., a review of Patient 17’s record was conducted with the Quality Analyst (QA). A facility document titled, “H&P [History and Physical],” dated May 18, 2026, at 12:16 a.m., was reviewed. The document indicated Patient 17 was admitted to the facility on May 17, 2026, with a diagnosis of intracranial hemorrhage (brain bleed inside the skull). The document indicated, “...Pupils unreactive [the black center of the eye does not change when exposed to light which often indicates damage to the nerves controlling the eye or severe underlying neurological (pertaining to the brain, spinal cord, and nerves]...She is unresponsive [unconscious and not responsive to sounds, touch, or pain]...no corneal reflex [the eye does not blink when touched and often a sign of deep unconsciousness, brainstem dysfunction, or nerve damage], no gag reflex [the throat muscles do not respond when the back of the throat is touched which can also indicate underlying nerve damage], unresponsive to pain [a patient deeply unconscious or sedated to the point where their brain does not react to strong physical stimulation such as pressing a knuckle against their breastbone]...GCS [Glaslow Coma Scale, a standardized clinical tool used to objectively measure a person’s level of consciousness and assess the severity of brain injuries with scores ranging from 3 to 15, with lower numbers indicating deeper levels of unconsciousness] eye subscore [eye opening scored from 1 to 4] is 1...GCS verbal subscore [verbal response scored from 1 to 5] is 1...GCS motor subscore [motor response (how a person’s body moves in reaction to a command or a physical touch) scored from 1 to 6] is 1 (total score of 3)...” A facility document titled, “Assessment Type...Neurological,” dated May 17, 2026, at 9:30 p.m., was reviewed. The document indicated, “...RUE [right upper extremity, right arm] Motor Strength [the power and ability of a person’s muscles to perform tasks or generate force]...Flicker of muscle [the bare visibility or palpability (easily felt) of muscle contraction without enough strength to move the associated joint]...LUE [left upper extremity, left arm] Motor Strength...Flicker of muscle...” A facility document titled, “Neurosurgical [Neurosurgery, a specialized field of medicine focused on diagnosing, treating, and surgically managing disorders of the nervous system (brain, spinal cord, and nerves)] Consultation,” dated May 17, 2026, at 9:40 p.m., was reviewed. The document indicated, “...She [Patient 17] does not have a corneal reflex...She does not have an oculocephalic response [eyes do not move when head is turned from side to side which may indicate severe brain damage]...She does not have a gag reflex...She’s not breathing over the vent [ventilator, a machine which assists a patient’s breathing for a patient who cannot breath on her own]...she has no response to pain...Patient is comatose [a deep stated of unconsciousness when a patient cannot be woken up]...There is a very large hemorrhage [bleed]...There is blood in all 4 [four] ventricles [hallow spaces inside the brain]...suggest comfort care only [medical care focused on keeping a dying person comfortable, peaceful, and free of pain during the final days or hours of life]...” A facility document titled, “Restraints non-violent or non-self destructive (Order...),” dated May 17, 2026, was reviewed. The document indicated a physician’s order to place Patient 17 on soft wrist restraints (wearable medical devices typically made of foam, fleece, or quilted fabric applied to the wrists and secured to the bed frame and limiting a patient’s movement) was given on May 17, 2026, at 7:34 p.m., and was ordered to be continued upon Patient 17’s admission on May 17, 2026, at 9:24 p.m., with a cancellation of the order on May 18, 2026, at 3:35 p.m. The document further indicated, “...Restraint type...Soft Wrist Left...Soft Wrist Right...Restraint reason...Interference with medical treatment...Attempting activity that poses a safety risk and unable to follow directions...” A facility documents titled, “Flowsheet History,” dated May 17, 2026, through May 18, 2026, were reviewed. The documents indicated bilateral soft wrist restraints were applied on Patient 17 on May 17, 2026, at 7:35 p.m., and the restraints were discontinued on May 18, 2026, at 3 p.m. (19 hours and 35 minutes). The flowsheets further indicated Patient 17 had a behavioral status of, “Subdued [quiet, still, or difficult to wake up],” during the length of the restraint application from May 17, 2026, at 7:35 p.m., to May 18, 2026, at 3 p.m. A facility document titled, “Plan of Care,” dated May 18, 2026, at 4:21 p.m., was reviewed. The document indicated, “...Restraints were discontinued at 3:00 p.m. after being continued throughout the morning and early afternoon, with behavioral status subdued...” On June 16, 2026, at 2:07 p.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated restraints are used on patients who are at risk of pulling lines, tubes, and drains (medical devices used to administer medications, monitor vital signs [measurements of the body’s basic, life-sustaining functions including heart rate (number of heart beats per minute), temperature, respiratory rate (number of breaths per minute), and blood pressure (the force of the blood pushing against the walls of the arteries as the heart pumps it through the body)] and remove excess bodily fluids), and for patient safety. RN 2 further stated, if a patient had a severe brain injury and was not moving, the restraints should be removed from the patient. On June 16, 2026, at 4:15 p.m., an interview was conducted with Physician (MD) 2. MD 2 stated Patient 17 was almost at the verge of brain dead [the complete, permanent loss of all brain functions] with half of the reflexes [automatic reflexes of the body such as blinking, pupil changes, coughing or gagging] being gone. MD 2 stated, “I don’t think we would need restraints for this one [Patient 17].” An undated facility policy and procedure (P&P) titled, “Restraint Policy,” was reviewed. The P&P indicated, “...Restraints may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time...Care of the patient requiring Non-Violent/Non-Self Destructive restraint...Assess the clinical justification for restrain such as:...attempting interruption of medical treatments or equipment, such as pulling lines, tubes, or drains...Attempting activity that poses a risk and unable to follow direction...” An undated facility P&P titled, “Patients’ Rights and Responsibilities,” was reviewed. The P&P indicated, “...You have the right to...Receive care in a safe setting...Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff...””

“PATIENT RIGHTS: ACCESS TO MEDICAL RECORD CFR(s): 482.13(d)(2) The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. If it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or if not, in a readable hard copy form or such other form or format as agreed by the facility and the individual, and within a reasonable timeframe. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. This Standard is not met as evidenced by: 35056 Based on interview and record review, the facility failed to ensure the medical record requested was provided in accordance with the facility’s policy and Procedure (P&P), for one of 19 sampled patients (Patient 2). This failure had the potential to place Patient 2 at risk of being uninformed of his condition which may affect Patient 2’s ability to make informed decisions concerning his care. Findings: On April 7, 2026, at 10:20 a.m., a review of Patient 2’s record was conducted with the Chief Nursing Officer (CNO). Patient 2 was admitted to the facility on January 27, 2026, with a diagnosis of left carotid artery occlusion (complete blockage of the main artery supplying blood to the left side of the brain). A facility document titled, “IR (Interventional Radiology, a medical specialty using imaging guidance perform treatments through tiny incisions) Angiogram Cerebral (a diagnostic imaging test used to visualize blood vessels in the brain and neck to detect blockages) Flowsheet,” dated January 27, 2026, was reviewed. The document indicated Patient 2 was admitted to the outpatient Interventional Radiology Department at on January 27, 2026, 7 a.m., for a cerebral angiogram. A facility document titled, “IR Angiogram Cerebral,” dated January 27, 2026, authored by Physician (MD) 3 was reviewed. The document indicated, “...Postoperative Procedure(s) Performed: Diagnostic cerebral angiogram...Complications: None; patient [Patient 2] tolerated the procedure well...” A facility document titled, “Perioperative [refers to before, during, and after the procedure] Nursing Note,” dated January 27, 2026, at 1:21 p.m., was reviewed. The document indicated, “...Discharge instructions given and all questions answered...patient [Patient 2] taken to curb in wheelchair by volunteer...” A facility’s document titled, “Facility A Authorization for Use or Disclosure of Protected Health Information (PHI),” dated February 8, 2026, was reviewed. The document indicated, “...Patient Information Patient Name: [name of Patient 2]...Release Records To I authorize [Name of Facility A] to release PHI to: Name of Recipient...[name of Patient 2]...Information to be Released...Entire Record which will include all of the above categories..Dates of Information...Date/Time period: January 27, 2026...” On April 8, 2026, at 1:45 p.m., an interview was conducted with the Health Information Management Director (HIMD). The HIM stated Patient 2 requested for his medical records and should have received the entire record right away. The HIM stated the HIM department only released pertinent (relevant) medical records to Patient 2 and this was against the facility’s policy. A review of the facility’s Policy & Procedure (P&P) titled, “Access of Individuals to Protected Health Information Health Information Management,” dated July 2, 2025, was conducted. The document indicated, “...Patients have a right to inspect and receive a copy of PHI contained in their records...If a patient requests an electronic copy of protected health information that is maintained in one or more designated record sets electronically, Health Information Management will provide the patient with access to the protected health information in the electronic form and format requested by the patient if it is readily producible in such form and format...””

“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: 35056 Based on interview and record review, the facility failed to ensure the facility’s policy and Procedure (P&P) were implemented, for three of 19 sampled patients (Patients 1, 10, and 18), when: 1. For Patient 1, the patient’s belongings were not documented every shift; and 2. For Patients 10 and 18, a second copy of the Important Message from Medicare (IMM, a mandatory hospital notice which informs patients on Medicare [a federal health insurance program for people age 65 and older] about their right to appeal a discharge and to participate in their hospital discharge planning [a centralized, interprofessional which develops a tailored plan to transition a patient safely from inpatient care to home or another facility]) was not provided to the patients before the patients were discharged from the facility. These failures had the potential for Patient 19’s personal belongings to be lost or stolen while the patient was admitted in the facility and for Patients 10 and 18 to not be informed of their rights to participate in their discharge planning and to not have an opportunity to appeal their discharge. Findings: 1. On April 6, 2026, a review of Patient 1’s record was conducted with the Chief Nursing Officer (CNO). A facility document titled, “Inpatient History & [and] Physical,” dated October 22, 2025, at 4:41 a.m., authored by Physician (MD) 2, was reviewed. The document indicated Patient 1 was brought to the Emergency Department (ED, a unit providing care for patients with sudden or severe illnesses) with a complaint of nausea (an urge to vomit), vomiting, and generalized abdominal (part of the body between the chest and the pelvis) pain. A facility document titled, “ED to Hosp [hospital]- Admission,” dated October 22, 2025, through October 26, 2025, was reviewed. The document indicated on October 22, 2029, at 5:38 a.m., Patient 1’s purse, wallet, keys, credit cards, clothing, shoes/slippers, cell phone, earrings, and necklace 1 (one) remained with Patient 1 at her bedside. The document indicated on October 23, 2025, at 8:30 a.m., Patient 1’s purse, wallet, keys, credit cards, clothing, shoes/slippers, cell phone, earrings, and necklace 1 remained with Patient 1 at her bedside. The document indicated on October 26, 2025, at 8 a.m., Patient 1’s purse, wallet, keys, credit cards, clothing, shoes/slippers, cell phone, earrings, and necklace 1 remained with Patient 1 at her bedside. A facility document titled, “Against Medical Advice [AMA, when a patient voluntarily leaves the hospital against the advice of the physician],” dated October 29, 2025, was reviewed and indicated Patient 1 left the hospital AMA. There was no documented evidence Patient 1’s belongings were documented every shift in accordance with the facility’s policy and procedure. On April 7, 2026, at 9:40 a.m., an interview was conducted with the CNO. The CNO stated Patient 1’s personal belongings should have been documented every shift according to the facility’s P&P. A review of the facility’s P&P titled, “Patient Valuables and Property,” dated May 6, 2025, was conducted. The policy indicated, “ ...Documenting patient personal items ...Epic [an electronic health system software] will be used by [name of Facility A] staff to document admitted patient’s personal belongings ...Reconciliation of patient personal items ...[name of Facility A] staff will conduct a reconciliation of personal items ...Before each shift change for admitted patients ...” 2 a. On April 8, 2026, at 10 a.m., an interview and concurrent record review of Patient 10’s records were conducted with the Chief Nursing Officer (CNO). A facility document titled, “Inpatient History & [and] Physical,” dated January 21, 2026, was reviewed. The document indicated Patient 10 was admitted to the facility on January 21, 2026, with a chief complaint of acute (sudden) on chronic (persistent or lasting for a long time) back pain. The document indicated Patient 10 was discharged from the facility on January 25, 2026, at 2:20 p.m. A review of the facility document titled, “Important Message from Medicare,” dated January 21, 2026, at 8:38 a.m., was conducted. The document indicated Patient 10’s family member received, dated, and signed the IMM on January 21, 2026. There was no documented evidence Patient 10, or his representative was provided with a copy of the IMM prior to his discharge on January 25, 2026. On April 8, 2026, at 10:40 a.m., an interview was conducted with the Director of Social Services (DSS). The DSS stated the facility is unable to find a copy of a signed IMM at Patient 10’s discharge. b. On April 7, 2026, at 2:47 p.m., a review of Patient 18’s records were conducted with the Patient Safety Program Manager (PSPM). A facility document titled, “History & Physical,” dated March 29, 2026, indicated Patient 18 was admitted to the facility on March 29, 2026, for an acute limb ischemia [a sudden, severe decrease in blood flow to a blocked main blood vessel in a leg]. A review of facility document titled, “Important Message from Medicare,” dated March 29, 2026, at 2:33 p.m., was conducted. The document indicated Patient 18’s family member received, dated, and signed the IMM on March 29, 2026, at 2:33 p.m. A review of facility document titled, “Care Timeline,” dated April 6, [2026], indicated Patient 18 was discharged from the facility on April 6, 2026, at 3:52 p.m. There was no documented evidence Patient 18, or their representative was provided with a copy of the IMM prior to Patient 18’s discharge on April 6, 2026. On April 8, 2026, at 9:20 a.m., an interview was conducted with the PSPM. The PSPM stated the facility could not produce documentation Patients 10 and 18 were provided a copy of the IMM before their discharge. The PSPM stated Medicare patients should receive a copy of the IMM to know they have a right to appeal their discharge. A review of the facility’s Policy and Procedure titled, “Important Message from Medicare,” dated May 29, 2025, was conducted. The P&P indicated, “...requirement that hospitals notify Medicare beneficiaries who are hospital inpatients about their hospital discharge rights...Patient Access must issue the Important Message for Medicare (IM) to the beneficiary within two (2) days of admission...The follow-up IM will be provided to the beneficiary or representative by the Case Manager as soon as possible prior to discharge, but no more than (2) calendar days before...so the beneficiary has ample time to review and act on it...the beneficiary must be given at least (4) hours prior to discharge to consider his/her rights...””

“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: 50304 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for five of 20 sampled patients (Patients 7, 9 13, 14, and 20), when: 1. For Patients 7 and 9, the physician was not notified by the nursing staff of the patient’s elevated blood pressure (BP, the force of the blood pushing against the walls of the arteries [big blood vessel], normal blood pressure is 120/80) readings on multiple days, in accordance with the physician’s order; 2. For Patient 9, the physician was not notified by the nursing staff of the patient’s elevated BP readings on September 8, 2025. In addition, the medication clonidine (medication to lower the BP) was not administered to Patient 9 in accordance with the physician’s order; 3. For Patient 13, the nurse did not notify the physician of SpO2 (oxygen saturation, the amount of oxygen in the blood, normal is 92 percent [%] or greater) less than or equal to 90; 4. For Patient 14, the physician was not notified by the nursing staff Patient 14’s respiratory rate (RR, the number of breaths a person takes per minute, normal is 12 to 20) was greater than or equal to 30, in accordance with the physician’s order; and 5. For Patient 20, RN 2 removed a pulmonary artery (PA, a large blood vessel from the heart leading to the lungs) catheter (a thin flexible tube inserted into a large vein and threaded into the heart and the pulmonary artery used to monitor heart and lung function) two hours and 15 minutes prior to the ordered time by the doctor. These failures had the potential to delay treatment and worsen Patients 7, 9 13, 14, and 20’s health conditions. Findings: 1. On November 17, 2025, at 10:30 a.m., a review of Patient’s 7’s record was conducted with the Registered Nurse Quality Analysis (RNQ) 3. A facility document titled, “Inpatient History & [and] Physical” dated September 9, 2025, was reviewed. The document indicated Patient 7 was admitted to the facility on September 9, 2025, and presented to the emergency department (ED) with a chief complaint (symptoms which led a patient to go to the ED) of weakness in both legs for the past two months and had an admitting diagnosis of metabolic acidosis (when acid builds up in the blood). The document indicated Patient 7 stated he was drinking alcohol prior to his arrival to the ED and his last alcohol drink was 12 hours prior to his arrival to the ED. The document indicated Patient 7 stated he usually drinks four to six shots of alcohol a day. An untitled facility document, dated September 2, 2025, was reviewed. The document indicated, “...Notify MD [physician] parameters [specific and measurable guidelines or limits used to monitor a patient’s health and guide clinical decisions] for vital signs [vs, measurements of your body’s basic functions, including temperature, pulse (heart rate), respiratory rate (RR, normal is 12 to 20 breaths per minute), oxygen saturation, and BP]...Order Details...Frequency...Until discontinued... SBP [systolic blood pressure, the top number in a blood pressure reading, measures the pressure in the arteries when the heart beats and pumps blood, normal is 120] less than or equal to 85...SBP greater than or equal to 160...” A facility document titled, “Flowsheet History,” dated August 6, 2025, through September 5, 2025, was reviewed. The document indicated, “...09/02/2025 [September 2, 2025] 0645 [6:45 a.m.]...[BP] ...116/103...09/04/25 [September 4, 2025]...171/85...09/05/2025 [September 5, 2025] 0408 [4:08 a.m.]...161/90...09/05/2025 0515 [5:15 a.m.]...161/107...” There was no documented evidence the physician was notified by the nursing staff notified of Patient 7’s elevated blood pressure readings on September 2, 4, and 5, 2025. On November 17, 2025, at 1:06 p.m., an interview was conducted with RNQ 3. RNQ 3 stated there was no documentation the nurse notified the physician of Patient 7’s elevated blood pressures. RNQ 3 stated the nurse did not follow the physicians’ order in reporting Patient 7’s vital signs that were abnormal. 2. On November 17, 2025, at 11 a.m., a review of Patient’s 9’s record was conducted with RNQ 3. A facility document titled, “Inpatient History & Physical,” dated September 6, 2025, was reviewed. The document indicated Patient 9 was admitted to the facility on September 6, 2025, and presented to the ED with a chief complaint of syncope (the medical term for fainting, which is a brief, temporary loss of consciousness caused by a sudden drop in blood flow to the brain) episodes and a urinary tract infection (UTI, an infection anywhere in the urinary system). a. An untitled facility document, dated September 5, 2025, was reviewed. The document indicated, “...Notify MD for vitals...Order Details...Frequency...Until discontinued...Order Questions...SBP less than or equal to 85...SBP greater than or equal to 160...” An untitled facility document, dated August 8, 2025, through September 8, 2025, was reviewed. The document indicated, “...09/08/2025 [September 8, 2025] 1519 [3:19 p.m.]...[blood pressure, normal is 120/80] ...188/77...09/08/2025 1613 [4:13 p.m.]...174/77...” There was no documented evidence the physician was notified by the nursing staff of Patient 9’s elevated blood pressure readings on September 8, 2025. b. An untitled facility document, dated September 6, 2025, was reviewed. The document indicated, “...cloNIDine (CATAPRES) Tablet 0.1 MG [milligram, unit of measurement]...Ordered Dose 0.1 mg...Frequency: Every 4 [four] hours PRN [as needed] for high blood pressure...Duration 3 [three] days...Scheduled Start Date/Time: 09/06/2025 [September 6, 2025] 1849 [6:49 p.m.]...End Date/Time: 09/08/25 1955 [7:55 p.m.]...Admin [sic, administration] Instructions: The indicated use for this medication is: PRN for SBP > [greater than] 180...” There was no documented evidence clonidine medication was administered on September 8, 2025, when Patient 9’s BP readings were 188/77 at 3:19 p.m., and 174/77 at 4:13 p.m. On November 17, 2025, at 11:15 a.m., an interview was conducted with RNQ 3. RNQ 3 stated there was no documentation the nurse notified the physician of Patient 9’s elevated BP radings on September 8, 2025. RNQ 3 stated the nurse did not follow the physicians’ order in reporting blood pressures which were abnormal. RNQ 3 stated the nurse did not administer clonidine medication when Patient 9 should have received a dose on September 8, 2025, in accordance with the physician’s order. 3. On November 17, 2025, at 2:17 p.m., a review of Patient 13’s record was conducted with the Chief Nursing Informatics Officer (CNI). An untitled and undated facility document was reviewed. The document indicated, “...Admit Date: 11/14/25 [November 14, 2025]...Adm [sic, Admitting] Diagnosis [the identification of the nature of an illness]: chronic osteomyelitis [a long-lasting infection of the bone]...” A facility document titled, “Inpatient History & Physical,” dated November 14, 2025, was reviewed. The document indicated, “...CHIEF COMPLAINT: cellulitis (an infection of deep layers of the skin)...with chronic osteomyelitis...” A facility document titled, “Order Report,” dated November 14, 2025, was reviewed. The document indicated, “...Notify MD for vitals signs...SpO2 less than or equal to 90...” An untitled and undated facility document was reviewed. The document indicated, “...11/16 [November 16, 2025] 0701 [7:01 a.m.] - [to] 11/17 [November 17, 2025] 0700 [7 a.m.]...1641 [4:41 p.m.]...SpO2...88...” There was no documented evidence the physician was notified of Patient 13’s SpO2 of 88 on November 16, 2025, at 4:41 p.m. On November 17, 2025, at 2:40 p.m., an interview was conducted with the CNI. The CNI stated there was no documentation from the nursing staff regarding Patient 13’s condition. The CNI stated there was no documentation the physician was notified of Patient 13’s SpO2 of 88 on November 16, 2025. On November 17, 2025, at 11:36 a.m., an interview was conducted with RN 1. RN 1 stated if there are “parameters” for vital signs set by the physician and “anything that falls outside of the parameters in the order,” the RN should communicate it with the doctor. 4. On November 18, 2025, at 9:42 a.m., a review of Patient 14’s record was conducted with the CNI. An untitled and undated facility document was reviewed. The document indicated, “...Adm Diagnosis...Acute respiratory failur* [sic, failure] [a sudden and life-threatening condition where the lungs cannot get enough oxygen]...” A facility document titled, “Inpatient History & Physical,” dated April 21, 2025, was reviewed. The document indicated, “...CHIEF COMPLAINT: shortness of breath...” A facility document titled, “Order Report,” dated April 21, 2025, was reviewed. The document indicated, “...Notify MD for vitals...RR greater than or equal to 30...” An untitled and undated facility document was reviewed. The document indicated, “...04/27 [April 27, 2025] 0701 [7:01 a.m.] - 04/28 [April 28, 2025] 0700 [7 a.m.]...2300 [11 p.m.]...resp rate [RR]...30...0000 [12 a.m.]...34...” There was no documented evidence the physician was notified of Patient 14’s RR of 30 on April 27, 2025, at 11 p.m., and the RR of 34 on April 28, 2025, at 12 a.m. On November 18, 2025, at 11:12 a.m., an interview was conducted with the CNI. The CNI stated there was no documentation the physician was notified of Patient 14’s RR of 30 on April 27, 2025, at 11 p.m., and RR of 34 on April 28, 2025, at 12 a.m. The CNI stated there were documentation from the nursing staff regarding Patient14’s condition. The CNI stated the nurse should have contacted Patient 14’s physician to notify him Patient 14’s elevated RR in accordance with the physician’s order. The CNI stated it is important to notify the physician because “if the patient is declining, the physician should be made aware of the patient’s condition.” On November 17, 2025, at 11:36 a.m., an interview was conducted with RN 1. RN 1 stated if there are “parameters” for vital signs set by the physician and “anything that falls outside of the parameters” in the physician’s order, the RN should communicate it with the doctor. 5. On November 18, 2025, at 2:02 p.m., a review of Patient 20’s record was conducted with the CNI. An untitled and undated facility document was reviewed. The document indicated, “...Admit Date: 11/8/25 [November 8, 2025]...Adm Diagnosis: Syncope and collapse...” A facility document titled, “CARDIOLOGY INPATIENT ADMISSION HISTORY & PHYSICAL,” dated November 8, 2025, was reviewed. The document indicated, “...CHIEF COMPLAINT/REASON FOR ADMISSION: Inferior STEMI [ST (a specific part of the heart’s electrical activity) Elevated Myocardial Infarction (heart attack), a specific type of heart attack where the bottom part of the heart muscle is damaged because its blood supply is blocked]...” A facility document titled, “Discharge Summary,” dated November 16, 2025, was reviewed. The document indicated, “...Admission Diagnosis: STEMI...Procedure: On 11/12/2025 [November 12, 2025] the patient [Patient 20] underwent Coronary Artery Bypass Grating times 3 [Triple Bypass, a heart surgery which creates new paths for blood to flow around three blocked coronary arteries (heart blood vessels)]...” A facility document titled, “Order Report,” dated November 12, 2025, was reviewed. The document indicated, “...Discontinue Swan -Ganz [a pulmonary artery catheter]...on 11/12/25...D/C [Discontinue] at 0600 [6 a.m.]...” A facility document titled, “Plan of care,” dated November 13, 2025, authored by RN 2, was reviewed. The document indicated, “...Patient had a desaturation event [an event where the amount of oxygen in a person’s blood drops to a level which is too low] following PA catheter removal at approximately 0345 [3:45 a.m.]...” A facility document titled, “Physician Notification,” dated November 13, 2025, was reviewed. The document indicated, “...PA [Physician Assistant] notified in person at 0500 [5 a.m.] of Patient’s [Patient 20’s] respiratory decline starting after laying flat for PA removal...” On November 18, 2025, at 2:52 p.m., an interview with RN 3 was conducted. RN 3 stated they should always follow the physician’s orders. RN 3 stated she would “never adjust the time” indicated in the doctor’s order. RN 3 stated it is important to follow the ordered time when a PA catheter needs to be removed “so that everybody is on the same page and everybody is in aggreance [sic, agreement] that the patient is stable” and the patient does not need additional “hemodynamic monitoring [a way nurses use measurements to see how well a patient’s heart is pumping and how well the blood is flowing through the body].” An article published online by the National Institute of Health (a nationally recognized organization for research) titled, “The contemporary pulmonary artery catheter. Part 1: placement and waveform [study of graphical representations of signals like electrical activity] analysis,” dated February 10, 2021, was reviewed. The article indicated, “...the classical pulmonary artery catheter has...its clinical use for hemodynamic monitoring...Adequate catheter placement and detailed understanding...are a prerequisite for the correct interpretation of physiology [the study of how the human body works] and pivotal in clinical decision making [the process health professionals use to gather and interpret patient data, diagnose conditions, and determine the best course of action for a patient’s treatment]...” A facility’s P&P titled, “Patient Care Manual,” dated December 5, 2023, was reviewed. The policy indicated, “...RN progress notes...Change in patient condition...Communication with the provider...The nurse must document and use the “Provider Notification” smart text [a standardized text template used by clinical staff]...all ...change in patient condition must be communicated to the provider in-person or by phone...””

“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: 47071 Based on interview and record review, the facility failed ensure the physician was notified of a change of condition (COC), for one of 30 sample patients (Patient 28), in accordance with the facility’s policy and procedure (P&P), when facial scratches on the right side of the face and ecchymosis (bruising) were observed on Patient 28’s right cheek and jaw line. This failure has the potential to cause a delay in care and treatment for Patient 28. Findings: A review of Patient 28’s record was conducted with Quality Improvement (QI). A facility document titled, “History and Physical (H&P),” dated August 6, 2025, was reviewed. The document indicated Patient 28 was admitted to the facility for a fall at home resulting in a displaced left intertrochanteric femur fracture (broken hip). A facility document titled, “ED Provider Note,” dated August 6, 2025, at 2:53 p.m., was reviewed. The document indicated, “...EMERGENCY DEPARTMENT ENCOUNTER...PHYSICAL EXAM...HENT [Head, Ears, Nose, and Throat]...Head: Normocephalic [normal size and shape] and atraumatic [free from signs of injury, bruising, swelling or other trauma]...Skin...General: Skin is warm and dry...” A facility document titled, “Op [operative, related to a surgical procedure] Note,” dated August 7, 2025, at 1:28 p.m., was reviewed. The document indicated, “...Procedure...HIP FRACTURE ORIF [Open reduction and internal fixation, a surgical procedure for repairing a broken bone] NAILING [using screws to stabilize the bone]...Postoperative [after a surgery] Diagnosis...Left hip fracture...” A facility document titled, “Media information,” dated August 7, 2025, at 4:50 p.m., was reviewed. The document included a photograph of Patient 28’s face. The document indicated bruising was identified on Patient 28’s right cheek. A facility document titled, “Flow Sheet History,” dated July 19, 2025, to August 18, 2025, was reviewed. The document indicated, “...Skin Abnormality...08/06/25 [August 6, 2025.] at 1545 [3:45 p.m.]...Brusing... 08/06/25 2000 [8 p.m.]...Bruising...8/7/2025 [August 7, 2025] 0800 [8 a.m.]...Bruising... 8/7/2025 at 1700 [5 p.m.]...Bruising...surgical... 8/7/2025 2000...Bruising ...surgical site...” There was no documented evidence the facility reported the change of condition for Patient 28, the bruising on Patient 28’s right cheek and jaw line, to the physician. On September 16, 2025, at 3:26 p.m., an interview was conducted with the Unit Manager (UM). The UM stated the bruise and scratch on Patient 28’s face and jaw line were not reported to the physician. The UM stated the nursing staff are expected to report a patient’s change of condition to the physician. A review of facility P&P titled, “Patient Care Manual,” dated May 16, 2025, was conducted. The facility policy indicated, “...Communication with the provider...All critical lab results and change in patient condition must be communicated to the provider in-person or by phone...””

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 47071 Based on interview and record reviews, the facility failed to ensure a patient who needed assistance for feeding was provided assistance to eat breakfast and lunch on August 9, 2025, and August 12, 2025, for one of 30 sample patients (Patient 28). This failure has the potential to and compromise the nutritional health and cause delay in wound healing for Patient 28. Findings: A review of Patient 28’s record was conducted with Quality Improvement (QI). A facility document titled, “History and Physical (H&P),” dated August 6, 2025, was reviewed. The document indicated Patient 21 was admitted to the facility for a fall at home resulting in displaced left intertrochanteric femur fracture (broken hip). A facility document titled, “nil per os [NPO, nothing by mouth],” dated August 6, 2025, was reviewed. The document indicated Patient 28 was placed on an NPO diet after midnight on August 6, 2025. A facility document titled, “Order Report,” dated August 7, 2025, was reviewed. The document indicated Patient 28 was placed on a full liquid (liquids food which can be eaten without chewing and liquefy at room temperature) for one meal on August 7, 2025, then the diet was advanced as tolerated by the patient to a regular diet (a normal diet which includes a variety of foods from all major food groups without any specific restrictions or modifications). A facility document titled, “[Name of Facility] Patient Meal delivery Times Scheduled,” dated August 22, 2025, was reviewed. The document indicated, “...[name of Unit A where Patient 28 was admitted]...Breakfast...7:30 a.m...Lunch...12:00 p.m...Dinner...5:30 p.m...” A facility document titled, “Flowsheet History,” dated September 16, 2025, at 2:04 p.m., was reviewed. The document indicated, “...Date/Time...Feeding...8/6/2025 [August 6, 2025] at 1545 [3:45 p.m.]...needs assist...8/7/2025 [August 7, 2025] 1737 [5:37]...Total assist... 8/9/2025 [August 9, 2025] 2000 [8 p.m.]...Needs set up; Needs assist; Total assist...8/18/2025 [August 18, 2025] 0800 [8 a.m.]...Total assist...” There was no documented evidence the facility provided assistance to feed Patient 28 lunch and dinner on August 9, 2025, and on August 12, 2025. On September 16, 2025, at 2:10 p.m., an interview was conducted with QI. The QI stated there is no documentation assistance to feed was provided to Patient 28 during lunch and dinner on August 9, 2025, and on August 12, 2025. The QI stated staff should have documented the meals provided to Patient 28 and the percentage of the meal the patient ate each meal. On September 16, 2025, at 2:10 p.m., an interview was conducted with Quality Applications Analyst (QAA). The QAA stated the facility does not have a policy for providing assistance to patients for feeding. A review of the facility policy and procedure titled, “Nutritional Care,” dated September 16, 2025, was conducted. The P&P indicated, “...Purpose...To document data pertinent to the nutritional care of the patient and develop a nutritional care plan for the individual patient throughout the continuum of care...””

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure coordination with the facility to which a patient was being discharged to was conducted, for one of 30 sample patients (Patient 21), when the facility did not coordinate nor inform the hemodialysis (HD, a medical treatment which removes waste products and excess fluid from the blood when a person’s kidneys are failing) center about Patient 21 being discharged and being sent to the HD center for dialysis upon discharge from the facility. This failure resulted in a late start for Patient 21’s HD and had the potential for Patient 21 to receive inadequate care after discharge from the facility which may cause harm to the patient. Findings: On September 16, 2025, at 9:26 a.m., a concurrent interview and review of Patient 21’s record were conducted with the Quality Analyst (QA). A facility document titled, “History & Physical,” dated July 18, 2025, was reviewed. The document indicated Patient 21 was admitted to the facility for leg swelling and shortness of breath. The document indicated Patient 21 has a past medical history of end stage renal disease (ESRD, a condition where the kidneys no longer function and the patient needs HD to filter the blood of wastes and excess fluids). A facility document titled, “Nephrology [a branch of medicine which specializes in the treatment and diagnosis of kidney diseases] Consultation,” dated July 17, 2025, was reviewed. The document indicated, “...with a history of ESRD on hemodialysis...complaint of lower extremity [legs] swelling...HD tonight...plan for HD again tomorrow...” A facility document titled, “Case Management Progress Notes,” dated July 18, 2025, was reviewed. The document indicated, “...Internal comment last updated by [name of case manager]...Spoke W/ [with name of HD center staff] @ [at] [name of HD center]...pt [Patient 21] still has his OP [outpatient, outside of a hospital] HD chair time [the duration a patient spends in the reclining chair at a HD center while receiving HD treatment] M [Monday] W [Wednesday] F [Friday] @ 11:30AM...facility will hold chair time only until 07/25/2025 [July 25, 2025] before they discharge him off...” A facility document titled, “Case Management Assistant Progress Notes,” dated July 23, 2025, at 8:37 a.m., was reviewed. The document indicated, “...HD follow up...please arrange one way wheelchair transport [the use of specialized vehicles equipped with ramps, lifts, and securement systems to accommodate and transport individuals who use wheelchairs] to HD [center]...transport arranged 10:30 [a.m.] via wheelchair [wheelchair transport]...” There was no documented evidence the facility contacted the HD center to notify the HD center regarding Patient 21 being discharged from the facility and transported to their HD center for dialysis. On September 16, 2025, at 2:56 p.m., an interview was conducted with Case Manager (CM) 1. CM 1 stated if a patient was receiving HD the case manager would call the HD center to inform them the patient was hospitalized and to verify the patient’s chair days and times. She further stated, when a patient was ready for discharge, the case manager would coordinate care with the HD center and inform them the patient was discharged and would be coming to their center for dialysis. On September 17, 2025, at 8:53 a.m., an interview was conducted with the Dialysis Center Staff (DCS). The DCS stated Patient 21’s normal chair time was 11:30 a.m., on Mondays, Wednesdays, and Fridays. The DCS stated Patient 21 arrived at the HD center 15 minutes late on July 23, 2025, at 11:45 a.m. The DCS further stated the HD center was not informed Patient 21 was being discharged from the facility and would be arriving at their HD center. The DCS stated, due to the Patient 21’s late arrival at the HD center, Patient 21’s HD did not start until 11:58 a.m., on July 23, 2025. A review of the facility document titled, “Discharge Planning,” dated July 26, 2023, was reviewed. The document indicated, “...Any patient who meets one of the following criteria shall be referred for discharge planning services...Currently require post-hospitalization care services...All patients...within the organization have care provided by their treating physician...Case Management...Diagnosis serious enough to cause life-style change...Specially...Chronic Renal Disease on Hemodialysis...The discharge planning assessment shall be completed on a timely basis so that appropriate arrangements for post-hospital care are made before discharge...The organization shall arrange for the initial implementation of the discharge plan. This includes arranging for necessary post-hospital services and care...””

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 50304 Based on observations, interviews, and record reviews, the facility failed to ensure surgical services were maintained when: 1. Black particles were observed in the dryer chamber of one of four big washers (Washer 1) in the Main Central Sterile Processing (CSP) Department. This failure had the potential for instruments which were sterilized in Washer 1 to be contaminated which had had the potential for patients in whom these instruments were used to be exposed to infection (Refer to A 0951); and 2. Unsterilized instruments were used during a surgical procedure, for one of 10 sample patients (Patient 3). This failure resulted in Patient 3 to be exposed to infection and/or blood-borne diseases (diseases caused by bacteria or viruses in the blood transmitted through contact with infected blood or body fluids) and had the potential to result in a delay in Patient 3’s recovery and may prolong the patient’s hospital stay (Refer to A 0951). The cumulative effect of these failures had the potential for patients to exposed to bacteria, viruses, and/or fungi from the unsterilized instruments which could result in hospital acquired infections (infections that patients develop while receiving care in a hospital) for patients and prolonged hospital stay.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 50304 Based on observations, interviews, and record reviews, the facility failed to ensure surgical services were maintained when: 1. Black particles were observed in the dryer chamber of one of four big washers (Washer 1) in the Main Central Sterile Processing (CSP) Department. This failure had the potential for instruments which were sterilized in Washer 1 to be contaminated which had had the potential for patients in whom these instruments were used to be exposed to infection; and 2. Unsterilized instruments were used during a surgical procedure, for one of 10 sample patients (Patient 3). This failure resulted in Patient 3 to be exposed to infection and/or blood-borne diseases (diseases caused by bacteria or viruses in the blood transmitted through contact with infected blood or body fluids) and had the potential to result in a delay in Patient 3’s recovery and may prolong the patient’s hospital stay. Findings: 1. On May 13, 2025, at 8:13 a.m., a tour of the Main CSP Department was conducted with the Associate Vice President of Surgical Services (AVP), the Chief Nursing Officer (CNO), the Quality Analyst (QA), the Central Services Manager (CSM) and the Director of Central Services (DCS). On May 13, 2025, at 8:22 a.m., during the tour, an inspection of the Main CSP big washer was done and black particles were observed in the dryer compartment of the big washer. On May 13, 2025, at 8:24 a.m., an interview was conducted with the CSM. The CSM stated there were black particles in the dryer compartment of the big washer. The CSM stated there should not be any black particle in the dryer compartment of the big washer. The CSM stated the dryer compartment of the washer should have been cleaned. On May 13, 2025, at 4:50 p.m., an undated document titled, “Operator Manual,” for the big washer, was reviewed. The document indicated, “...it is the responsibility of the customer to verify HEPA [High Efficiency Particulate Air] filter [a type of filter designed to remove airborne particles] condition to help ensure safe and reliable operation of filter...HEPA filter replacement should be carried out only by [Name of company] trained, qualified, facility service technicians or [Name of Company] service technicians...” On May 13, 2025, at 4:50 p.m., an undated and untitled document was reviewed. The document indicated, “...May 13, 2025, at 9:36:45 [9:36 a.m.]...Subject...(Dry Chamber)...The dry chamber is an empty chamber that the washer rack will pass thru once the devices have been cleaned and thermally disinfected [a process that removes infections such as bacteria and viruses through the use of hot water]...There are HEPA filters that are changed...but end users do not do this only trained service team...” There was no documented evidence the Operator Manual for the big washer contained instructions on what is to be done if there were black particles in the dryer chamber of the big washer. On May 13, 2025, at 4:50 p.m., an interview was conducted with the DCS. The DCS stated they do not have a policy on the cleaning, testing, and maintenance of the washers in the CSP department. The DCS stated they follow the operator manual in the cleaning, testing, and maintenance of the big washer. On May 14, 2025, at 8:48 a.m., an interview was conducted with the CSM. The CSM stated the Operator Manual for the big washer did not contain instruction regarding the cleaning of black particles in its dryer chamber. The CSM stated that the Operator Manual indicated the staff should have been checking the condition of the dryer compartment. The CSM stated there was no staff assigned to check the condition of the dryer compartment in the big washer. 2. On May 12, 2025, at 9:38 a.m., a tour of the Main CSP Department was conducted with the QOS, the AVP, the CNO, the QA, and the DCS. Two unlabeled carts were observed in front of Sterilizer (an equipment that kills bacteria, fungi [microorganism such as molds or yeasts] and spores [cell that bacteria or fungi produce to defend themselves against high temperatures or conditions])12. On May 12, 2025, at 11 a.m., an interview was conducted with CSP Technician (CST) 1. CST 1 stated there were no labels on the two carts in front of Sterilizer 12. CST 1 stated the CSP personnel will check for the chemical test (CT, a test to ensure the instruments or trays are sterilized) on the trays on the carts to know which cart holds the sterilized trays and which cart holds the unsterilized trays. On May 13, 2025, at 9:16 a.m., a review of the Quality Assurance testing (testing done to ensure equipment meet specified quality standards and requirements) for the equipment in the Main CSP Department was conducted with the Instrument Management Coordinator (IMC). On May 13, 2025, at 9:48 a.m., an untitled and undated facility document was reviewed. The document indicated, “...[Name of Sterilizer]...Site: MAIN...Date opened: 1/7/2025 [January 7, 2025] 2:14 AM [a.m.]...Contents...Neuro [neurology, branch of medicine specializing on the diagnosis and treatment of disorders of the brain and spinal cord] Spine Tray 1 Item Index [a unique identifier used to track and manage individual instruments] 001...Biologicals [a test system used to verify the effectiveness of sterilization (a process that destroys bacteria, viruses, fungi, and spores) ...]...Test...Chemical...Result...Fail...Date Recorded 1/7/2025 4:20 AM...” On May 13, 2025, at 10:02 a.m., an untitled and undated facility document was reviewed. The document indicated, “...Date...1/7/2025 2:14 AM...[Name of CST 2] ...Neuro Spine Tray 1...[Name of Sterilizer 12]...QTY [Quantity]1...1/12/2025 [January 12, 2025] 7:03 AM...Tray 1...Case Cart-010 ...01/12/2025 3:29 PM...Washer 1...1/13/2025 [January 13, 2025] 1:29 AM...Tray 1...Sterilizer 12...” On May 13, 2025, at 10:11 a.m., an undated facility document titled, “Case Cart Details,” was reviewed. The document indicated, “...Case Number n2061440...1/12/2025 7:30 AM...Main OR [operating room, room number]...[Name of MD]...Neuro Spine Tray # [number]1...Date Added to Cart 1/12/2025 7:03 AM...” On May 13, 2025, at 10:25 a.m., an interview with the IMC was conducted. The IMC stated the chemical test for Sterilizer 12 failed. The IMC stated Neuro Spine Tray 1 was not re-sterilized on January 7, 2025. The IMC stated Neuro Spine Tray 1 should have been re-sterilized on January 7, 2025. The IMC stated Tray 1 was used for a surgical procedure on January 12, 2025, at 7:30 a.m. On May 13, 2025, at 10:35 a.m., an interview was conducted with the CSM. The CSM stated the chemical test for Sterilizer 12 failed. The CSM stated the instruments or trays in Sterilizer 12 were not sterile. The CSM stated Neuro Spine Tray 1 should have been re-sterilized. The CSM stated Neuro Spine Tray 1 should not have been used on a surgical procedure since it was not sterilized. On May 13, 2025, at 3:12 p.m., a review of Patient 3’s medical record was conducted with the Manager Perioperative Informatics and Education (MPI). Patient 3 was admitted to the facility on January 7, 2025, for back and leg pain. On May 13, 2025, at 3:18 p.m., an undated facility document titled, “Verification of Informed Consent,” was reviewed. The document indicated, “...your physician [Name of MD]...has recommended the following surgery...Signature [Signature of Patient 3]...1/9/25 [January 9, 2025]...1342 [1:42 p.m.]...” On May 13, 2025, at 3:19 p.m., an undated and untitled document was reviewed. The document indicated, “ ...Care Timeline ...01/12 [January 12, 2025] Lumbar Three Lumbar Four Lumbar Five [bones in the lower portion of the spine] Decompression Fusion [a surgical procedure used to address back pain and nerve compression] ...” On May 14, 2025, at 9:14 a.m., an interview was done with the CSM. The CSM stated the facility policy titled, “Recall of Hospital Sterilized Items,” was not implemented for Neuro Spine Tray 1. The CSM stated everything that was supposed to be done in the policy should have been followed. On May 14, 2025, at 9:32 a.m., an interview was done with the Quality Analyst (QA). The QA stated the Neuro Spine Tray 1 was used for Patient 3’s surgery. On May 14, 2025, at 10:23 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated the facility policy titled, “Recall of Hospital Sterilized Items,” should have been followed for Neuro Spine Tray 1. The IP stated she was not informed an unsterile tray was used during Patient 3’s surgery. The IP stated she should have been informed so the patient could be monitored for infection and complications of surgery. The IP stated it is important to recall the unsterilized items to keep unsterile packs or instruments from being used on a patient and to prevent infection. On May 14, 2025, at 10:33 a.m., a document tiled, “[Name of Company] Attest Steam Chemical Integrators 1243A and 1243B,” was reviewed. The document indicated, “...Directions for Use ...After processing, the dark color should have entered the green ACCEPT window...If the dark color has not entered the green ACCEPT window, a red REJECT result is indicated and the items in the pack, peel pouch, container system, or tray were not exposed to sufficient steam sterilization conditions. These items should be returned for reprocessing...” A facility policy titled, “Recall of Hospital Sterilized Items,” dated June 21, 2005, was reviewed. The policy indicated, “...if a biological culture is positive or a sterilizer has malfunctioned a recall shall be initiated...notify the central sterile processing director who will notify the Surgical Services Director and infection preventionist...Identify and Retrieve items from the load not in use...If suspected items have been used, the Central Sterile Processing Director and the Infection Preventionist will notify the physicians and supply patient names for proper treatment and follow up...Administrative Director of Surgical Services shall be notified of the above when a recall is initiated...” The facility Infection Control Plan titled, “Infection Prevention and Epidemiology (the study of the distribution and control of health-related events or diseases) Program Plan 2024 Evaluation 2025 Goals,” was reviewed. The plan indicated, “...Mission...The infection prevention program is in place to reduce the incidence of preventable...infections...conduct ongoing surveillance (the ongoing systematic collection, analysis, and interpretation of health-related data) and analysis...to recognize trans and address issues in a timely manner...protect patients...by reducing risks of healthcare associated infections (infections acquired by patients while receiving care in a health facility)...and providing timely exposure follow up and management...””

“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: 33972 Based on interview and record review, the facility failed to implement their “Pain Management” policy for one of 30 sample patients (Patient 1), when Patient 1 was not provided pain medication for three hours and 58 minutes after arriving at the Emergency Department (ED), complaining of chest pain. This failure resulted in Patient 1’s chest pain to not be treated in a timely manner. Findings: On March 12, 2025, an unannounced visit was conducted at the facility for a complain validation survey. On March 12, 2025, at 1 p.m., Patient 1’s medical record was reviewed with the Director of Quality (DQ). The facility document titled, “ED Provider Notes”, dated March 2, 2025 at 6:32 a.m., was reviewed. It indicated Patient 1 presented to the ED on March 2, 2025 at 12:02 a.m., with a chief complaint of shortness of breath for one month. The facility document titled, “Flowsheet History”, dated March 2, 2025, at 12:08 a.m., was reviewed and indicted Patient 1 rated his chest pain seven of 10 on the pain scale (numerical tool used to assess intensity of pain). The facility undated document titled, “Medication Administration Report,” was reviewed and indicated, Morphine four milligrams (mg’s, unit of measurement) Intravenous (IV, in the vein), was ordered and administered at 4 a.m., three hours and 58 minutes after Patient 1 presented to the ED with chest pain. There was no documented evidence pain medications were ordered or administered to Patient 1 prior to the Morphine. On March 12, 2025, at 2:20 p.m., an interview was conducted with the DQ. The DQ stated, per the facility policy Patient 1 was not provided pain medication in a timely manner. A review of the facility policy titled, “Pain Management,”, revised August 2024, was reviewed and indicated, “Purpose: To ensure optimal patient comfort through a proactive pain control plan...The patient’s right to pain management is respected and supported. This is accomplished by...effective pain management strategies and interventions...[Name of facility] staff will respond quickly to communication of unrelieved pain to the physician for resolution...””