Uci Health-Lakewood

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 45774 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Discharge Planning as evidenced by: 1.To ensure one of thirty sampled patient’s (Patient 15), had a re-evaluation of the patient’s condition and identify changes that led to the modification (change) of the discharge plan. There was no discharge plan update when Patient 15, who was identified to have no ability or capacity to care for himself, was discharged to Recuperative Care Facility (RC1- provides short-term residential, housing, and support services for homeless individuals or those with housing instability who are recovering from an illness or injury and no longer require hospitalization) without wandering supervision. This deficient practice can potentially lead to lack of supervision, falls, environmental accidents, or death from exposure to harsh environmental elements, particularly if the patient wanders off outside RC1. (Refer to A-0802). 2. To ensure Patient 1’s was not discharged to a recuperative care (provides short-term residential, housing, and support services for homeless individuals or those with housing instability who are recovering from an illness or injury and no longer require hospitalization) despite of physician discharge order to board and care with home health. Patient 1’s discharge planning and post hospital care arrangement was unsafe, inadequate, and inappropriate to Patient 1’s condition and care needs. This deficient practice result in Patient 1 was sent to a recuperative care without Home Health arrangement. Patient 1 was brought to emergency department (ED) in a different hospital (GACH 2) 5 days after being discharged to recuperative care via paramedics due to chest pain. Per Emergency Medical Services (EMS) Patient 1 was soiled with urine and stool during transfer, and GACH 2 Emergency Department (ED) found Patient 1 have elevated troponin, low blood pressure and malnutrition. (Refer to A-0804). The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“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: 45774 Based on observation, interview, and record review the facility failed to: A. Ensure nursing staff followed standards of practice for blood transfusion ( a procedure when a person receives blood intravenously (IV-into the vein) ) administration for one of thirty sampled patients (Patient 10), when Patient 10’s IV site used for blood transfusion was not labeled with required identifiers (date, time, and initials) and the medical record lacked accurate documentation of transfusion completion indicating the transfusion remained in progress over two day period. This deficient practice had the potential for compromised patient safety and harm, which included the inability to assess IV site age, increased risk for infection, and failure to detect complications due to lack of appropriate monitoring and unclear transfusion status. B. Ensure nursing staff provided and documented repositioning (to place in a different position) for approximately 12 hour period for one of thirty sampled patients (Patient 9), when Patient 9 who was identified as a risk for skin breakdown was discharged and readmitted the same day with a stage 2 pressure injury (Partial-thickness loss of skin, presenting as a shallow open sore or wound) which was consistent with a lack of timely repositioning creating the potential for avoidable patient harm. This deficient practice resulted in the development of a stage 2 pressure injury identified upon same-day readmission and reflects a failure to implement basic pressure injury prevention measures, including timely repositioning, placing the patient at risk for avoidable harm, including further skin breakdown, infection, and complications. Findings: During a review of Patient 10’s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient’s current illness, medical history, and a physical examination) dated 3/11/2026, indicated, Patient 10 was admitted to the facility on 3/11/2026 with syncope (fainting or passing out) and rectal bleeding (blood passing from the rectum). The H&P indicated that Patient 10 had an assessment of a lower gastrointestinal (GI- bleeding in the stomach) bleed and the plan was to monitor Hematocrit and Hemoglobin (H/H- a test that measures the amount of red blood cells in the body) every six hours for one day and transfuse as needed for hemoglobin (HGB-a protein responsible for delivering oxygen to the body) less than 7.0. During a review of Patient 10’s “Blood Administration Flowsheet” dated 3/14/2026 to 3/17/2026, the Flowsheet indicated that a completed transfusion has not been stopped. During a review of Patient 10’s “Blood Administration Flowsheet” dated 3/14/2026 to 3/17/2026, the Flowsheet indicated that Patient 10 received two units of blood. The first unit dated 3/15/2026 transfused 2,700ml and the second unit dated 3/16/2026 transfused 400ml. During a review of Patient 10s “Transfusion Information Flowsheet” dated 3/14/2026, The flow sheet indicated that one unit of blood was started on 3/14 at 1:10 PM and was completed on 3/18 2026 at 8:30 AM. During an observation on 3/16/2026 at 2:19 PM Patient 10 was observed lying in bed with a blood transfusion transfusing through an IV site on her right arm. The IV site was not physically dated or labeled. During an interview on 3/16/26 at 2:21 PM, with Registered Nurse 1 (RN 1), RN1 stated that they think the IV was inserted yesterday. RN 1 stated that the IV should be dated and the consequences of not dating and labelling an IV are that patients are at risk for getting an infiltration (leakage of a medication from the vein into the surrounding tissue) from the or getting an infection (growth of germs in the body). And it is the expectation that when the IV is placed it is labeled with the date and time. During an interview on 3/17/2026 at 4:15 PM with Telemetry Manager 1 (TM1), TM1 stated that the consequences of not properly documenting the end time of a blood transfusion could cause potential fluid overload. TM1 stated the nurse who had this patient went home very sick that day and the charge nurse took responsibility and assumed responsibility. TM1 stated, it was human error (something that was done that was not intended) and unfortunately it was not discontinued (stopped permanently), the expectation is that nurses document within a timely manner and it should be documented during handoff. During a review of the hospital’s Policy and Procedures (P&P) titled, “Adult Core Nursing Standards of Care” (dated 02/2026), the P&P indicated “ ...... Documentation of all .... peripheral IVs will include .... insertion date ....” During a review of the hospital’s Policy and Procedures (P&P) titled, “Blood/ Blood Component Transfusion” (dated 09/2024), The P&P indicated “ ...... A single unit of blood/ blood component must be transfused within 4 hours of the time it is received from the blood bank .... All infusions must be completed within 4 hours.” B. During a review of Patient 9’s History and Physical (H&P-a formal, comprehensive, and mandatory medical document detailing a patient’s current illness, medical history, and a physical examination) dated 12/11/2025, indicated, Patient 9 arrived by ambulance on 12/10/2025 and was admitted to the facility for abdominal(stomach) pain on 12/11/2025. During a review of Patient 9’s “Emergency Department (ED) Triage Form” dated 12/10/2025, the form indicated that Patient 9 had no existing or history of pressure injury. During a review of Patient 9’s “Integumentary (outer protective covering-skin, nails, and hair) Flowsheet” dated 12/11/2025, the flowsheet indicated that Patient 9 had a Braden score (risk assessment scale tool that is used to determine a patient’s risk for skin breakdown) of 18. During a review of Patient 9’s “Orders” dated 12/11/2025, the orders indicated that Patient 9 had the following order “Turn Patient every 2 hours”. During a review of Patient 9’s “Adult ADLs Flowsheet” dated 12/12/2025, the flowsheet indicated that there was a 12-hour gap of no turning between 8PM to 8AM. The documentation indicated for patient position was “Self (able to turn without help)”. During a review of Patient 9’s “Integumentary Flowsheet” dated 12/11/2025, the flowsheet indicated to “Consult Wound Care Nurse”. During a review of Patients 9’s “Wound Care Note” dated 12/14/2026, the note indicated the following: “Turns self with minimal assistance ... ... sacral, coccyx and bilateral buttocks redness. Sacrum in coccyx area of skin has what appears as old scar tissue that appears with skin indentation. Coccyx dark maroonish purple skin discoloration 2 x1 centimeters (cm, unit of measurement) that appears as possible mole/skin growth. Unknown history of pressure injury. Triad cream applied to all areas. Continue to turn from left to right every two hours to offload pressure.” During a concurrent interview and record review on 3/17/2026 at 2:51 PM with RN 2, Patient 9’s “Adult ADL Flowsheet” dated 12/12/ 2025 was reviewed. The flowsheet indicated that there was a 12-hour gap of no turning between 8PM to 8AM. The documentation indicated for patient position was “Self”. RN 2 stated I cannot tell what position the patient is in when it is documented as “self”. I would document the position the patient is in even if they are alert and oriented and can turn themselves. The consequences of not turning a patient every two hours is skin breakdown. The expectation when an order is placed to turn a patient every two hours is to carry out those orders as a nurse. During a review of the Case Manager/Social Services (CM/SS) note dated 12/16/2025 at 5:12PM, the note indicated patient 9 was discharged home with home health. The note indicated that the family of patient 9 called the paramedics to be brought back to the Emergency Room (ER) due to not receiving proper endorsements from the doctor. During a review of Patient 9’s “Discharge Summary” dated 12/18/2025, the summary indicated Patient 9 was re-admitted to the facility by paramedics on 12/16/2025 at 7:02PM due to family not being able to care for patient alone. The summary indicated the primary discharge diagnosis was Sacral Decubitus Ulcer (Partial-thickness loss of skin, presenting as a shallow open sore or wound). During a review of Patient 9’s “Wound Care Note” dated 12/17/2025, the note indicated the following: “Sacral noted with stage 2 pressure injury, maroon, purple with partial thickness skin loss 2 x 2 CM ...... Turn and reposition every two hours” During a review of the facilities policies and procedures (P&P) titled, “Tissue and Pressure Ulcer Prevention and Management Policy” (dated 2/2025), the policy indicated “ ......The Braden Risk Assessment Scale Is the tool that must be utilized to assess, identify, and document patient risk for skin breakdown and patients aged 18 and over ... ... To identify those who are at risk for tissue integrity impairment ...... Score 18 and below indicates risk for skin breakdown.” During a review of the facilities P&P titled, “Skin Care Standard of Care” (dated 7/2025), the P&P indicated “ ...... Turn every two hours using posey pillows/wedges; use your hand to determine if sacrum is offloaded.””

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 45774 Based on interview and record review the facility failed to ensure one of thirty sampled patient’s (Patient 15), had a re-evaluation of the patient’s condition and identify changes that led to the modification of the discharge plan. There was no discharge plan update when Patient 15, who was identified to have no ability or capacity to care for himself, was discharged to Recuperative Care Facility (RC1- provides short-term residential, housing, and support services for homeless individuals or those with housing instability who are recovering from an illness or injury and no longer require hospitalization)without wandering supervision. This deficient practice can potentially lead to lack of supervision, falls, environmental accidents, or death from exposure to harsh environmental elements, particularly if the patient wanders off outside RC1. Findings: During a review of Patient 15’s “History & Physical” (H&P, a formal and complete assessment of the patient and the problem),” dated 08/22/2024, the H&P indicated Patient 15 with unknown medical history and limited history due to his mental status brought into the Emergency Department (ED) after being found in someone else’s car in the ED parking lot. The Patient was found to have altered mental status (AMS, a broad term for an acute change in brain function, including confusion, reduced alertness, or behavioral changes) and was diagnosed with heat stroke (a medical emergency where the body temperature rises rapidly causing the body’s cooling system to fail and internal organs to malfunction). During a review of Patient 15’s “Intensive Care Unit (ICU-provide constant monitoring and life support critically ill and injured patients) Physical Assessment - Neurological” dated 04/02/2025 at 7:28 AM, and 8:00 PM indicated patient’s nursing mental status assessment (a structured, ongoing evaluation of a patient’s cognitive, emotional, and behavioral functioning at a specific time) and nursing thought process assessment (evaluates the logic, coherence, and relevance of a patient’s thoughts) was confused (signifies an acute alteration in mental status, characterized by disorientation, impaired memory, or poor judgment) and his nursing speech assessment (a clinical evaluation of a patient’s ability to produce speech sounds, understand language, and communicate effectively) was noted unintelligible speech (verbal communication that is difficult or impossible for a listener to understand). During a review of Patient 15’s “Progress Note - Psychiatric Note” dated 04/02/2025 at 12:19 PM indicated patient was awake, confused and confabulates (the unconscious production of false, distorted, or fabricated memories without the intent to deceive). It is also noted that Patient 15 has no capacity or ability to care for himself. During a review of Patient 15’s “Progress Note” dated 04/02/2025 at 4:52 PM indicated patient’s identified medical problems include Heat stroke, confusion (the inability to think clearly, fast, or make decisions, often accompanied by disorientation and memory loss), acute psychosis (a rapid loss of touch with reality) versus dementia (a chronic, progressive decline in cognitive function), and diabetes (a chronic metabolic disorder where the body cannot properly regulate blood sugar due to insufficient insulin production) on insulin (a synthetic or human-derived hormone used to manage high blood sugar in people with diabetes). It also indicated that the discharge plan is to send patient to a locked facility (a secure, 24-hour treatment facility designed to provide high-level supervision and care for individuals with acute psychiatric issues, severe behavioral health challenges, or those requiring secure rehabilitation). During a review of Patient 15’s “ICU Physical Assessment - Neurological” dated 04/03/2025 at 7:55 AM, indicated patient’s nursing mental status assessment (a structured, ongoing evaluation of a patient’s cognitive, emotional, and behavioral functioning at a specific time) and nursing thought process assessment (evaluates the logic, coherence, and relevance of a patient’s thoughts) was confused (signifies an acute alteration in mental status, characterized by disorientation, impaired memory, or poor judgment) and his nursing speech assessment (a clinical evaluation of a patient’s ability to produce speech sounds, understand language, and communicate effectively) was noted unintelligible speech (verbal communication that is difficult or impossible for a listener to understand). During a review of Patient 15’s “Discharged Plan Update” dated 04/03/2025 at 12:52 PM, indicated Case Manager (CM) receipt of endorsement from Chief Financial Officer (CFO) that a letter of agreement (LOA, is a legally binding contract defining partnership responsibilities, patient care standards, and payment terms. It ensures continuity of care during transfers, sets transfer protocols, and clarifies liability.) is completed with accepting Board and Care - RC1. It also noted Patient discharge planning for Room and Board to RC1. During a review of Patient 15’s “Order Information - Discharge Patient” dated 04/03/2025 at 1:04 PM, indicated patient was to be discharged to “room and board”. During an interview on 3/17/2026 at 2:35 PM with Clinical Social Worker (SW1), the SW1 stated that a recuperative care facility is a type of residential care that housed patients who are experiencing homelessness, these are non-license facility that requires patients to be independent in Activities of Daily Living (ADLs) such as bathing, dressing, and toileting, as they generally offer “room and board” residential support rather than skilled nursing care. Patients must be medically stable. During a concurrent interview and record on 03/19/2025 at 3:45 PM, with Stroke Coordinator Nurse (SCN), the review of Patient 15’s “Discharge Summary” dated 04/03/2025 2:58 PM, indicated patient’s discharge plan is to discharge patient to a Boarding Care (provides a home and assistance with daily living) with wandering supervision and be sent with diabetic supplies and Lantus (insulin glargine, a prescription, long-acting man-made insulin used once daily to improve glycemic control in adults with diabetes). SCN stated that the written discharged order was that the patient be discharged to a “room and board”, not Board and Care with wandering supervision. SCN added that, there are no records on Patient 15’s electronic medical record (EMR, a digital version of a patient’s chart, containing medical history, diagnoses, medications, and lab results used by care providers) of any update as to why the disposition and care arrangement is different from the discharge order compared to the discharge summary plan, which was written close to 2 hours after the discharge order. No notes from case management team (Care team that involves nurses and social workers coordinating patient care from admission to discharge, developing discharge plans, arranging post-hospital services i.e. rehabilitation and home care) that wandering supervision was arranged for the patient. Patient 15 was discharged to RC1 on 04/03/2025 at around 4:42 PM. During an interview on 3/20/2026 at 11:05 PM with Director of Case Management (DCM), the DCM stated that board and care homes are state-licensed residential settings providing supervision and personal care (bathing, medication, meals), while “Room and Board” facilities provide housing and food, they do not provide care or supervision. Although care and supervision can be arranged with a Room and Board Facility, but it must be stipulated in a contract or a LOA. During a review of the facility’s policy and procedure (P&P) titled, Plan of Care Interdisciplinary, dated 11/2025, indicated that the patient will be reassessed prior to discharge to determine to what extent the identified goals were reached and whether the plan of care was effective .....If modifications are made to the plan of care that result in the patient’s discharge to another setting or service, then the care, treatment and rehabilitation needed after discharge from the hospital are planned and coordinated .... Upon discharge, all problems will be evaluated and outcome status completed.”

“DISCHARGE PLANNING - PAC PROVIDER DATA CFR(s): The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use on measures. The hospital must ensure that the post-acute care data on quality measures and data on resource measures is relevant and applicable to the patient’s goals and treatment preferences. This Standard is not met as evidenced by: 45774 Base on interview and record review the facility failed to ensure Patient 1’s was not discharged to a recuperative care (provides short-term residential, housing, and support services for homeless individuals or those with housing instability who are recovering from an illness or injury and no longer require hospitalization) despite of physician discharge order to board and care (assistance with activities of daily living but do not require skill nursing services) with home health. Patient 1’s discharge planning and post hospital care arrangement was unsafe, inadequate, and inappropriate to Patient 1’s condition and care needs. This deficient practice result in Patient 1 was sent to a recuperative care without Home Health arrangement. Patient 1 was brought to emergency department (ED) in a different hospital (GACH 2) 5 days after being discharged to recuperative care via paramedics due to chest pain. Per Emergency Medical Services (EMS) Patient 1 was soiled with urine and stool during transfer, and GACH 2 ED found Patient 1 have elevated troponin (protein found in the heart muscle and when elevated in the blood indicates heart damage), low blood pressure and malnutrition (not eating enough). On 3/19/2026, at 3:02 PM, the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ‘s noncompliance with one or more requirements have, caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer, Chief Operative Officer, Chief Executive Director, Chief Medical Director, and Director of Clinical Quality Improvement. The above-mentioned facility administrators were informed of the IJ situation regarding the failure to ensure one of 30 sampled patients (Patient 1) was a quadriplegia (partial or total loss of sensation and voluntary motor function in all four limbs (arms and legs) and the torso), post anterior cervical decompression (surgical procedure to relieve pressure on the spinal cord or nerve roots in the neck), transgender male to female, chronic pain, sacrum and left buttock stage 4 pressure injury (damage to skin and underlying tissue caused by prolonged pressure, friction, or shear), left elbow stage 3 pressure injury, and left heel unstageable pressure injury (severe, full-thickness wound where damage depth is hidden by necrotic tissue (slough or eschar), preventing accurate staging), had a discharge order for a Board and Care Facility with Home Health, however Patient 1 was instead sent to a Recuperative Care Home without Home Health arrangement. Patient 1 was brought to ED in a different hospital (GACH 2) 5 days after being discharged to Recuperative Care Facility via paramedics due to chest pain. Patient 1 had poor oral intake and placement issues. Per EMS Patient 1 was soiled with urine and stool during transfer, and GACH 2 ED found Patient 1 have elevated troponin. On 3/20/2026 at 4:17 p.m., while onsite, the IJ was removed after verifying and confirming the facility’s implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence with Director of Clinical Quality Improvement. The IJ Removal Plan included the following: 1. Re Education on Interdisciplinary Discharge Planning Policy All Case Managers have been re educated on the hospital’s policy “Interdisciplinary Discharge Planning.” Education included the requirement that discharge planning assessments must address, at minimum: The patient’s capacity for self care at the time of discharge The patient’s ability to return to their previous living environment The patient’s psychosocial and physical care needs at discharge The patient’s need for post hospital care, treatment, and services The Case Manager will verify with physician if the discharge order level is not appropriate for patient’s level of care and needs Any misalignment or discrepancy between the discharge order or discharge plan and the patient’s needs will require a request for a Care Conference with the patient’s provider, case manager and patient/family. If there is any disagreement within the Care Conference team, then escalation to risk management department to ensure that the patient’s needs align with the discharge destination prior to discharge. Step by step Board and Care and Assisted Living Facility License Verification (Attachment A) Case Managers were instructed that, as part of the required reassessment prior to discharge, and once receiving facility accepted the patient, case manager will call the receiving facility to verify the level of care provided by the receiving facility meets patient’s needs. Verification of the receiving facility’s licensure is required prior to discharge from the receiving board and care or assisted living facilities and documenting the license number in medical records. 2. Re Education on Home Health Arrangement Requirements All Case Managers, Discharge Planners, and Social Workers have been re educated on the required process for arranging Home Health services. Staff were instructed that Home Health arrangements must be completed prior to the patient’s departure from the hospital. When Home Health services are arranged directly by the patient’s insurance provider, Case Management must document the following in the medical record before discharge: Home Health agency name Agency phone number Estimated date of service To ensure consistent compliance, a standardized smart phrase has been implemented in the Electronic Health Record (EHR). Case Management staff are required to use this smart phrase to document all required elements prior to discharge. 3. Verification of Discharge Orders All Case Managers, Discharge Planners, and Social Workers have been re educated on the requirement that discharge orders must align with the patient’s post acute discharge arrangements. Case manager must conduct a discharge reassessment to verify that the discharge destination, level of care, and ordered services are appropriate and consistent with the patient’s assessed needs. If there is any disagreement within the Care Conference team, then escalation to risk management department to ensure that the patient’s needs align with the discharge destination prior to discharge. 4. Completion of Required Education All Case Managers, Discharge Planners, and Social Workers are required to complete the above education prior to the start of their next scheduled shift. Staff who do not complete the required training will not be permitted to work until completion is verified. II. Monitoring and Compliance Audit Process The Case Management Department will do random audits of a minimum of 30 medical records a month to ensure compliance with the following: The discharge order matches the documented discharge destination The discharge destination is appropriate for the patient’s assessed needs Home Health arrangements include documentation of the agency name, phone number, and expected date of service If patients were discharged to a Board and Care Facility, the facility is licensed. Audits will continue until 100% compliance is achieved for three (3) consecutive months. After sustained compliance is achieved, random audits will be conducted to ensure ongoing adherence. Audit findings will be reviewed by the Director of Case Management and reported to the Quality Committee. III. Responsible Individual Director, Case Management Department Responsible for implementation, oversight, and monitoring of all corrective actions. IV. Date of Completion March 20, 2026 Findings: During a review of Patient 1’s discharge summary (reported prepared by a healthcare provider to summarize a patient’s hospital stay, including diagnosis, treatments, and follow-up plans) dated 4/5/2025, indicated Patient 1 was admitted to the facility on 6/24/2024 for quadriplegia (partial or total loss of sensation and voluntary motor function in all four limbs (arms and legs) and the torso), post anterior cervical decompression (surgical procedure to relieve pressure on the spinal cord or nerve roots in the neck), transgender male to female, chronic pain, sacrum and left buttock stage 4 pressure injury (damage to skin and underlying tissue caused by prolonged pressure, friction, or shear), left elbow stage 3 pressure injury, and left heel unstageable pressure injury (severe, full-thickness wound where damage depth is hidden by necrotic tissue (slough or eschar), preventing accurate staging). Patient 1 was disposition to board and care (assistance with activities of daily living but do not require skill nursing services) with home health for wound care. Patient was discharged in good condition. During a review of Patient 1”s “Rehab Note (medical documentation created by healthcare professionals-such as physical therapists, occupational therapists, or speech-language pathologists-to record a patient’s progress, treatment, and response to therapy during a recovery process)” dated 1/7/2025, the rehab note indicated that Patient 1 needed and required dependent care/total assist for all mobility and care-bedbound patient and needed extensive assessment for all care. Patient 1 is bedbound secondary to pre-exiting limited and contractures from baseline quadriplegia and will require custodial care. During a review of Patient 1’s physician order dated 4/4/2025, the physician order stated that Patient 1 was ordered to be discharged to board and care with home health. During an interview on 3/17/2026 at 10:54 a.m. with Director of Clinical Quality Improvement (DCQI), DCQI stated that Patient 1 was a patient in this facility for 9 months, Patient is quadriplegic, alert, awake, bed bound (someone confined to a bed or chair for most or all of the day, unable to safely walk, stand, or transfer independently), require maximum assistance, with multiple wounds, and is a feeder. Patient initially had a discharge order to skill nursing facility (SNF) on 8/12/2024, but later faced discharge challenges and issue, there was no accepting Skilled Nursing Facility (SNF). On 4/4/2025, discharge order was change to discharge to Board and Care (B&C) with Home Health and was sent to Recuperative Care Facility (RC1- provides short-term residential, housing, and support services for homeless individuals or those with housing instability who are recovering from an illness or injury and no longer require hospitalization). During an interview on 3/17/2026 at 2:00 p.m. with case manager (CM1), stated that they could not find any placement for patient 1 for a very long period since the first discharge order in August 2024 to discharge Patient 1 to skilled nursing facility. CM 1 stated that her leadership, director of case manager, found a placement for Patient 1 which is a board and care (B&C) facility, she followed leadership to process for B&C discharge. Concurrently, CM 1 stated that this is not the practice and scope for them to check if the B&C is license or not. During an interview on 3/17/2026 at 2:35 p.m. with Social Worker (SW1), SW stated that Patient 1 was known to her because it was difficult to find post-acute placement for the patient. She was then referred by the case management - orange office to reach out to outsource agency (AG1), A patient placement agency that helps place patient with discharge challenges. SW added that she faxed the patient clinicals and information document to the agency, and they were able to find a place that will accept Patient 1 post - acute care. It was RC 1. Recuperative Care is a facility that primarily caters to homeless patient or patient who needs to recuperate. They are unlicensed and can only accept patient who are independent of their activities of daily living (ADL). Recuperative facility only offer room and meals to patient. During an interview on 3/18/2026 at 10:28 a.m. with Physical Therapist (PT1), PT1 stated that Patient 1 was being seen by Physical Therapy for evaluation and treatment. Patient was quadriplegic with extensive disability, is a total assistance and requires 2-person assist with mobility. Case Managers are responsible to arrange disposition and safe patient placement after discharge. At time of discharge, Patient 1 requires to be in a place that can provide custodial care (non-medical assistance with daily activities) and can assist patient to all care needs. During an interview on 3/18/2026 at 10:55 a.m. with Wound Care Nurse (WCN), WCN stated that wound care was consulted to see Patient 1 on 6/29/24. Patient 1 was found with the following pressure injury wound: sacral pressure injury stage 4, left buttock pressure injury stage 4. left elbow pressure injury stage 3, right lateral foot pressure injury stage 3, left heel pressure injury unstageable. At time of discharge on 4/4/25, not much change of patient wound condition, Patient continued to require daily wound dressing and packing. Patient would also need wound care follow up after discharge. During an interview on 3/18/2026 at 11:23 a.m. with Director, Case Management (DCM), DCM stated that Case Managers are responsible to developed patient-oriented discharge plan. And patient is sent to a safe and appropriate facility to patient who require post-acute care. Patient 1 was inappropriately discharge because the MD discharge order was to a board and care with home health but was instead sent to a recuperative care facility. During an interview on 3/18/2026 at 12:10 p.m. with Director of Clinical Quality Improvement (DQCI) stated that AG1 reported that RC 1 is an unlicensed recuperative care facility. It is not a Board and Care Facility. No records on file that a Home Health arrangement was completed on Patient 1. During an interview on 3/20/2026 at 11:45 PM with Director of Clinical Quality Improvement (DCQI), the DCQI stated that Patient 15 has no contract or letter of agreement (LOA- is a legally binding contract defining partnership responsibilities, patient care standards, and payment terms. It ensures continuity of care during transfers, sets transfer protocols, and clarifies liability.) created between facility and RC1 for Patient 15’s housing and care arrangements. A review of GACH 2 Patient 1’s Emergency Department medical record dated 4/9/25; indicated that Patient 1 was brought in by ambulance for chest pain. EMS found Patient 1 sitting in bed soiled in urine and feces. Per Patient 1, stated that she has not been fed, cleaned or taken care of properly by staff since being there. Patient 1’s troponin (protein found in the heart muscle and when elevated in the blood indicates heart damage) level was 332, blood pressure is 89/62, and heart rate 117. Body Mass Index (BMI) is 17.25. A review of GACH 2 Patient 1’s Initial Nutrition Assessment, dated 4/10/2025, indicated Patient 1’s nutrition diagnosis was “malnutrition related to status post car vs pedestrian accident as evidenced by suspected neglect at facility.” During a review of the facility’s policy and procedure (P&P) titled, Plan of Care Interdisciplinary, dated 11/2025, indicated that the patient will be reassessed prior to discharge to determine to what extent the identified goals were reached and whether the plan of care was effective .....If modifications are made to the plan of care that result in the patient’s discharge to another setting or service, then the care, treatment and rehabilitation needed after discharge from the hospital are planned and coordinated .... Upon discharge, all problems will be evaluated and outcome status completed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: The facility failed to ensure registration staff made two attempts within 48 hours to have one of 32 sampled patients (Patient 4) sign the Conditions of Service (serves as a contract detailing patient obligations for payment and treatment) and the Important Message from Medicare (IMM - a required notice for hospitalized Medicare beneficiaries, explaining their rights, especially the right to appeal a discharge decision) in accordance with the facility ’ s policy and procedure on admitting procedures. This failure had the potential to result in Patient 4 not being aware of their rights as the facility ’ s patient nor as a Medicare beneficiary, which could cause Patient 4 to not make the most knowledgeable decisions possible regarding their medical care. (Refer to A-0117) The facility failed to provide privacy curtains (physical barriers used to create temporary, private spaces) for two of 32 sampled patients (Patient 18 and Patient 19) in a shared hospital environment in accordance with the facility ’ s policy and procedure on patient rights. This deficient practice violated Patient 18 ’ s and Patient 19 ’ s right to privacy and had the potential to breach confidentiality (kept secret or private), increase the potential spread of pathogens (germs), and increase stress due to lack of personal private space. (Refer to A-0143) The facility failed to ensure a constant observer (provides direct, one on one observation and supervision for patients) was utilized to promote patient safety and prevent falls (unplanned descent to the floor with or without injury to the patient) for one of 32 sampled patients (Patient 8), who was considered a high risk for falls, in accordance with the facility ’ s policy and procedure on fall prevention. This deficient practice resulted in Patient 8 falling off the bed two times during their hospital admission and sustaining a nondisplaced left parietal skull fracture (a break in the left parietal bone [a large, flat bone on the side of the skull] that has not shifted from its original position). (Refer to A-0144) The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: The facility failed to ensure the nursing staff included home health arrangement (skilled medical services and therapies in a patient’s home to help manage illness, injury, or chronic conditions) in the discharge instructions for one of 32 sampled patients (Patient 30) in accordance with the facility ’ s police and procedure on discharge planning. This deficient practice had the potential to result in Patient 30 being unable to identify when care is inconsistent and delaying necessary treatment. (Refer to A-0395) The facility failed to ensure the nursing staff provided discharge education and instruction of their diagnosis for one of 30 sampled patients (Patient 30), who was newly diagnosed with diabetes mellitus (a disease of inadequate control of blood levels of glucose) and hyperglycemia (high blood sugar or glucose), in accordance with the facility ’ s policy and procedure on patient discharges. This deficient practice had the potential to result in Patient 30 not recognizing or appropriately responding to worsening symptoms, leading to preventable health decline. (Refer to A-0395). 3. Based on interview and record review, the facility failed to ensure for one of 32 sampled patients (Patient 7), Patient 7 ’ s spouse was notified of a fall (a fall is an assisted or unassisted drop or descent from a standing, sitting or lying position) Patient 7 sustained while being assisted to the bedside commode (a portable toilet). This deficient practice violated Patient 7 ’ s rights and/or the Spouse ’ s right to be fully informed of Patient 7 ’ s post (after) fall. This deficient practice also had the potential to impede the spouse ’ s involvement to work with the healthcare team to achieve recovery for Patient 7. (Refer to A-0395). 4. The facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), pain, and blood pressure (the pressure within the major arteries of the body) for two of 32 sampled patients (Patient 17 and Patient 22). This deficient practice had the potential to result in Patient 17 and Patient 22 not receiving the right level of care and not meeting the needs for the identified patient concerns. (Refer to A-0396) 5.Ensure the Nursing staff for 3 of 30 sampled patients (Patient 1, Patient 28, and Patient 29), a Interfacility Transfer Form (a standardized document used to communicate essential patient information for when a patient moves from one healthcare facility to another) will be completed and sent with the patient and a copy of the transfer record will be provided to the patient/family/responsible party in accordance with the facility’s policy and procedure (P&P) regarding admission, transfer and discharges. These deficient practices can potentially expose patient ’ s significant risks and can result in medical errors, delays in care, and adverse patient outcomes. The form is a tool designed to ensure the accurate and complete exchange of critical patient information between facilities. (Refer to A-0398). 6. Ensure three patients (Patient 2, Patient 3 and Patient 4) of 32 sampled patients, to ensure medications were given within the ordered time frame per facility ’ s policy and procedure (P&P). This deficient practice has the potential for Patient 2, Patient 3 and Patient 4 to have prolonged treatment and recovery due to delayed medication administration times. (Refer to A-0398). The cumulative effect of these deficient practices resulted in the facility ’ s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to ensure registration staff made two attempts within 48 hours to have one of 32 sampled patients (Patient 4) sign the Conditions of Service (serves as a contract detailing patient obligations for payment and treatment) and the Important Message from Medicare (IMM - a required notice for hospitalized Medicare beneficiaries, explaining their rights, especially the right to appeal a discharge decision) in accordance with the facility ’ s policy and procedure on admitting procedures. This failure had the potential to result in Patient 4 not being aware of their rights as the facility ’ s patient nor as a Medicare beneficiary, which could cause Patient 4 to not make the most knowledgeable decisions possible regarding their medical care. Findings: During a review of Patient 4 ’ s “History & Physical (H&P)”, dated 8/31/2025, the H&P indicated Patient 4 was admitted to the facility on 8/31/2025 for altered mental status related to sepsis (a life-threatening blood infection). Patient 4 has a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer ’ s disease (a disorder that affects memory, thinking and behavior), cerebral palsy (a disorder that affects movement, balance and posture), schizophrenia (a mental illness that is characterized by disturbances in thought), and prior cerebrovascular accident (stroke, loss of blood flow to a part of the brain). During a review of Patient 4 ’ s form titled, “Condition of Service,” (serves as a contract detailing patient obligations for payment) dated 8/31/2025, the form indicated the first attempt for signature was made on 8/31/2025 at 3:41 PM. During a review of Patient 4 ’ s form titled, “Condition of Service,” dated 9/3/2025, the form indicated the second attempt for signature was made on 9/3/2025 at 7:20 PM (more than 48 hours after first attempt was made). During a review of Patient 4 ’ s form titled, “Important Message from Medicare,” (IMM - a required notice for hospitalized Medicare beneficiaries, explaining their rights, especially the right to appeal a discharge decision) dated 8/31/2025, the form indicated the first attempt for signature was made on 8/31/2025 at 6:46 PM. During a review of Patient 4 ’ s form titled, “Important Message from Medicare,” dated 9/3/2025, the form indicated the first attempt for signature was made on 9/3/2025 at 7:20 PM (more than 48 hours after first attempt was made). During an interview on 9/17/2025 at 3:45 PM with the Director of Admission (Dir Admit), the Dir Admit stated the only attempts made for getting Patient 4 ’ s Condition of Service and the Important Message from Medicare were on 8/31/2025 and 9/3/2025, which are not within 48 hours of each other. She stated the risk of these forms not having two attempts of signatures made within 48 hours was that Patient 4 would not know what their rights were as a patient, what they would be billed for, and the services to be rendered (services provided) During a review of the facility ’ s policy and procedure (P&P) titled, “Completion of Admitting Forms,” dated 6/2025, indicated, “It is the policy of [name of facility] Admitting Department to ensure that all forms are completed accurately and correctly . . . Completion of Forms: Terms and Conditions of Service . . . Message from Medicare.” The P&P also indicated, “Registration staff shall make an additional attempt to obtain signatures at least two (2) times within forty-eight (48) hours.””

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 38310 Based on observation, interview, and record review, the facility failed to provide privacy curtains (physical barriers used to create temporary, private spaces) for two of 32 sampled patients (Patient 18 and Patient 19) in a shared hospital environment in accordance with the facility ’ s policy and procedure on patient rights. This deficient practice violated Patient 18 ’ s and Patient 19 ’ s right to privacy and had the potential to breach confidentiality (kept secret or private), increase the potential spread of pathogens (germs), and increase stress due to lack of personal private space. Findings: During a review of Patient 18 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/15/2025 at 12:26 pm, Patient 18 ’ s H&P indicated Patient 18 presented to the emergency department (ED) for flank pain (pain located on the sides of the lower back), fever, and urinary (related to urine) changes. Patient 18 was seen in the ED previously and prescribed (ordered) antibiotics (a medicine that prevents or stops the growth of bacteria) for Extended-Spectrum ß-Lactamase-producing (ESBL, a protein produced by some bacteria that makes them resistant to many common antibiotics) Escherichia coli (E. coli, bacteria found in the intestines) bacteria but did not take them. Patient 18 had worsening symptoms resulting in acute pyelonephritis (an infection of the kidneys), bandemia (a condition where the bone marrow releases too many white blood cells into the bloodstream), and leukocytosis (a high level of white blood cells in the blood). Patient 18 had no significant medical history. During a review of Patient 19 ’ s H&P, dated 9/15/2025 at 15:11 pm, Patient 19 ’ s H&P indicated Patient 19 had a dry cough that was persistent (continuous) and not improving. Patient 19 reported a loss of 20 pounds over the past two months. Patient 19 ’ s computed tomography angiography (CTA, 3D images of a person ’ s blood vessels to detect issues like blockages, aneurysms, or abnormal formations) of the chest indicated multifocal pneumonia (a type of lung infection that affects multiple areas of the lungs) requiring hospitalization for treatment. Patient 19 had no other known medical problems. During an tour on 9/15/2025 at 1:40 pm of the with the Quality Management/Patient Safety (QMPS) staff and the Charge Nurse of Three East (CN3E), Patient 18 and Patient 19 ’ s room was observed to have no privacy curtain in place for bed A or B. Patient 18 (bed A) and Patient 19 (bed B) ’ s room, a double occupancy room (two people sharing one room), was observed with Patient 18 and Patient 19 lying in their beds and no curtains available for privacy. Patient 18 observed to be resting but easily aroused (awakened) by staff entering the room and hallway noises. Patient 19 was observed self-positioning (moving one ’ s own body to improve comfort) to face the door and immediately repositioned back facing the room ’ s inner wall to avoid the hallway light which appeared to directly shine in Patient 19 ’ s face. During an interview on 9/15/2025 at 1:45 pm with Patient 19, Patient 19 stated that Patient 18 was recently admitted to the room. Patient 19 stated that it would be nice to have privacy curtains to prevent being seen during such a vulnerable (weak and/or easily hurt physically or emotionally) time. Patient 19 also expressed concerns about being watched if Patient 18 had visitors. Patient 19 stated that both occupants lacked privacy while resting/relaxing due to their inability to eliminate lights and sound (i.e. the television). Patient 19 further stated having privacy curtains would help to keep personal conversations semi-private. During an interview on 9/15/2025 at 1:51 pm, with CN3E, CN3E stated the unit consisted of 25 beds and a current census (official patient count) of 21. CN3E reported one room was under repair and ten rooms were private rooms (personal space used by one person). CN3E stated everyone needed privacy. CN3E further stated that curtains were not only important for privacy, but also for dignity, respect, and was a patients ’ rights requirement. CN3E stated that curtains may provide privacy for personal needs (i.e. getting dressed, receiving treatments, or discussing medical needs). CN3E stated privacy curtains may also decrease unwarranted smells (i.e. incontinent [inability to control the flow of urine or the escape of stool] episode) and sounds (i.e. loud telephone conversation), limit exposure of germs (i.e. patients coughing), and create boundaries (a dividing line). CN3E stated that this was extremely important for patients that share space/rooms, as some patients may not be kind or receptive (willing to accept) to having a roommate. During a review of the facility ’ s policy & procedures (P&P), titled “Patients ’ Rights and Responsibilities”, undated, the P&P indicated, “Patients have the right .... To privacy. Conversations, exams, and treatments should be kept private. The patient can ask why someone is there. Visitors must leave before exams or treatment talks if the patient does not want them there. Curtains will be used in shared rooms.””

“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: 38310 Based on interview, and record review, the facility failed to ensure a constant observer (provides direct, one on one observation and supervision for patients) was utilized to promote patient safety and prevent falls (unplanned descent to the floor with or without injury to the patient) for one of 32 sampled patients (Patient 8), who was considered a high risk for falls, in accordance with the facility ’ s policy and procedure on fall prevention. This deficient practice resulted in Patient 8 falling off the bed two times during their hospital admission and sustaining a nondisplaced left parietal skull fracture (a break in the left parietal bone [a large, flat bone on the side of the skull] that has not shifted from its original position). Findings: During a review of Patient 8 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/27/2024, the H&P indicated Patient 8 was admitted to the facility with a diagnosis of urinary tract infection (UTI - an infection in the bladder/urinary tract) and sepsis (a life-threatening blood infection). The H&P further indicated Patient 8 had history of dementia (a progressive state of decline in mental abilities) and a fall 2 months prior to admission date. During a concurrent interview and record review on 9/16/2025 at 10:10 a.m. with Nursing Manager 1 (NM 1), NM 1 stated on 9/25/2024 at 6:10 p.m., Patient 8 ’ s “Morse Fall Risk Assessment (a tool used to assess a patient ’ s risk of falling)” score was 50 (high fall risk scores are 45 and above). NM 1 verified that Patient 8 was at high risk for falls. NM 1 verified Patient 8 ’ s Morse Fall risk assessment score on 10/2/2024 at 7:44 p.m. was 75 (high fall risk scores are 45 and above). NM 1 verified Patient 8 ’ s Morse Fall risk assessment score on 10/11/2024 at 7:48 a.m. was 75. During a concurrent interview and record review on 9/16/2025 at 10:30 a.m. with NM 1, NM 1 verified Patient 8 ’ s “Neurological Assessment (comprehensive evaluation of the brain, spinal cord, nerves, and muscles to determine the function of the nervous system) flowsheet,” dated 10/2/2024 to 10/3/2024, indicated the following: - On 10/2/2024 at 7:44 p.m. to 10/3/2024 at 2:45 a.m., Patient 8 was confused and Patient 8 ’ s thought process (a series of mental activities; reasoning, problem-solving and decision making) was confused. - On 10/3/2024 at 1:45 a.m., Patient 8 was confused, Patient 8 ’ s behavior was anxious, and Patient 8 ’ s thought process was confused. - On 10/3/2024 at 2:15 a.m., Patient 8 was confused, Patient 8 ’ s behavior was combative, and Patient 8 ’ s thought process was confused. During a review of Patient 8 ’ s “Nursing Narrative,” (documentation where nurses use paragraph format to tell a story of the patient ’ s condition) dated 10/3/2024, indicated, “ Patient 8 sustained an unwitnessed fall around 1:30 a.m. Patient 8 was found down with an open sacral wound and a headache...” During a concurrent interview and record review on 9/16/2025 at 11:00 a.m. with NM 1, NM 1 verified Patient 8 ’ s “Patient Rounding flowsheet,” (document use to ensure patient core needs are met during hourly checks) dated 10/11/2024, indicated the following: - On 10/11/2024 at 2:00 p.m., Patient 8 “[was] wanting to get OOB (out of bed). Assisted [Patient 8] to chair” - On 10/11/2024 at 4:00 p.m. Patient 8 “[was] attempting to get OOB multiple times, bed alarm reactivated once [Patient 8 was] situated back into bed. [Patient 8] does not follow or comprehend repeated instructions to stay in bed...” During a review of Patient 8 ’ s “Nursing Narrative,” dated 10/11/2024 at 6:07 p.m., the indicated, “[Patient 8 was] found down on floor near bed on her back. No obvious injury noted when found, [Patient 8] in her usual mental state of confusion but alert and awake. [Patient 8 was] lifted from floor and placed into bed. Assigned nurse of [Patient 8] was with another patient at time of event ...[Patient 8] in bed, side rails up times three [meaning three side rails up], bed alarm activated, CNA [Certified Nursing Assistant] at bedside to watch patient ...” During a review of Patient 8 ’ s “Computed Tomography (CT, a medical imaging that uses electromagnetic radiation to create detailed cross-sectional images of the body) Head,” dated 10/11/2024, the record indicated, “Impression: Nondisplaced left parietal skull fracture (a break in the left parietal bone [a large, flat bone on the side of the skull] that has not shifted from its original position). New since October 3, 2024 ...” During an interview on 9/17/2025 at 1:03 p.m. with Registered Nurse (RN) 6, RN 6 stated that on 10/11/2024 she was the assigned nurse for Patient 8. RN 6 stated Patient 8 was confused and attempting to get out of bed on multiple occasions. RN 6 stated she informed Charge Nurse (CN) 3 that Patient 8 needed a constant observer (provides direct, one on one observation and supervision for patients). RN 6 stated she informed CN 3 because Patient 8 started to be more confused and trying to get out of bed, and Patient 8 was a high risk for falls and uncooperative. RN 6 stated Patient 8 should have had a constant observer to prevent the first and second fall since Patient 8 needed a constant observer for patient safety. During an interview on 9/18/2025 at 1:25 p.m. with Director of Medical Surgical Unit (DMST), DMST stated for patients that were confused and a high risk for falls, the facility staff should do everything to prevent a fall. DMST stated for Patient 8, who had a history of dementia, previous falls ,confused, and was not following instructions, should have had a constant observer in place before the first fall occurred to promote patient safety. During a review of the facility ’ s policy and procedure (P&P) titled, “Fall Prevention and Resources,” dated 5/24/2022, the P&P indicated, “Falls can be a source of serious injuries to patients within healthcare facilities. The assessment and accompanying measures are designed to prevent and/or reduce the number and severity of falls. The ultimate goal of a falls program is prevention of injury. This hospital will take steps to reduce the number and severity of patient falls by: ... B. Preventing patient falls through appropriate assessment, communication and proactive intervention; ...E. Fall Prevention Plan of Care Strategies for all Patients at High Risk for Falls: 1. Following patient assessment for high risk for falls, prevention strategies customized to the patient ’ s needs will be planned, implemented and documented. General risk reduction strategies for fall risk patients may include, but are not limited to: ...Considering the use of a sitter when indicated. Follow specific ’ Sitter Usage Policy and Procedure ... ’ “ During a review of the facility ’ s policy and procedure (P&P) titled, “Constant Observer Assessment, Implementation, And Discontinuation For Non-Behavioral Health Patients In Non-Behavioral Health Settings A,” dated 3/20/2023, the P&P indicated, “The hospital recognizes that Constant Observers may be utilized in order to provide continuous observation of a patient to support safety. The use of Constant Observes will include a clinical assessment to determine clinically based assignment and implementation. The hospital will have a process in place to monitor constant observer usage to ensure appropriate assignment and management of resources. The nurse will assess the patient ’ s physical condition, behaviors, and emotional status at the time of the initial assessment, at scheduled routine assessments, and with any change in patient status to determine if constant observation of the patient is warranted to promote patient safety. A. Assessment of Patient: 1. Currently exhibits behaviors consistent with impaired judgment, disorientation, confusion, agitation, impulsivity that are directly impacting patient safety. (Example: pulling lines, tubes, or devices, attempts to climb out of bed or elope from unit/room) 2. At risk for falls/injury per assessment follow the falls policy (Fall Prevention and Resources) ...C. Validation of Need for Constant Observer: 1. Primary nurse identifies the need for a constant observer. 2. Primary nurse consults with the Charge Nurse/Manager/Director during standard business hours or Clinical coordinator/House Supervisor after hours and weekends. 3. Charge Nurse/Manager/Director/House Supervisor will go to the bedside to validate the patient ’ s current behaviors and that the nurse driven interventions have failed ...””

“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: 38310 Based on interview, and record review, the facility failed to: Ensure the nursing staff included home health arrangement (skilled medical services and therapies in a patient’s home to help manage illness, injury, or chronic conditions) in the discharge instructions for one of 30 sampled patients (Patient 30) in accordance with the facility ’ s policy and procedure on discharge planning. This deficient practice had the potential to result in Patient 30 being unable to identify when care is inconsistent and delaying necessary treatment. Ensure the nursing staff provided discharge education and instruction of their diagnosis for one of 30 sampled patients (Patient 30), who was newly diagnosed with diabetes mellitus (a disease of inadequate control of blood levels of glucose) and hyperglycemia (high blood sugar or glucose), in accordance with the facility ’ s policy and procedure on patient discharges. This deficient practice had the potential to result in Patient 30 not recognizing or appropriately responding to worsening symptoms, leading to preventable health decline. Ensure for one of 32 sampled patients (Patient 7), Patient 7 ’ s spouse was notified of a fall (a fall is an assisted or unassisted drop or descent from a standing, sitting or lying position) Patient 7 sustained while being assisted to the bedside commode (a portable toilet). This deficient practice violated Patient 7 ’ s rights and/or the Spouse ’ s right to be fully informed of Patient 7 ’ s post (after) fall. This deficient practice also had the potential to impede the spouse ’ s involvement to work with the healthcare team to achieve recovery for Patient 7. Findings: A review of patient ’ s 30 “History and Physical”, dated 01/10/2025, the record indicated that the patient is a 75-year-old morbidly obese female with chief complaint of fall from home and bilateral (both side) leg pain for 1 day. Patient had no reported medical history who arrives for evaluation of worsening bilateral lower extremity swelling and weeping. Patient reported of living alone and had an unwitnessed fall yesterday (01/09/2025). During a concurrent interview and record review on 09/16/2025 at 4:20 p.m. of Patient 30 ’ s medical record titled “Discharge Plan Update”, dated 01/19/2025 14:50 p.m., and interview with Case Manager (CM 1), the patient ’ s record indicates that a home health was arranged with Home Health Company (HHC1). CM1 stated that patient 30 had a home health order to arrange a nurse visit for safety evaluation (a home safety assessment where a healthcare professional visits a patient’s home to identify potential hazards and recommend modifications to prevent accidents and ensure safety), medication reconciliation (the process of creating the most accurate list of all medications a patient is taking and comparing it to the medication orders to identify and resolve discrepancies) and Physical/ Occupational therapy services(a rehabilitative programs where therapists provide one-on-one care and training within a patient’s home, focusing on improving movement, function, and independence in daily activities) was placed on 01/19/2025. Home Health orders are typically carried out by case managers (healthcare professionals who assess patient needs, create comprehensive care plans, coordinate with doctors and nurses, and ensure a smooth and safe transition to post-hospital care or home). The case manager will then make the arrangement and update the patient discharge instruction sheet to include the home health services information. Information like which home health service company will go see patient in their home and what services will be rendered. Nurses are responsible to go through the discharge instructions sheet with the patient upon discharge. During a concurrent interview and record review on 09/16/2025 at 4:30 p.m. of Patient 30 ’ s medical record titled “Patient Discharge Instruction”, signed and dated by patient on 01/19/2025 17:00 p.m. (5:00 p.m.), and interview with Case Manager (CM 1), the patient ’ s record indicates to discharge patient home and there was no home health services arranged. CM stated that the patient discharge instruction should have included information about the home health services arranged. It seems that the case manager who signed off the order failed to update patient (Patient 30) discharge instruction sheet. CM1 added that it is important that discharge instructions are complete and accurate to ensure that patients understand their post-hospital care needs. A review of the Policy and Procedure titled “Interdisciplinary Discharge Planning”, with last revised date of 03/17/2025, the document indicates the following: Interdisciplinary discharge planning services are provided to patients and their families throughout the continuum of care. The discharge process begins at the time of admission and continues through discharge or transfer to the appropriate setting. UCI Health will discharge or transfer patients to an appropriate level of care/setting based on the patient’s individual needs. Discharge planning assessments include, but are not limited to, the likelihood of patient’s capacity for self-care at time of discharge, patient returning to previous living environment, patient’s need for psychosocial or physical care at time of discharge and/or patient’s need for post-hospital care/treatment/ services. Discharge planning activities also include ongoing communication and collaboration with the patient and family to incorporate patient’s treatment goals and to validate patient’s agreement with proposed discharge plan. A discharge order must be completed by the physician prior to patient discharge. Appropriate arrangements will be made for post-hospital care, including but not limited to, care at home, skilled nursing facility, intermediate care facility, other acute care hospitals or hospice. If it is determined that the patient and family members or interested persons need to be counseled to prepare them for post-hospital care, appropriate resources will be provided. Patient choice will be documented. A review of patient ’ s 30 “History and Physical”, dated 01/10/2025, the record indicated that the patient is a 75-year-old morbidly obese female with chief complaint of fall from home and bilateral (both side) leg pain for 1 day. Patient had no reported medical history who arrives for evaluation of worsening bilateral lower extremity swelling and weeping. Patient reported of living alone and had an unwitnessed fall yesterday (01/09/2025). A review of patient ’ s 30 “Consult Note”, dated 01/11/2025, the record indicated that reason for consult is because patient (Patient 30) is newly diagnosed with diabetes mellitus with hyperglycemia. During a concurrent interview and record review on 09/17/2025 at 11:14 p.m. of Patient 30 ’ s medical record titled “Patient Discharge Instruction”, signed and dated 01/19/2025 14:50 p.m., and interview with Director of Medical Surgical/ Telemetry (DMST), the patient ’ s record did not include diabetes mellitus in the list of patient diagnosis. There was also no education material on diabetes mellitus provided to patient (Patient 30). DMST stated that the discharge nurse failed to update and include diabetes mellitus in patients discharge instructions. Patient was newly diagnosed with diabetes mellitus and it should have been included in the patient discharge instruction and education. Discharge instructions are important for patient safety, it ’ s a way to provide vital home care instruction to patient including medications, diet, activity levels, and when to recognize early symptoms and seek further medical attention. A review of the Policy and Procedure titled “Admission, Transfer and Discharge”, with last revised date of 10/2020, the document indicates the following: Nursing Responsibility: Assure that the patient, and family/significant others understand discharge instructions. Enter any new medications and update changes to previous. Medication which occurred during hospitalization into the patient’s Home Medication List (this will update medications for future admissions). The nurse will complete all other areas of the Depart Discharge Instructions including Discharge Nursing Assessment. The nurse will review with patient, family or caregiver all Discharge Instructions and obtain all signatures required. A copy shall be given to the patient or representative. A discharge timeout will occur to ensure the correct forms/instructions go with the correct patient. The charge nurse and the discharging nurse will verify and sign the Admission/Discharge Core Measures Timeout page. The nurse will complete the outcome status section of the Plan of Care and reconcile any outstanding problems. Return to the patient any medications the patient may have brought to the hospital on admission. Administer scheduled medications up to point of discharge. Indicate the time of next dose due on the depart discharge instructions. (Example: “The next dose is due at 12 noon”). Review new prescriptions and provide a copy for the patient. Return valuables on deposit in Admitting/Patient Registration. Assist the patient in dressing if appropriate and assembling of personal belongings. Arrange for hospital transporter to escort the patient to designated discharge area of hospital by wheelchair and assist with transfer to car. Ensure patient is secured in vehicle. Complete time of discharge on depart discharge Notify Charge Nurse when bed is vacated and the RN Administrative Supervisor when bed is ready for use (for bed availability purposes) 3. During a review of Patient 7 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 5/7/2025, the H&P indicated that Patient 7 was admitted to the facility with a diagnosis of Acute Cerebrovascular Accident (CVA-stroke, loss of blood flow to a part of the brain.) The H&P further indicated Patient 7 had a history of Hypertension (HTN-high blood pressure). During a review of Patient 7 ’ s “Nursing Narrative,” dated 5/11/2025, the record indicated, “Patient (Patient 7) sustained a witness fall while being ambulated to the commode ... Found patient attempting to get out of bed without alerting staff. Educated patient on the need to press to call button. Patient stated “I can ’ t hold it anymore.” Loose watery stool was noted on the patient ’ s gown and linen. Patient had managed to take off non-slip socks while kicking the sheets off of self. Patient was also educated at that time the necessity for non-slip socks and patient replied please, I really need to use the bathroom. Was assisting patient, bed was lowered to lowest height and two arms were place under patient ’ s axillae as ambulatory support. As patient was attempting to turn around onto commode. Patient was instructed to wait, until I [Registered Nurse 8 (RN 8)] was able to fully get behind him to support his turn onto the commode. Patient was in a rush to sit down and attempted to use the bedside table located on the right of him as support. Stated, just wait for me. As soon as that was stated, patient had fallen do to the bedside table moving to his right. Patient braced with both arms in front and did not hit his head onto the wall, floor, or bedside table but did fall onto knee and hip. Fall was sustained at 2140 (9:40 p.m.).” During an interview on 9/17/2025 at 4:52 p.m. with Registered Nurse 8 (RN 8), RN 8 stated, Patient 7 sustained a fall on 5/10/2025 at 9:40 p.m. RN 8 stated, she did not notify Patient 7 ’ s spouse about the fall because she was focused on stabilizing Patient 7. RN 8 stated is important to inform Patient 7 ’ s spouse about the fall because a fall is consider a change of condition and Patient 7 ’ s spouse needs to be informed to be involved in the recovery for Patient 7. During a review of the facility ’ s P&P titled, “Fall Reduction Program: Adult & (and) Pediatric,” revised in 3/2025, the P&P indicated, “I. Purpose To provide guidelines for the implementation of the falls reduction program in order to ensure the safety of all patients ...J. After a patient falls, staff will: 1. Utilize Post Fall Algorithm -Inpatient and Emergency Department (see attachment) ...” During a review of the document title, “[Name of the Facility] Inpatient Post Fall Algorithm,” V.8 5-2016, not dated, provided by the facility indicated “Notify family update family with patient location if patient moved to a new room/location ...””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 38310 Based on interview and record review, the facility failed to develop a nursing care plan (a written action plan that documents a patient ’ s needs, risks, and goals to ensure consistent, quality care) addressing bleeding (loss of blood), pain, and blood pressure (the pressure within the major arteries of the body) for two of 32 sampled patients (Patient 17 and Patient 22). This deficient practice had the potential to result in Patient 17 and Patient 22 not receiving the right level of care and not meeting the needs for the identified patient concerns. Findings: 1. During a review of Patient 17 ’ s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/7/2024 at 9:57 p.m., indicated Patient 17 was brought in for abdominal (tummy) pain. Patient 17 has a history of abdominal aortic aneurysm (AAA, swelling in the aorta, the artery that carries blood from the heart to the tummy). Patient 17 began to develop a mild headache (head pain), hip pain, and shortness of breath (SOB, the feeling of difficulty or labored breathing). Computed Tomography (CT, a type of imaging that creates detailed images of the body) exam showed a small bowel obstruction (SBO, a blockage in the small intestine that prevents food and waste from moving through the digestive tract normally). Patient 17 was later observed to be tachypneic (abnormally fast breathing rate), with altered mentation (a change in a person ’ s mental state or level of consciousness), lethargy (lack of energy), and no urine output. Patient 17 ’ s admitting diagnosis (a medical determination of the cause of a patient ’ s symptoms) includes acute kidney injury (AKI, a sudden decline in kidney function), dehydration (when the body loses more fluids than it takes in, resulting in a lack of water in the body), lactic acidosis (an acid build up in the bloodstream), metabolic acidosis (an excessive amount of acid in the body ’ s fluids), elevated troponin (indicates the presence of heart muscle damage), history of endovascular stent graft (a tube [catheter] used to reinforce a weak or bulging artery) for AAA, and sepsis (a serious condition in which the body overreacts to an infection). During a review of Patient 17 ’ s “Consult Note” dated 9/9/2024 at 9:03 a.m., indicated that Patient 17 developed atrial fibrillation (Afib, a heart rhythm disorder were the heart ’ s upper chambers [atria] beat irregularly and rapidly). Patient 17 was given heparin (a fast-acting anticoagulant [blood thinner] medication that prevents the formation and growth of blood clots) to treat this condition. Patient 17 had a normal platelet (a blood cell that play a crucial role in blood clotting) count but after being placed on heparin, Patient 17 had progressively decreased from 98,000 to 91,000 resulting in thrombocytopenia (low number of platelets in the blood). During a review of Patient 17 ’ s “Consult Note” dated 9/9/2024 at 2:15 p.m., indicated that Patient 17 was on heparin for Afib; however, due to decreasing platelets, enoxaparin (Lovenox, a blood thinner medication) was considered instead. During a review of Patient 17 ’ s “Progress Note” dated 9/22/2024 at 2:24 p.m. indicated that Patient 17 ’ s Lovenox for Afib was changed back to heparin in anticipation of possible surgery. Patient 17 was also receiving nothing by mouth (NPO, “nil per os”, Latin for nothing by mouth) requiring antihypertensives (medications to treat high BP) to be held. Patient 17 was borderline hypotensive (low blood pressure) During a review of Patient 17 ’ s “Medication Administration Record (MAR, a document that provides a list of all medications given to a patient by a healthcare professional)”, indicated that Patient 17 was receiving morphine (a powerful pain medication that treats moderate to severe pain) 4 milligrams (mg) as needed for pain. A dose was administered on 10/3/24 at 8:35 am for severe abdominal pain of 8 out of 10 on a numeric pain scale (a tool used for assessing pain intensity). Patient 17 ’ s MAR indicated that Patient 17 was also receiving heparin 25,000 units (1,200 units per hour) via IV, which was changed to Lovenox 90 mg subcutaneously (SQ, an injection into the subcutaneous tissue, just below the skin), and back to heparin 25,000 units for Afib and deep vein thrombosis (a blood clot in a deep vein , usually in the legs) management/prevention. Patient 17 also received metoprolol (a medication used to treat heart conditions such as high BP, angina [chest pain], and heart failure [heart doesn ’ t pump blood as well as it should]) 2.5 mg, amiodarone (a medication used to treat heart rhythm disorders), and norepinephrine (Levophed, an IV medication [vasopressor] to treat life-threatening low BP) 4 mg (5 mcg/min) to address Patient 17 ’ s BP and cardiac (relating to the heart) needs. During a concurrent interview and record review on 9/16/25 at 11:14 a.m., with Registered Nurse 9 (RN 9), RN 9 stated there was no care plan addressing Patient 17 ’ s risk for bleeding, pain, or Blood Pressure (BP)/cardiac needs. RN 9 further stated that care plans are important to ensure patients receive care that is personalized (made particularly for an individual) to their needs. RN 9 also stated that care plans are needed to properly monitor and educate patients. They also assist with monitoring patient goals. RN 9 stated that Patient 17 should ’ ve had a care plan identifying Patient 17 ’ s risk for bleeding due to being on blood thinners. RN 9 states this was important as most patients on blood thinners may develop bruising (discoloration of the skin caused by blood leaking under the skin) and uncontrollable (hard to stop) external/internal bleeding. Per RN 9, this was important for healthcare workers to include in Patient 17 ’ s care as some food, medications, and activities may require avoiding. RN 9 stated pain should also be addressed as it was a primary reason for Patient 17 ’ s visit to the hospital (abdominal pain). Per RN 9, identifying Patient 17 ’ s pain needs assist with identifying Patient 17 ’ s acceptable level of pain, preferred distractions (something that prevent a person from giving full attention to something else), and pain goals. RN 9 further stated that Patient 17 received several doses of pain medication for severe pain, a care plan would address all needs to maintain Patient 17 ’ s comfort. Lastly, RN 9 stated there should be a care plan identifying Patient 17 ’ s BP and/or cardiac needs. RN 9 stated that Patient 17 developed new onset Afib, and irregular heart rhythms which could impact a patient ’ s cardiac output (how much blood a person ’ s heart pumps in one minute). RN 9 further stated that Patient 17 suffered from dehydration and sepsis which may decrease cardiac volume (the amount of blood in a person ’ s body) and further affect the cardiac output. Per RN 9, Patient 17 was also prescribed BP meds for hypertension, but experienced hypotension due to other medical conditions. RN 9 stated, a care plan may have prevented Patient 17 from receiving antihypertensive medications during hypotensive episodes. During a review of the facility ’ s policy & procedures (P&P), titled “Nursing Plan of Care”, dated 11/2024, the P&P indicated: Guidelines Nursing Care Plan The following are considered for nursing plans of care Based on the goal-oriented plan of care Standard procedure-based interventions and precautions used in surgery (including preoperative, intra-operative, and post-operative care) Standard interventions and precautions for high-risk procedures other than surgery Admission Diagnosis Updated upon change of condition The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals Care plans are reviewed and acknowledges every shift. The nursing assessment in short term and high-risk locations (e.g. emergency department, procedural areas) should be focused on the presenting complaint or anticipated procedure. Inpatient nursing assessments and reassessments should be comprehensive and based on the domains reflected in the current nursing documentation system. 2. During a review of Patient 22 ’ s “History and Physical (H&P)”, dated 9/9/25 at 3:31 am, with Registered Nurse 9 (RN 9), Patient 22 ’ s H&P indicated Patient 22 had a history of congestive heart failure (CHF, a chronic condition in which the heart doesn ’ t pump blood as well as it should), aortic valve replacement (a surgery to remove a damaged aortic valve in the heart and replace it with a new one), mitral valve replacement (a surgical procedure to remove a damaged mitral valve in the heart and replace it with a new one), chronic obstructive pulmonary disease (a group of lung conditions that make it hard to breathe by blocking airflow to and from the lungs), and pacemaker (a small implantable device that helps regulate the heart ’ s rhythm). Patient 22 reported to the hospital for shortness of breath (SOB, the feeling of difficulty or labored breathing) that became worse over the past couple days. Patient 22 was hospitalized in July for pleural effusion (an abnormal buildup of excess fluid in the area between the lungs and the chest wall, pleural space) which was drained. Patient 22 was noted to have hypertension (high blood pressure), 145/78. Patient 22 was admitted for acute respiratory failure with hypoxia (a medical emergency where the lungs can ’ t get enough oxygen to the blood) and acute pneumothorax (a condition where air leaks into the space between the lungs and the chest wall, causing the lung to collapse). During a review of Patient 22 ’ s “Consult Note” dated 9/10/25 at 5:39 pm, indicated that Patient 22 had a significant cardiac history, including rheumatic heart disease (RHD, permanent damage to heart valves caused by rheumatic fever), atrial fibrillation (Afib, a heart rhythm disorder were the heart ’ s upper chambers [atria] beat irregularly and rapidly), stroke (when blood flow to the brain is interrupted), and pulmonary hypertension (PH, a condition where blood pressure in the arteries of the lungs is abnormally high). A chest tube (a thin tube inserted into the space between the lung and chest wall [pleural space] to drain air, blood, or fluid) was inserted and Patient 22 was started on heparin (an anticoagulant [blood thinner] medication that prevents blood clots) drip intravenously (IV, within a vein) for valvular heart disease and Afib. During a review of Patient 22 ’ s “Medication Administration Record (MAR, a document that provides a list of all medications given to a patient by a healthcare professional),” indicated that Patient 22 was receiving heparin 25,000 units (600 units per hour) continuously for valvular heart disease and Afib. During a concurrent interview and record review on 9/16/25 at 4:42 pm, with RN 9, RN 9 stated there was no care plan addressing Patient 22 ’ s heparin use or bleeding risk. RN 9 stated a care plan was important as most patients on blood thinners may develop bruising (discoloration of the skin caused by blood leaking under the skin) or uncontrolled (hard to stop) external/internal bleeding. RN 9 further stated having a care plan to address Patient 22 ’ s bleeding risks was extremely important due to Patient 22 ’ s cardiac history, age, and medication use. RN 9 further stated that having a care plan was necessary to properly monitor patient ’ s symptoms, educate the patient and family on their diagnosis and appropriate treatment options, and to monitor individualized goals. During a review of the facility ’ s policy & procedures (P&P), titled “Nursing Plan of Care”, dated 11/2024, the P&P indicated: Guidelines Nursing Care Plan The following are considered for nursing plans of care Based on the goal-oriented plan of care Standard procedure-based interventions and precautions used in surgery (including preoperative, intra-operative, and post-operative care) Standard interventions and precautions for high-risk procedures other than surgery Admission Diagnosis Updated upon change of condition The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals Care plans are reviewed and acknowledges every shift. The nursing assessment in short term and high-risk locations (e.g. emergency department, procedural areas) should be focused on the presenting complaint or anticipated procedure. Inpatient nursing assessments and reassessments should be comprehensive and based on the domains reflected in the current nursing documentation system.”

“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: 38310 Based on interview, and record review, the facility failed to: Ensure the Nursing staff for 3 of 30 sampled patients (Patient 1, Patient 28, and Patient 29), a Interfacility Transfer Form (a standardized document used to communicate essential patient information for when a patient moves from one healthcare facility to another) will be completed and sent with the patient and a copy of the transfer record will be provided to the patient/family/responsible party in accordance with the facility’s policy and procedure (P&P) regarding admission, transfer and discharges. These deficient practices can potentially expose patient ’ s significant risks and can result in medical errors, delays in care, and adverse patient outcomes. The form is a tool designed to ensure the accurate and complete exchange of critical patient information between facilities. Ensure three patients (Patient 2, Patient 3 and Patient 4) of 32 sampled patients, to ensure medications were given within the ordered time frame per facility policy and procedure. This deficient practice has the potential for Patient 2, Patient 3 and Patient 4 to have prolonged treatment and recovery due to delayed medication administration times. Ensure one patient (Patient 3) of 32 sampled patients, had a restraint order was in place while the patient was actively being restrained per facility policy and procedure. This deficient practice has the potential for Patient 3 to be restrained without just reasoning provided by a physician ’ s order. Findings: A. During a review of Patient 1 ’ s “History and Physical (H&P),” dated 12/7/2024, the H&P indicated Patient 1 admitted to the facility on 12/7/2024 for altered mental status (a change in a person’s level of consciousness, awareness, and cognitive function) related to myocardial infarction (heart attack). Patient 1 had past medical history of Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), chronic obstructive pulmonary disease (condition that causes difficulty breathing), coronary artery disease (heart condition that causes reduced blood flow to heart muscle) and chronic kidney disease (condition where kidneys gradually lose ability to filter waste). During a review of Patient 1 ’ s “Nursing Narrative,” (documentation where nurses use paragraph format to tell a story of the patient ’ s condition) dated 12/11/2024, indicated, ambulance had arrived at 8:08 PM to transfer Patient 1 to the skilled nursing facility and left the facility in stable condition. During a review of Patient 1 ’ s, “Final Discharge Disposition Form”(patient ’ s final location) dated 12/11/2024, indicated, at final discharge, Patient 1 was being transferred to a skilled nursing facility (SNF, a type of healthcare facility that provides 24-hour medical care and assistance to individuals who require skilled nursing services) for skilled care. The note indicated Patient 1 ’ s daughter was aware and agreed to the transfer. During an interview on 9/16/2025 at 2:23 PM with the Nurse Manager (NM 2), the NM 2 stated, the interfacility form is completed by nurses for patients who are being transferred out of the facility. NM 2 also stated this form is the nurse ’ s written endorsement report to the receiving facility that is shared via a phone call. During an interview on 9/16/2025 at 3:12 PM with the Director of Quality Improvement (DQI), the DQI stated, Patient 1 did not have an interfacility form that was ever completed prior to transfer to the receiving facility. The DQI stated the risk of not having this form completed was that it may confusion about what documents were sent, the continuum of care was not clear, and the patient ’ s information and history of illness was not being shared with the receiving facility. During a review of the facility ’ s policy and procedure (P&P) titled, “Hand Off Communication,” dated 03/2025, indicated, “Transfer of a Patient to another Hospital, Nursing Home, or Home Health Agency – at a minimum, a written report will be provided. The minimum content of the written report will be noted on the inter-facility transfer form.” B. A review of Patient 28 ’ s “History and Physical”, dated 09/04/2025, indicated X-ray showed oblique fractures (a broken bone where the break occurs at an angle across the bone’s surface, rather than straight across) of the distal tibial (refers to the tibia, the larger, inner bone of the lower leg) and fibular (a long, thin bone located on the lateral side of the lower leg, parallel to the tibia). Significant soft tissue trauma (injuries that affect the muscles, tendons, ligaments, and other non-bony structures of the body), suggesting an open fracture (broken bone that pierces the skin, creating an open wound). During an interview on 9/16/2025 at 2:33 p.m. with the Nurse Manager (NM2), NM2 stated that an interfacility transfer form should be completed when a patient was transferred to another hospital or a skilled nursing facility (SNF, a type of healthcare facility that provides 24-hour medical care and assistance to individuals who require skilled nursing services). Although it was widely practice by nurses in the ED (Emergency Department), it seemed the in-patient nurses did not complete an interfacility transfer form when discharging Patient 28 to a SNF, they would likely complete one if it was a patient transfer to another acute hospital. Best practice was to complete an interfacility transfer form to all patient transfer. Completing the form was important because it served as a communication tool between facility and it would contain important information about Patient 28 ’ s care needs. During a concurrent interview and record review on 09/18/2025 at 1:02 p.m. of Patient 28 ’ s medical record titled “Discharge Summary”, dated 09/16/2025 and interview with Quality Management and Patient Safety (QMPS), the patient ’ s record indicated that Patient 28 was discharge to a SNF on 09/16/2025. QMPS stated that there was no records in Patient 28 ’ s electronic medical record (EMR, is a digital version of a patient’s medical history that stores and organizes all healthcare information) that an interfacility transfer form was completed. It was hospital policy that an interfacility transfer form must be completed when a patient was discharged to SNF. A review of the Policy and Procedure titled “Admission, Transfer and Discharge”, with last revised date of 10/2020, the document indicates the following: For patients transferring/discharged to a skilled facility: Case Manager will: Discuss transfer/discharge options with the patient/family. Contact the receiving facility to verify acceptance of the Patient, and follow insurance specific directions. Family members (if available) will be notified sometime over the 24 hours prior to transfer/discharge to a skilled facility. If unable to make contact, a message may be left with a responsible family member. Send a Transition of Care (TOC)/Summary of Care on transfer. The interfacility Transfer Form, and Belongings Inventory Record Form will be completed and sent with the patient. A copy of the transfer record will be provided to the patient/family/responsible party. C. A review of patient ’ s 29 “History and Physical”, dated 07/25/2025, the record indicated that the patient 60-year-old female with a history of cerebrovascular accident (stroke), myocardial infarction (heart attack), who presented to the emergency department from home with complaints of chest tightness which started approximately one hour prior to arrival. During an interview on 9/16/2025 at 2:33 p.m. with the Nurse Manager (NM2), NM2 stated that an interfacility transfer form should be completed when a patient was transferred to another hospital or a skilled nursing facility (SNF, a type of healthcare facility that provides 24-hour medical care and assistance to individuals who require skilled nursing services). Although it was widely practice by nurses in the ED (Emergency Department), it seemed the in-patient nurses did not complete an interfacility transfer form when discharging Patient 29 to a SNF, they would likely complete one if it was a patient transfer to another acute hospital. Best practice was to complete an interfacility transfer form to all patient transfer. Completing the form was important because it served as a communication tool between facility and it would contain important information about the Patient 29 ’ s care needs. During a concurrent interview and record review on 09/17/2025 at 12:02 p.m. of Patient 29 ’ s medical record titled “Discharge Summary”, dated 08/29/2025 and interview with Quality Management and Patient Safety (QMPS), Patient 29 ’ s record indicated that patient was discharge to a SNF on 09/29/2025. QMPS stated that there was no records in Patient 29 ’ s electronic medical record (EMR, is a digital version of a patient’s medical history that stores and organizes all healthcare information) that an interfacility transfer form was completed. It was hospital policy that an interfacility transfer form must be completed when a patient was discharged to SNF. A review of the Policy and Procedure titled “Admission, Transfer and Discharge”, with last revised date of 10/2020, the document indicates the following: For patients transferring/discharged to a skilled facility: Case Manager will: Discuss transfer/discharge options with the patient/family. Contact the receiving facility to verify acceptance of the Patient, and follow insurance specific directions. Family members (if available) will be notified sometime over the 24 hours prior to transfer/discharge to a skilled facility. If unable to make contact, a message may be left with a responsible family member. Send a Transition of Care (TOC)/Summary of Care on transfer. The interfacility Transfer Form, and Belongings Inventory Record Form will be completed and sent with the patient. A copy of the transfer record will be provided to the patient/family/responsible party. 2.A. During a review of Patient 2 ’ s H&P, dated 3/5/2023, the H&P indicated, Patient 2 was admitted to the facility on 3/5/2023 for altered level of consciousness and confusion related to hepatic encephalopathy (a complication of brain function related to poor function of the liver). Patient 2 had a past medical history of cirrhosis of liver (damage that disrupts liver function) and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent interview and record review, on 9/16/2025 at 3:26 PM, with the STEMI(Segment Elevation Myocardial Infarction-heart attack) Program Coordinator (SPC), Patient 2 ’ s medication administration record (MAR), dated 3/4/2023, was reviewed. The MAR indicated, lactulose (a medication used to treat high ammonia levels) 200 gram(unit of mass) enema (a procedure in which liquid injected into the one ’ s rectum) via rectal was ordered STAT (to be given as quickly as possible without delay) on 3/4/2023 at 1:58 PM. The MAR also indicated the STAT order was administered on 3/4/2023 at 4:02 PM (about two hours after ordered). The SPC stated, she observed the medication to be administered two hours late. The SPC also stated, there was no documentation indicating the medication was unavailable for administration. During a review of the facility ’ s policy and procedure (P&P) titled, “MM: Medication Administration, Administration Time, Monitoring and Documentation,” dated 03/2025, indicated, “STAT and NOW medications shall be administered within fifteen and sixty minutes, respectively of being available.” B. During a review of Patient 3 ’ s History and Physical (H&P), dated 9/5/2025, the H&P indicated, Patient 3 was admitted to the facility on 9/5/2025 for lower abdominal pain with fever related to sepsis (a life-threatening blood infection) and acute perforated appendicitis (a severe medical condition where the lower part of intestines bursts). Patient 3 has no pertinent past medical history. During a concurrent interview and record review, on 9/17/2025 at 3:15 PM, with the STEMI(Segment Elevation Myocardial Infarction-heart attack) Program Coordinator (SPC), Patient 3 ’ s MAR (medication administration record), dated 9/5/2025, was reviewed. The MAR indicated, vancomycin (an antibiotic) 1,750 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) via intravenous (inside veins) piggyback (method of administering intravenous medication) was ordered STAT (Now) on 9/5/2025 at 3:50 PM. The MAR also indicated, the STAT order was administered on 9/5/2025 at 4:55 PM (about an hour and five minutes after ordered). The SPC stated, she observed the medication to be administered one hour and five minutes late. The SPC also stated, there was no documentation indicating the medication was unavailable for administration. During a review of the facility ’ s policy and procedure (P&P) titled, “MM: Medication Administration, Administration Time, Monitoring and Documentation,” dated 03/2025, indicated, “STAT and NOW medications shall be administered within fifteen and sixty minutes, respectively of being available.” C. During a review of Patient 4 ’ s History and Physical (H&P), dated 8/31/2025, the H&P indicated, Patient 4 was admitted to the facility on 8/31/2025 for altered mental status related to sepsis (a life-threatening blood infection). Patient 4 has a past medical history of diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer ’ s disease (a disorder that affects memory, thinking and behavior), cerebral palsy (a disorder that affects movement, balance and posture), schizophrenia (a mental illness that is characterized by disturbances in thought) and prior cerebrovascular accident (stroke, loss of blood flow to a part of the brain). During a concurrent interview and record review, on 9/17/2025 at 3:50 PM, with the SPC, Patient 4 ’ s MAR, dated 8/31/2025, was reviewed. The MAR (medication administration record) indicated, vancomycin 1,500 mg via intravenous piggyback was ordered STAT ((to be given as quickly as possible without delay) on 8/31/2025 at 5:30 PM. The MAR also indicated, the STAT order was administered on 8/31/2025 at 6:41 PM (about an hour and 11 minutes after ordered). The SPC stated, she observed the medication to be administered one hour late. The SPC also stated, there was no documentation indicating the medication was unavailable for administration. During a review of the facility ’ s policy and procedure (P&P) titled, “MM: Medication Administration, Administration Time, Monitoring and Documentation,” dated 03/2025, indicated, “STAT and NOW medications shall be administered within fifteen and sixty minutes, respectively of being available.” 3.During a review of Patient 3 ’ s History and Physical (H&P), dated 9/5/2025, the H&P indicated, Patient 3 admitted to the facility on 9/5/2025 for lower abdominal pain with fever related to sepsis (a life-threatening blood infection) and acute perforated appendicitis (a severe medical condition where the lower part of intestines bursts). Patient 3 has no pertinent past medical history. During a review of Patient 3 ’ s doctor ’ s order for “Restraint Renewal Non Violent,” dated 9/12/2025 indicated, restraint soft limb(soft padded fabric cuff use to gently limit a patient ’ s movement of the arms or legs ) 2 point restraint, bilateral upper extremity, once schedule was ordered with start date and time of 9/12/2025 at 1:58 AM and stop date and time of 9/12/2025 at 7:31 AM. During a review of Patient 3 ’ doctor ’ s order for “Restraint Renewal Non Violent,” dated 9/13/2025 indicated, restraint soft limb, 2 point restraint, bilateral upper extremity, once schedule was ordered with start date and time of 9/13/2025 at 1:20 AM and stop date and time of 9/13/2025 at 6:05 PM. During a review of Patient 3 ’ doctor ’ s order for “Restraint Renewal Non Violent,” dated 9/14/2025 indicated, restraint soft limb, 2 point restraint, bilateral upper extremity, once schedule was ordered with start date and time of 9/14/2025 at 5:44 PM with stop date and time of 9/14/2025 at 6:08 PM. During a review of Patient 3 ’ doctor ’ s order for “Restraint Renewal Non Violent,” dated 9/15/2025 indicated, restraint soft limb, 2 point restraint, bilateral upper extremity, once schedule was ordered with start date and time of 9/15/2025 at 7:44 AM with stop date and time of 9/15/2025 at 10:36 AM. During a review of Patient 3 ’ doctor ’ s order for “Restraint Renewal Non Violent,” dated 9/16/2025 indicated, restraint soft limb, 2 point restraint, bilateral upper extremity, once schedule was ordered with start date and time of 9/16/2025 at 6:43 AM with a stop date and time of 9/16/2025 7:50 AM. During concurrent interview and record review, on 9/17/2025 at 2:30 PM, with the STEMI Program Coordinator (SPC), Patient 3 ’ s “Restraint Patient Assessment” flowsheet, dated multiple dates was reviewed. The flowsheet indicated, Patient 3 was documented to have restraints applied on the following dates and times: 9/12/2025 at 8:00 AM 9/12/2025 at 6:00 PM 9/12/2025 at 8:00 PM 9/14/2025 at 8:00 PM 9/15/2025 at 6:00 AM 9/15/2025 at 6:00 PM 9/15/2025 at 8:00 PM 9/16/2025 at 6:00 AM. The SPC stated Patient 3 was documented to be under restraint without necessary restraint orders present during the multiple times the restraints were applied. During an interview on 9/17/2025 at 2:59 PM with the Director of Quality Improvement (DQI), the DQI stated it is a violation of patient rights to have a patient under restraints without a restraint order that indicates the same pertaining timespan in which the restraints were applied. During a review of the facility ’ s policy and procedure (P&P) titled, “ Restraint & Seclusion,” dated 03/2025, indicated, “Each episode of restraint will be initiated: 1. Upon the order of a Medical Provider.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36329 Based on interview and record review the facility failed to: 1.Ensure 1 of 20 sampled patients (Patient 8) signed a consent acknowledging the risks and benefits of transferring to another facility after a medical emergency was identified and stabilized (state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected). This deficient practice can result in Patient 8 not knowing the benefits and risks of transfer to another facility which can impact the ability to make an informed decision. 2. Ensure the receiving hospital physician agreed to accept 1 of 20 sampled patients (Patient 1) to expedite care for this patient who was not able to receive stabilizing treatment at this facility. This deficient practice may result in a delay of care which can compromise patient safety. Findings: 1. During an interview on 12/18/2024 at 3:22 p.m., the Quality Improvement (QI) Director acknowledged, after examining the transfer documents for Patient 8, that the consent for transfer to another hospital had not been signed by the patient or a responsible party. The QI Director subsequently stated all patients who qualify for a transfer to another facility, must sign the facility ’ s consent form for further care, to be informed of the benefits and risk of transfer as stated in the facility ’ s policy. The QI Director then stated the reason for Patient 8 being transferred to another facility was that this facility does not treat pediatric (less than 14 years of age) orthopedic (treatment of conditions affecting bone and muscle) patients. During a review of the ED Note-Physician ’ Final Report, ’ (signed 1/15/2024), this document indicated Patient 8 , who was 12 years old, entered the emergency department with her mother for an evaluation of Patient 8 ’ s left elbow pain and numbness. The mother of Patient 8 stated Patient 8 was at cheer practice when Patient 8 stumbled and dislocated her elbow. During a physical examination, Patient 8 exhibited limited range of motion (the extent or limited to which a body part can be moved around a joint) due to pain in the left elbow. This report indicated, from an x-ray of the left elbow, a dislocation (area where the ends of two bones separate at the joint where they meet) and a fracture at the point where the left elbow and left upper arm bone meet. This report indicated that the Attending Physician arranged to transfer Patient 8 to another facility because Patient 8 was a pediatric patient and may require transfer for pediatric evaluation. During a review of the ’ Patient Transfer ’ form all the following were verified before transferring Patient 8: name of facility sent to; all pertinent medical records, Patient 8 ’ s condition upon transfer was stable. There was no record of consent to transfer by a responsible party. During a review of the facility ’ s policy titled ’ Transfers Interfacilities from the ED ’ (emergency department) PolicyStat ID 15760226, this policy indicated that a charge nurse (leader of a nursing unit) in the emergency department, if the patient is stable, will initiate the inter-facility transfer form for each patient. The ’ Transfers Interfacilities from the ED ’ policy indicated stable as being the state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected. 2. During an interview on 12/19/2024 at 1:00 p.m.PM, the ED Physician stated Patient 1 entered the emergency department on 8/2/2024 with active bleeding from the left leg from injury during an automobile accident; Patient 1 had history of hemophilia (a disorder that prevents blood from clotting properly, resulting in excessive bleeding) and history of Von Willebrand disease (a disorder that prevents blood from clotting properly, but more common than hemophilia). The ED Physician stated it was her recommendation to transfer Patient 1 to another hospital having a supply of Factor VIII (an agent in the blood, when reacted with Factor IX, sets off a chain reaction to form a blood clot) and having the ability to monitor the activity level of Factor VIII (percentage of Factor VIII reacting in the blood to initiate clotting). At this time the ED Physician stated it was her understanding the mother of Patient 1 had a supply of Factor VIII with her and it was decided it (the mother ’ s supply) should be given at the bedside in the emergency department. The ED Physician subsequently said that, through miscommunication, Patient 1 was sent to the other hospital before sending Patient 1and the transferringreceiving physicians had a chance to communicate with the receiving physician. Finally the ED Physician stated the process for transferring a patient by 911 (transfer by ambulance to another hospital due to the transferring facility not having ability to stabilize the patient) is as follows: if the patient meets the criteria for transfer by 911 (inability to stabilize patient), the charge nurse prepares the transfer paperwork; the unit secretary calls the receiving facility and coordinates a sending physician to receiving physician conversation; 911 is called when all the aforementioned are completed. During an interview on 12/19/2024 at 1:23 p.m.PM, the ED Charge Nurse stated the unit secretary (name unknown) dialed 911 but did not discuss this conversation with anyone or any conversation with the receiving hospital. The ED Charge Nurse then stated the unit secretary said she (the unit secretary) asked to consult with the receiving physician and said there was an accepting physician at the other hospital. The ED Charge Nurse subsequently stated the unit secretary told the waiting ambulance staff there was an accepting physician at the other facility. The ED Charge Nurse stated this is not the normal process for 911 transfer; the order of the process is as follows: verify the patient ’ s condition qualifies for 911 transfer; verify there has been a sending physician to receiving physician consultation; the transfer package is completed; the sending physician creates an order to transfer to another facility; after all above process is complete, call 911 for patient pickup. The ED Charge Nurse then stated there now is a written process for 911 transfers to follow. During an interview on 12/19/2024, the Unit Secretary Supervisor stated the unit secretary involved in the transfer of Patient 1 on 8/2/2024 was on a leave at this time but the Unit Secretary Supervisor said she is familiar with the process of 911 transfer from the emergency department but there is was no formal procedure for 911 transfers at that time. The Unit Secretary Supervisor stated she usually hears ED physician conversations and gets the authorization to call for 911 transfer of the patient from this physician; the Unit Secretary Supervisor then prepares the transfer documents. Finally, the Unit Secretary Supervisor said after preparing the documents, she requests the receiving hospital to arrange a doctor to doctor conversation regarding the 911 transfer and usually the sending doctor usually informs her that conversation did occur. During a review of the ’ Emergency/Urgent Care ’ note authored by the ED Physician, the note indicated Patient 1 was evaluated by an Advanced Practice Provider (health care provider who is not a physician but performs many of the activities performed by a physician) and was evaluated for pain in the left thigh pain post motor vehicle accident. Patient 1 ’ s medical history included hemophilia A (hereditary bleeding disorder caused by lack of clotting factor VIII) and Willebrand ’ s disease. This document indicated Patient 1 had experienced tenderness and increased swelling over the left thigh; because of the threat of compartment syndrome (dangerous condition caused by pressure buildup from internal bleeding or swelling of tissue) and history of hemophilia the facility ’ s plan was administering Factor VIII, consultation with hematology oncology (medical specialty dealing with treatment of blood cancers and disorders), transport Patient 1 to higher level of care facility. Finally, this note indicated this facility ’ s staff and 911 crew were alerted that the receiving physician was not going to accept Patient 1 as Patient 1 was given Factor VIII before arriving at the receiving hospital and there was no need to transfer Patient 1. The ED Charge Nurse stated the unit secretary told the 911 crew there was an accepting physician and the 911 crew departed with Patient 1 before the receiving physician could speak with the sending physician. During a review of the ’ Emergency Medical Treatment and Labor Act of 1986 – EMTALA ’ PolicyStat ID 15675670, this policy indicated this facility will provide an MSE (medical screening examination, examination by a qualified healthcare provider to determine if an emergency medical condition exists that may require stabilizing treatment). This stabilizing treatment may include admission for inpatient care, or arrangement of an appropriate transfer of the individual to another medical facility with the capability to provide the stabilizing care.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36329 Based on interview and record review the facility failed to: 1.Ensure 1 of 20 sampled patients (Patient 8) signed a consent acknowledging the risks and benefits of transferring to another facility after a medical emergency was identified and stabilized (state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected). This deficient practice can result in Patient 8 not knowing the benefits and risks of transfer to another facility which can impact the ability to make an informed decision. 2. Ensure the receiving hospital physician agreed to accept 1 of 20 sampled patients (Patient 1) to expedite care for this patient who was not able to receive stabilizing treatment at this facility. This deficient practice may result in a delay of care which can compromise patient safety. Findings: 1. During an interview on 12/18/2024 at 3:22 p.m., the Quality Improvement (QI) Director acknowledged, after examining the transfer documents for Patient 8, that the consent for transfer to another hospital had not been signed by the patient or a responsible party. The QI Director subsequently stated all patients who qualify for a transfer to another facility, must sign the facility ’ s consent form for further care, to be informed of the benefits and risk of transfer as stated in the facility ’ s policy. The QI Director then stated the reason for Patient 8 being transferred to another facility was that this facility does not treat pediatric (less than 14 years of age) orthopedic (treatment of conditions affecting bone and muscle) patients. During a review of the ED Note-Physician ’ Final Report, ’ (signed 1/15/2024), this document indicated Patient 8 , who was 12 years old, entered the emergency department with her mother for an evaluation of Patient 8 ’ s left elbow pain and numbness. The mother of Patient 8 stated Patient 8 was at cheer practice when Patient 8 stumbled and dislocated her elbow. During a physical examination, Patient 8 exhibited limited range of motion (the extent or limited to which a body part can be moved around a joint) due to pain in the left elbow. This report indicated, from an x-ray of the left elbow, a dislocation (area where the ends of two bones separate at the joint where they meet) and a fracture at the point where the left elbow and left upper arm bone meet. This report indicated that the Attending Physician arranged to transfer Patient 8 to another facility because Patient 8 was a pediatric patient and may require transfer for pediatric evaluation. During a review of the ’ Patient Transfer ’ form all the following were verified before transferring Patient 8: name of facility sent to; all pertinent medical records, Patient 8 ’ s condition upon transfer was stable. There was no record of consent to transfer by a responsible party. During a review of the facility ’ s policy titled ’ Transfers Interfacilities from the ED ’ (emergency department) PolicyStat ID 15760226, this policy indicated that a charge nurse (leader of a nursing unit) in the emergency department, if the patient is stable, will initiate the inter-facility transfer form for each patient. The ’ Transfers Interfacilities from the ED ’ policy indicated stable as being the state where, within reasonable clinical confidence, the emergency condition resolved or no deterioration is expected. 2. During an interview on 12/19/2024 at 1:00 p.m.PM, the ED Physician stated Patient 1 entered the emergency department on 8/2/2024 with active bleeding from the left leg from injury during an automobile accident; Patient 1 had history of hemophilia (a disorder that prevents blood from clotting properly, resulting in excessive bleeding) and history of Von Willebrand disease (a disorder that prevents blood from clotting properly, but more common than hemophilia). The ED Physician stated it was her recommendation to transfer Patient 1 to another hospital having a supply of Factor VIII (an agent in the blood, when reacted with Factor IX, sets off a chain reaction to form a blood clot) and having the ability to monitor the activity level of Factor VIII (percentage of Factor VIII reacting in the blood to initiate clotting). At this time the ED Physician stated it was her understanding the mother of Patient 1 had a supply of Factor VIII with her and it was decided it (the mother ’ s supply) should be given at the bedside in the emergency department. The ED Physician subsequently said that, through miscommunication, Patient 1 was sent to the other hospital before sending Patient 1and the transferringreceiving physicians had a chance to communicate with the receiving physician. Finally the ED Physician stated the process for transferring a patient by 911 (transfer by ambulance to another hospital due to the transferring facility not having ability to stabilize the patient) is as follows: if the patient meets the criteria for transfer by 911 (inability to stabilize patient), the charge nurse prepares the transfer paperwork; the unit secretary calls the receiving facility and coordinates a sending physician to receiving physician conversation; 911 is called when all the aforementioned are completed. During an interview on 12/19/2024 at 1:23 p.m.PM, the ED Charge Nurse stated the unit secretary (name unknown) dialed 911 but did not discuss this conversation with anyone or any conversation with the receiving hospital. The ED Charge Nurse then stated the unit secretary said she (the unit secretary) asked to consult with the receiving physician and said there was an accepting physician at the other hospital. The ED Charge Nurse subsequently stated the unit secretary told the waiting ambulance staff there was an accepting physician at the other facility. The ED Charge Nurse stated this is not the normal process for 911 transfer; the order of the process is as follows: verify the patient ’ s condition qualifies for 911 transfer; verify there has been a sending physician to receiving physician consultation; the transfer package is completed; the sending physician creates an order to transfer to another facility; after all above process is complete, call 911 for patient pickup. The ED Charge Nurse then stated there now is a written process for 911 transfers to follow. During an interview on 12/19/2024, the Unit Secretary Supervisor stated the unit secretary involved in the transfer of Patient 1 on 8/2/2024 was on a leave at this time but the Unit Secretary Supervisor said she is familiar with the process of 911 transfer from the emergency department but there is was no formal procedure for 911 transfers at that time. The Unit Secretary Supervisor stated she usually hears ED physician conversations and gets the authorization to call for 911 transfer of the patient from this physician; the Unit Secretary Supervisor then prepares the transfer documents. Finally, the Unit Secretary Supervisor said after preparing the documents, she requests the receiving hospital to arrange a doctor to doctor conversation regarding the 911 transfer and usually the sending doctor usually informs her that conversation did occur. During a review of the ’ Emergency/Urgent Care ’ note authored by the ED Physician, the note indicated Patient 1 was evaluated by an Advanced Practice Provider (health care provider who is not a physician but performs many of the activities performed by a physician) and was evaluated for pain in the left thigh pain post motor vehicle accident. Patient 1 ’ s medical history included hemophilia A (hereditary bleeding disorder caused by lack of clotting factor VIII) and Willebrand ’ s disease. This document indicated Patient 1 had experienced tenderness and increased swelling over the left thigh; because of the threat of compartment syndrome (dangerous condition caused by pressure buildup from internal bleeding or swelling of tissue) and history of hemophilia the facility ’ s plan was administering Factor VIII, consultation with hematology oncology (medical specialty dealing with treatment of blood cancers and disorders), transport Patient 1 to higher level of care facility. Finally, this note indicated this facility ’ s staff and 911 crew were alerted that the receiving physician was not going to accept Patient 1 as Patient 1 was given Factor VIII before arriving at the receiving hospital and there was no need to transfer Patient 1. The ED Charge Nurse stated the unit secretary told the 911 crew there was an accepting physician and the 911 crew departed with Patient 1 before the receiving physician could speak with the sending physician. During a review of the ’ Emergency Medical Treatment and Labor Act of 1986 – EMTALA ’ PolicyStat ID 15675670, this policy indicated this facility will provide an MSE (medical screening examination, examination by a qualified healthcare provider to determine if an emergency medical condition exists that may require stabilizing treatment). This stabilizing treatment may include admission for inpatient care, or arrangement of an appropriate transfer of the individual to another medical facility with the capability to provide the stabilizing care.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by: 1. The facility failed to ensure for four of 31 sampled patients (Patients 22, 27, 29, and 30) the following: 1.a. Patient 22 and/or the patient’s representative was provided a copy of the Conditions of Admission (COA, contract between the hospital and patient explaining patient’s right and responsibilities) and the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) upon admission to the facility. 1.b. Patient 27 and/or the patient’s representative was provided a copy of the “Consent for Treatment (COT - a patient’s permission to receive medical treatment, tests, or examinations) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient’s responsibilities for the hospital services they receive)” and the IMM letter upon admission to the facility. 1.c. Patient 29’s “COT (Consent for Treatment) and COA (Conditions of Admission)” was provided in Patient 29’s preferred language (Mandarin). 1.d. Patient 30’s “COT (Consent for Treatment) and COA (Conditions of Admission)” and IMM (Important Message from Medicare) letter was provided in Patient 30’s preferred language (Spanish). These deficient practices resulted in Patients 22, 27, 29, 30 and/or the patients’ representative to not be informed of their rights as a patient and their rights to appeal for discharge from the hospital, which may lead in Patients 22, 27, 29, and 30’s inability to effectively make decisions regarding their care and treatment. (Refer to A-0117) 2. The facility failed to ensure the patient’s rights requirement was met for one of 31 sampled patients (Patient 12), in accordance with the facility’s policy and procedure regarding Patients Rights (Example: the right to considerate, respectful care at all times and under all circumstances), when Patient 12 was placed on an involuntary hold (detain a person for treatment against their will) in the facility’s Emergency Department (ED, provides immediate care to patients arriving at the hospital) without evidence of a 5150 form (The 5150 form, also known as the “Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment” or 5150,” is a legal document that must be signed by an authorized professional person to initiate an involuntary detention [for evaluation and treatment], for someone who is showing signs of severe mental distress.) filled out and completed. This deficient practice had the potential of violating patient’s rights by placing Patient 12 on an involuntary hold without proper documentation and justification of the 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) by an authorized professional person. (Refer to A-0129) 3. The facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22 and/or the patient’s representative was provided a “Blood Transfusion (used for low blood levels, and is an important procedure that moves blood or blood products into a person’s body through the bloodstream, and can carry risks such as an allergic reaction, heart, or lung problems) Information and Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered),” prior to Patient 22 receiving blood transfusion, in accordance with the physician’s order and the facility’s policy and procedure regarding blood transfusion. This deficient practice resulted in Patient 22 and the patient’s representative to not exercise their right to make an informed decision regarding Patient 22’s care, as well as understand the risks and benefits of blood transfusion. (Refer to A-0131) 4. The facility failed to ensure for four of 31 sampled patients (Patients 22, 26, 27, and 29) the following: 4.a. Patients 22’s Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) copy was obtained by the facility upon admission. 4.b. Patient 26’s AD (Advance Directive) copy was obtained by the facility upon admission. 4.c. Patient 27 and/or the patient’s representative was provided information on how to formulate an AD (Advance Directive) upon admission. 4.d. Patient 29’s AD (Advance Directive) copy was obtained by the facility upon admission. These deficient practices had the potential to negatively affect Patients 22, 26, 27, and 29’s rights and wishes for treatment when the patient receives medical care that was not in accordance with the patients’ AD (Advance Directive). (Refer to A-0132) 5. The facility failed to ensure for one of 30 sampled patients (Patient 23), Patient 23’s care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) for the use of restraint (chemical or physical device that prevents a person from freely moving), was developed, in accordance with the facility’s policy and procedure regarding restraints use. This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patient 23’s needs and risks. (Refer to A-0166) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure three of five sampled patients (Patients 1, 11, and 12) were screened, in accordance with the facility’s policy and procedure using the Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening in which the answers help users identify whether someone is at risk for suicide [death caused by injuring oneself with the intent to die], determine the severity and immediacy of that risk, and gauge the level of support that the person needs) tool: 1.a. For Patient 1, there was no C-SSRS completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered by Registered Nurse (RN) 1 as “no” but should have been answered “yes,” and no C-SSRS was completed when Patient 1’s mental status condition worsened. This deficient practice led to undetected suicidal ideation (thoughts of killing oneself) and/or plans, delayed treatment, and compromised Patient 1’s safety. Patient 1 eloped (when a patient leaves an area they are expected to stay within, for their safety) from the facility and jumped from the second floor of the parking structure and sustained injury. (Refer to A-0395) 1.b. For Patient 11, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as “no” but should have been answered “yes.” This deficient practice led to incomplete screening of Patient 11 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice also had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 11’s safety. (Refer to A-0395) 1.c. For Patient 12, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as “no” but should have been answered “yes.” This deficient practice led to incomplete screening of Patient 12 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice also had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 12’s safety. (Refer to A-0395) 2. The facility failed to ensure one of five sampled patient’s (Patient 1) change in behavior (emotions and behaviors that affect individual overall well-being) was communicated to the physician, in accordance with the facility’s policy and procedure regarding assessment and physician notification about change of condition. This deficient practice likely led to Patient 1’s elopement (when a patient leaves an area they are expected to stay within, for their safety) from the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital) and ran into the facility’s parking structure and jumped from the second floor, sustained injuries to the face and forehead and required transport to a trauma specialized hospital (handles the extreme cases where there is an issue immediate survival). (Refer to A-0395) 3. The facility failed to ensure the pain level of two of 31 sampled patients (Patients 6 and Patient 30), was reassessed, after pain medication was administered, in accordance with the facility’s policy and procedure regarding pain management standard of care. This deficient practice had the potential for Patient 6’s and Patient 30’s pain to not be managed effectively and in a timely manner, and may result in delayed treatment, which could worsen the patients’ (Patient 6 and 30) pain level. (Refer to A-0395) 4. The facility failed to ensure one of 31 sampled patients (Patient 25) was reassessed (reevaluated), in accordance with the nursing standard of care and the facility’s policy and procedure regarding reassessment, after Ativan (medication used for relaxation), ordered as needed (PRN) for anxiety, was administered, in order to determine the effectiveness of the medication or the patient’s (Patient 25) response to the medication (Ativan). This deficient practice had the potential to cause a delay in determining Patient 25’s change of condition and/or a delay in the provision of care needed which could worsen the patient’s condition. (Refer to A-0395) 5. The facility failed to ensure one of 31 sampled patients (Patient 26) was reassessed, in accordance with the facility’s policy and procedure regarding reassessment, after Hydralazine (medication used for lowering blood pressure [BP, amount of force blood uses to move through the body]), ordered PRN (as needed) for systolic (SBP, maximum amount of pressure the blood uses to move through the body) greater than 160 mmHg (millimeters of mercury, a unit of measure), was administered. This deficient practice had the potential to cause a delay in determining Patient 26’s change of condition and/or a delay in the provision of care needed which could worsen the patient’s condition. (Refer to A-0395) 6. The facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22’s care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), was developed, in accordance with the accepted standards of nursing practice and the facility’s policy and procedure regarding care planning. This deficient practice resulted in Patient 22 not having an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for Patient 22’s care. In addition, this deficient practice had the potential for Patient 22’s needs and risks to not be addressed. (Refer to A-0396) 7. The facility failed to ensure two of 31 sampled patients’ (Patients 1 and 2), who were admitted to the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), focused reassessment at a minimum of every four hours, were completed, in accordance with the facility’s policy and procedure regarding frequency of focused reassessment in the ED. This deficient practice had the potential for missed changes in condition, delay in care, and treatment, which may compromise Patient 1 and Patient 2’s safety. (Refer to A-0398) 8. The facility failed to ensure one of 31 sampled patient’s (Patient 1’s) refusal to take Keppra (Levetiracetam, medication used to treat seizures) medication was properly documented when Patient 1 did not take the medication, in accordance with the facility’s policy and procedure regarding medication administration documentation. This deficient practice had the potential to result in mismanagement of Patient 1’s treatment and affect patient’s (Patient 1) safety, as Patient 1 was brought into the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) for suspected seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). (Refer to A-0398) 9. The facility failed to ensure one of 31 sampled patient’s (Patient 3) IV (Intravenous, through the vein) catheter was changed after 96 hours (4 days) instead of 192 hours (8 days), in accordance with the facility’s policy and procedure regarding IV catheter management. This deficient practice had the potential to increase Patient 3’s risk for catheter-related bloodstream infection, inflammation of the vein due to blood clot (thrombophlebitis), and discomfort. (Refer to A-0398) 10. The facility failed to ensure one of 31 sampled patient’s (Patient 8) IV (Intravenous, through the vein) catheter was removed after discovering a hematoma (collection of blood that pools outside the blood vessel) at the catheter site, and notify the physician, in accordance with the facility’s policy and procedure regarding IV catheter site maintenance. This deficient practice resulted in Patient 8’s left inner arm, from the armpit to above the elbow, to develop swelling and with dark purple discoloration. (Refer to A-0398) 11. The facility failed to ensure one of 31 sampled patient’s (Patient 4) medication was not left unattended in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) room in the back of a gurney, in accordance with the facility’s policy and procedure regarding medications brought from home. This deficient practice had the potential to compromise Patient 4’s safety due to the risk of the patient’s (Patient 4) own medications being lost as well as the risk for a mental health patient in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) who may unintentionally ingest the medications. (Refer to A-0398) 12. The facility failed to ensure one of 31 sampled patient’s (Patient 11) constant observation, due to risk of self-harm, was properly carried out and documented, while Patient 11 was in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), in accordance with the facility’s policy and procedure regarding Suicide (death caused by injuring oneself with the intent to die) risk assessment and intervention. This deficient practice had the potential to compromise Patient 11’s safety and may result in Patient 11 causing self-harm. (Refer to A-0398) 13. The facility failed to ensure Patients 22 and 31’s wound photos were documented, in accordance with the facility’s policy and procedure regarding wound care, when Patients 22 and 31’s wound photos did not have wound measurement. This deficient practice had the potential to result in an inaccurate assessment of Patients 22 and 31’s wounds and staff may not be able to monitor for signs and symptoms of the patients’ wound deterioration. (Refer to A-0398) 14. The facility failed to ensure for two of 31 sampled patients (Patients 26 and 29) the following: 14.a. Patient 26’s Hydralazine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes (such as continuously elevated blood pressure and complications of stroke [blood clot in the brain]), which could negatively affect Patient 26’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient. (Refer to A-0405) 14.b. Patient 29 received the first dose of cefepime (antibiotic, used for treatment of an infection) in a timely manner, in accordance with the facility’s Policy and Procedure regarding medication administration. This deficient practice resulted in a delay in treatment and had the potential for the antibiotic to be ineffective in the treatment of Patient 29’s infection. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50632 Based on observation, interview, and record review, the facility failed to ensure for four of 31 sampled patients (Patients 22, 27, 29, and 30) the following: 1. Patient 22 and/or the patient’s representative was provided a copy of the Conditions of Admission (COA, contract between the hospital and patient explaining patient’s right and responsibilities) and the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) upon admission to the facility. 2. Patient 27 and/or the patient’s representative was provided a copy of the “Consent for Treatment (COT - a patient’s permission to receive medical treatment, tests, or examinations) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient’s responsibilities for the hospital services they receive)” and the IMM letter upon admission to the facility. 3. Patient 29’s “COT (Consent for Treatment) and COA (Conditions of Admission)” was provided in Patient 29’s preferred language (Mandarin). 4. Patient 30’s “COT (Consent for Treatment) and COA (Conditions of Admission)” and IMM (Important Message from Medicare) letter was provided in Patient 30’s preferred language (Spanish). These deficient practices resulted in Patients 22, 27, 29, 30 and/or the patients’ representative to not be informed of their rights as a patient and their rights to appeal for discharge from the hospital, which may lead in Patients 22, 27, 29, and 30’s inability to effectively make decisions regarding their care and treatment. Findings: 1. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/17/2024, the H&P indicated Patient 22 was admitted for low oxygen levels. Patient 22 had a history of End Stage Renal Disease (ESRD, poor kidney function), on dialysis (procedure that cleans the blood and removes wastes and extra fluids through a machine), and was in a vegetative state (unable to intentionally move or speak and is unaware of surroundings). During a review of Patient 22’s “Face sheet” (document containing basic patient information including emergency contact), the record indicated Patient 22 had an emergency contact listed. During a concurrent interview and record review on 10/3/2024 at 11:20 a.m. with the Clinical Educator (CE) and the Clinical Informatics Manager (CIM), the CE and the CIM verified Patient 22’s record did not have a copy of Conditions of Admission (COA, contract between the hospital and patient explaining patient’s right and responsibilities) and the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights). During an interview on 10/3/2024 at 10:17 a.m. with the Admitting Director (AD), the AD stated the process for providing a copy and obtaining a signature of the patient for the COA and IMM letter included visiting the unit the patient was admitted to and see if the patient was alert to receive and sign the document. The AD further stated the patient’s representative should be called if the patient was not alert or unable to sign. During a concurrent interview and record review on 10/3/2024 at 11:35 a.m. with the AD, the AD verified Patient 22’s record did not have a COA and IMM letter. The AD stated there were two attempts made for Patient 22 to sign the COA and IMM letter. The AD said it was documented that Patient 22 was unable to sign and there was no family at the bedside. The AD stated there was no documentation Patient 22’s representative was contacted. The AD said Patient 22 had an emergency contact listed and should have been called to discuss Patient 22’s COA and IMM Letter. During a review of the facility’s policy and procedure (P&P) titled, “Medicare Beneficiary Appeal Rights,” dated 7/2022, the P&P indicated, “Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his or her representative ... When a beneficiary is unable to understand the notice, the hospital may have the beneficiary’s representative receive and sign the notice in accordance with state or other applicable law. If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary’s rights as a hospital patient, including the right to appeal a discharge decision.” During a review of the facility’s policy and procedure (P&P) titled, “Completion of Admitting Forms,” dated 2/22/2023, the P&P indicated, “If a patient is unable to sign due to mental or physical capacity at time of admission and a patient representative is not available to sign, documentation shall include “Patient unable to sign.” Registration staff shall make an additional attempt to obtain signatures at least 2 times.” 2. During a review of Patient 27’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/27/2024, the H&P indicated, Patient 27 was admitted to the facility on 9/25/2024 for a leaking gastrostomy tube (G-tube - a tube that’s surgically inserted through the abdominal wall and into the stomach; allows for nutrition, fluids, and medications to be delivered directly to the stomach). The H&P further indicated, Patient 27 had a past medical history of a chronic (long term) tracheostomy (a surgical procedure that creates an opening in the neck to allow air to reach the lungs) and ventilator (a machine or device used medically to support or replace the breathing of a person) dependence. During a review of Patient 27’s face sheet (document containing basic patient information including emergency contact), , dated 9/26/2024, the face sheet indicated Patient 27 was admitted on 9/25/2024 at 10:06 p.m. and that Patient 27 had an emergency contact listed. 2.a. During a concurrent interview and record review on 10/3/2024 at 10:19 a.m. with the Admitting Director (AD), the AD verified Patient 27’s “Consent for Treatment (COT - a patient’s permission to receive medical treatment, tests, or examinations) and Conditions for Admission (COA - a contract between a patient and a hospital that outlines the patient’s responsibilities for the hospital services they receive),” indicated a verbal consent was provided by Patient 27’s listed emergency contact on 10/3/2024 (8 days after Patient 27 was admitted to the facility). During the same interview and record review on 10/3/2024 at 10:19 a.m., the AD stated a copy of the “COT and COA” was not provided to Patient 27 and the patient’s representative at the time of admission. The AD said Patient 27’s record had a documentation of an attempt to provide the “COT and COA” on admission and indicated Patient 27 was unable to sign. The AD stated Patient 27’s representative should have been contacted when Patient 27 was unable to sign. During a review of the facility’s policy and procedure (P&P) titled, “Medicare Beneficiary Appeal Rights,” dated 7/2022, the P&P indicated, “Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his or her representative ... When a beneficiary is unable to understand the notice, the hospital may have the beneficiary’s representative receive and sign the notice in accordance with state or other applicable law. If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary’s rights as a hospital patient, including the right to appeal a discharge decision.” During a review of the facility’s policy and procedure (P&P) titled, “Completion of Admitting Forms,” dated 2/22/2023, the P&P indicated, “If a patient is unable to sign due to mental or physical capacity at time of admission and a patient representative is not available to sign, documentation shall include “Patient unable to sign.” Registration staff shall make an additional attempt to obtain signatures at least 2 times.” 2.b. During a concurrent interview and record review on 10/3/2024 at 10:19 a.m. with the Admitting Director (AD), The AD verified Patient 27’s “Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights),” indicated a verbal consent was provided by Patient 27’s listed emergency contact on 10/3/2024 (8 days after Patient 27 was admitted to the facility). During the same interview and record review, on 10/3/2024 at 10:19 a.m., the AD stated the IMM letter was not provided to Patient 27 and the patient’s representative at the time of admission. The AD stated Patient 27’s record had a documentation of an attempt to provide the IMM letter on admission and indicated Patient 27 was unable to sign. The AD stated Patient 27’s representative should have been contacted when Patient 27 was unable to sign. During a review of the facility’s policy and procedure (P&P) titled, “Medicare Beneficiary Appeal Rights,” dated 7/2022, the P&P indicated, “Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his or her representative ... When a beneficiary is unable to understand the notice, the hospital may have the beneficiary’s representative receive and sign the notice in accordance with state or other applicable law. If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary’s rights as a hospital patient, including the right to appeal a discharge decision.” During a review of the facility’s policy and procedure (P&P) titled, “Completion of Admitting Forms,” dated 2/22/2023, the P&P indicated, “If a patient is unable to sign due to mental or physical capacity at time of admission and a patient representative is not available to sign, documentation shall include “Patient unable to sign.” Registration staff shall make an additional attempt to obtain signatures at least 2 times.” 3. During a concurrent observation and interview on 10/2/2024 at 10:25 a.m. with Registered Nurse (RN) 12, in Patient 29’s room, Patient 29 was observed resting in bed with his eyes closed. RN 12 stated Patient 29 only speaks Mandarin. RN 12 stated she communicated with Patient 29 using a language interpreter (translates medical information between patients and healthcare providers) via the electronic tablet. During a review of Patient 29’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/1/2024, the H&P indicated, Patient 29 was admitted to the facility for fever (a body temperature that is higher than normal) with vomiting and productive cough. During a concurrent interview and record review on 10/3/2024 at 3:10 p.m. with the Clinical Manager of Medical Surgical (CMMS), the CMMS verified Patient 29’s face sheet (document containing basic patient information including emergency contact), dated 10/2/2024, indicated Patient 29’s preferred language was English. Subsequently, the CMMS called the nursing unit, and the CMMS verified Patient 29’s preferred language was Mandarin, and not English. The CMMS stated the face sheet would be updated to reflect that Patient 29’s preferred language was Mandarin. During a concurrent interview and record review on 10/3/2024 at 3:45 p.m. with the CMMS, the CMMS verified Patient 29’s “Consent for Treatment (COT - a patient’s permission to receive medical treatment, tests, or examinations) and Conditions for Admission (COA - a contract between a patient and a hospital that outlines the patient’s responsibilities for the hospital services they receive),” dated 10/1/2024, was written in English (Patient 29’s preferred language was Mandarin). The CMMS stated Patient 29’s “COT and COA” did not have an information if a language interpreter was used. The CMMS stated Patient 29’s “COT and COA” should have been written in the patient’s preferred language or an interpreter was used to ensure the patient understood his rights as a patient. During a review of the facility’s policy and procedure (P&P) titled, “Interpreters - Translation of Documents,” dated 03/2024, the P&P indicated: - “Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and information recorded in the document.” - “Consents are available in English and Spanish; Other languages require the use of the interpreter service. The name of the interpreter or the interpreter ID number must be documented on the consent.” 4. During a review of Patient 30’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/26/2024, the H&P indicated Patient 30 was admitted to the facility for fever (a body temperature that is higher than normal) of three days, nausea (a feeling of sickness with an inclination to vomit), vomiting, dysuria (a symptom that describes the sensation of pain, burning, stinging, or itching when urinating), and increased urinary frequency related to sepsis (a life-threatening medical emergency that occurs when the body’s immune system has an extreme response to an infection or injury) and pyelonephritis (a kidney infection). During a concurrent interview and record review on 10/3/2024 at 4:12 p.m. with the Clinical Manager of Medical Surgical (CMMS), the CMMS verified Patient 30’s face sheet (document containing basic patient information including emergency contact), dated 9/26/2024, indicated Patient 30’s preferred language was Spanish. 4.a. During a concurrent interview and record review on 10/3/2024 at 4:48 p.m. with the Patient Safety Officer (PSO), the PSO verified Patient 30’s “Consent for Treatment (COT - a patient’s permission to receive medical treatment, tests, or examinations) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient’s responsibilities for the hospital services they receive),” dated 9/26/2024, indicated the “COT and COA” was written in English (Patient 30’s preferred language was Spanish). The PSO stated Patient 30’s “COT and COA” did not have an information if a language interpreter was used. The CMMS stated Patient 30’s “COT and COA” should have been written in the patient’s preferred language or an interpreter was used. During a review of the facility’s policy and procedure (P&P) titled, “Interpreters - Translation of Documents,” dated 03/2024, the P&P indicated: - “Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and information recorded in the document.” - “Consents are available in English and Spanish; Other languages require the use of the interpreter service. The name of the interpreter or the interpreter ID number must be documented on the consent.” 4.b. During a concurrent interview and record review on 10/3/2024 at 4:48 p.m. with the PSO, the PSO verified Patient 30’s Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights), dated 9/26/2024, was written in English (Patient 30’s preferred language was Spanish). The PSO stated Patient 30’s IMM letter did not have an information if a language interpreter was used. The CMMS said Patient 30’s IMM letter should have been written in the patient’s preferred language or an interpreter was used. During a review of the facility’s policy and procedure (P&P) titled, “Interpreters - Translation of Documents,” dated 03/2024, the P&P indicated: - “Documents requiring patient’s signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and information recorded in the document.” - “Consents are available in English and Spanish; Other languages require the use of the interpreter service. The name of the interpreter or the interpreter ID number must be documented on the consent.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure the patient’s rights requirement was met for one of 31 sampled patients (Patient 12), in accordance with the facility’s policy and procedure regarding Patients Rights (Example: the right to considerate, respectful care at all times and under all circumstances), when Patient 12 was placed on an involuntary hold (detain a person for treatment against their will) in the facility’s Emergency Department (ED, provides immediate care to patients arriving at the hospital) without evidence of a 5150 form (The 5150 form, also known as the “Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment” or 5150,” is a legal document that must be signed by an authorized professional person to initiate an involuntary detention [for evaluation and treatment], for someone who is showing signs of severe mental distress.) filled out and completed. This deficient practice had the potential of violating patient’s rights by placing Patient 12 on an involuntary hold without proper documentation and justification of the 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) by an authorized professional person. Findings: During a concurrent interview and record review on 10/3/2024 at 2:17 p.m. with the Clinical Informatics Manager (CIM), Patient 12’s Electronic Medical Record ([EMR], digital version of paper chart), was reviewed. The EMR indicated that Patient 12 was seen by an ED (Emergency Department, where patients in need of immediate care are seen upon arrival at the hospital) Provider on 9/22/2024 at 11:50 p.m. The EMR indicated that Patient 12 was a 25 years old female brought in by ambulance from home for evaluation after drinking cleaning fluid with the intention of harming herself. Patient 12 was placed on a 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) prior to her (Patient 12) arrival in the ED. CIM stated that there were no records of a completed signed 5150 form in Patient’s 12 EMR. CIM added that without the 5150 forms, Facility was unable to determine who signed the 5150 form or that person’s assessment, evaluation, and justification in placing Patient 12 on a 72-hour hold (temporary detention of a person for evaluation and treatment in a mental health facility against their will). During a concurrent interview and record review on 10/4/2024 at 10:44 a.m. with the Director of Emergency Department (DED), Patient 12’s Electronic Medical Record ([EMR], digital version of paper chart), was reviewed. DED stated that the ED practice for a patient coming in with a completed 5150 form was for staff to scan and keep a copy of the form in the patient’s EMR. The original 5150 form will be sent out with the patient upon transfer to a behavioral health facility. For Patient 12, most likely staff may have forgotten to scan the 5150 form into the patient’s (Patient 12) EMR. DED further said “It’s important that the facility must have a 5150 form.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights Responsibilities,” last approved date 04/2023, the P&P indicated the following: “Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity. Consideration shall be given to the psychosocial, spiritual and cultural variables influencing the patient. The patient has the right to express spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of medical therapy for the patient. During a review of the facility’s policy and procedure (P&P) titled, “Psychiatric Patients in the ED,” last approved date 01/2022, the P&P indicated the following: “PURPOSE: To protect the patient who is compromised and act in the patients’ best interest while the patient’s judgment may be impaired. Psychiatric patients who are a danger to themselves, to others, or gravely disabled, under California Welfare and Institutions Code 5150, may be placed in protective custody either by a peace office or qualified individual. When this occurs, the patient MUST be placed in a designated psychiatric facility. The ED Physician is not considered a qualified individual unless he/she has received specific training regarding 5150 placement.””

“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: 50516 Based on interview and record review, the facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22 and/or the patient’s representative was provided a “Blood Transfusion (used for low blood levels, and is an important procedure that moves blood or blood products into a person’s body through the bloodstream, and can carry risks such as an allergic reaction, heart, or lung problems) Information and Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered),” prior to Patient 22 receiving blood transfusion, in accordance with the physician’s order and the facility’s policy and procedure regarding blood transfusion. This deficient practice resulted in Patient 22 and the patient’s representative to not exercise their right to make an informed decision regarding Patient 22’s care, as well as understand the risks and benefits of blood transfusion. Findings: During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/17/2024, the “H&P” indicated, Patient 22 was admitted for low oxygen levels, with bilateral (both sides) pleural effusions (fluid buildup in the space between the lungs and chest wall), and had a thoracentesis (procedure to remove fluid or air in the space between the lungs and chest wall). Patient 22’s medical history included End Stage Renal Disease (ESRD, poor kidney function), on dialysis (procedure that cleans the blood by removing extra fluids and waste). During a review of Patient 22’s “Transfuse Red Blood Cells (RBC, blood) Active Bleed-Adult/Adolescent (RBC transfusion order),” dated 9/21/2024, the order indicated for Patient 22 to have 1 unit (bag) of RBC given for a low Hemoglobin (Hgb, part of the red blood cell that carries oxygen) level of 7.1 (normal is at 12 g/dl [a unit of measurement]). During a review of Patient 22’s RBC transfusion order, dated 9/26/2024, the order indicated for Patient 22 to have 1 unit (bag) of RBC given for a Hgb level less than 7. During a review of Patient 22’s “Verify (confirm) Consent” order, dated 9/21/2024, the order indicated to verify Patient 22’s consent for blood transfusion. During a concurrent interview and record review on 10/1/2024 at 12:37 p.m. with the Director of ICU (DICU), Patient 22’s “Transfusion Record,” dated 9/21/2024 and 9/26/2024, indicated Patient 22 received blood transfusions. The DICU verified Patient 22’s record did not have a blood transfusion consent when Patient 22 received blood transfusion on 9/21/2024 and 9/26/2024. The DICU stated Patient 22 should have a blood transfusion consent prior to receiving blood transfusion. During a review of the facility’s policy and procedure (P&P) titled, “Administration of Blood and Components,” dated 09/2022, the P&P indicated, “The process of blood administration should begin and end with patient’s safety in mind ...and maintenance of appropriate records ...Blood transfusion will occur only when the following criteria are met ...The patient has signed consent for transfusion, and the physician must document informed consent in the medical record ...Pre-Transfusion Requirements (Nursing): The patient or an authorized representative must read and sign the required consent form to receive blood.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights Responsibilities,” dated 02/2023, the P&P indicated, “The patient has the right to receive as much information about any proposed treatment or procedure as the patient may need in order to give informed consent, or refuse this course of treatment...This information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternative courses of treatment or non-treatment and the risks involved in each, and to know the name of the person who will carry out the procedure or treatment.””

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 50632 Based on interview and record review, the facility failed to ensure for four of 31 sampled patients (Patients 22, 26, 27, and 29) the following: 1. Patients 22’s Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) copy was obtained by the facility upon admission. 2. Patient 26’s AD (Advance Directive) copy was obtained by the facility upon admission. 3. Patient 27 and/or the patient’s representative was provided information on how to formulate an AD (Advance Directive) upon admission. 4. Patient 29’s AD 9Advance Directive) copy was obtained by the facility upon admission. These deficient practices had the potential to negatively affect Patients 22, 26, 27, and 29’s rights and wishes for treatment when the patient receives medical care that was not in accordance with the patients’ AD. Findings: 1. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/17/2204, the H&P indicated Patient 22 was admitted for low oxygen levels. Patient 22 had a history of End Stage Renal Disease (ESRD, poor kidney function), on dialysis, and was in a vegetative state (unable to intentionally move or speak and is unaware of surroundings). During a concurrent interview and record review on 10/3/2024 at 11:20 a.m. with the Clinical Educator (CE) and the Clinical Informatics Manager (CIM), Patient 22’s questionnaire for having an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) was marked, “Yes.” The CE and CIM verified Patient 22’s medical record did not have a copy of Patient 22’s AD. During a concurrent interview and record review on 10/3/24 at 12:21 p.m. with Charge Nurse 5 (CN) 5, CN 5 stated the facility did not have a copy of Patient 22’s AD. CN 5 stated the patient’s primary nurse, unit secretary, and/or charge nurse should follow up in getting a copy of the patient’s AD if the patient had an AD. During a review of the facility’s policy and procedure (P&P) titled, “Advanced Healthcare Directives,” dated 5/2022, the “P&P” indicated, “This hospital shall provide each adult patient over 18 years of age, at the time of his/her admission as an inpatient, written information describing ...The hospital’s policies regarding these rights to make healthcare decisions and to formulate AHCD (Advanced Healthcare Directives) and regarding the way such decisions and directives will be implemented in the hospital ... Nursing will confirm the information on the AHCD Questionnaire Form with the patient when completing the Initial Assessment. If the AHCD Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient’s family/significant other and document the attempt in the chart. 2. During a review of Patient 26’s “Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital),” dated 10/2/2024, the summary indicated, Patient 26 was admitted on 9/23/2024 for back pain. During a concurrent interview and record review on 10/3/2024 at 4:00 p.m. with the Clinical Educator (CE) and ST Segment Elevation Myocardial Infarction (STEMI, deadly type of heart attack) Coordinator (SC), The CE verified Patient 26’s questionnaire for having an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) was marked, “Yes.” The SC stated she (SC) could not recall seeing a copy of Patient 26’s AD on the patient’s medical record. During a concurrent interview and record review on 10/4/2024 at 11:07 a.m. with the Clinical Manager of Med-Surg (CMMS), the CMMS stated if patient stated “Yes,” to having an AD, the nurse should follow up in getting a copy of the patient’s AD. During a review of the facility’s policy and procedure (P&P) titled, “Advanced Healthcare Directives,” dated 5/2022, the “P&P” indicated, “This hospital shall provide each adult patient over 18 years of age, at the time of his/her admission as an inpatient, written information describing ... The hospital’s policies regarding these rights to make healthcare decisions and to formulate AHCD (Advanced Healthcare Directives) and regarding the way such decisions and directives will be implemented in the hospital ...The hospital shall document in the individual’s medical record whether or not the individual has executed an AHCD ... Nursing will confirm the information on the AHCD Questionnaire Form with the patient when completing the Initial Assessment. If the AHCD Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient’s family/significant other and document the attempt in the chart. 3. During a review of Patient 27’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/27/2024, the H&P indicated Patient 27 was admitted to the facility on 9/25/2024 for a leaking gastrostomy tube (G-tube - a tube that’s surgically inserted through the abdominal wall and into the stomach; allows for nutrition, fluids, and medications to be delivered directly to the stomach). The H&P further indicated, Patient 27 had a past medical history of a chronic (long term) tracheostomy (a surgical procedure that creates an opening in the neck to allow air to reach the lungs) and ventilator (a machine or device used medically to support or replace the breathing of a person) dependence. During a review of Patient 27’s face sheet (a document that summarizes a person’s personal and demographic information), dated 9/26/2024, the face sheet indicated Patient 27 was admitted on 9/25/2024 at 10:06 p.m. and that Patient 27 had an emergency contact listed. During a concurrent interview and record review on 10/3/2024 at 9:52 a.m. with the Clinical Informatics Manager (CIM), the CIM verified Patient 27’s “Admission History Adult,” indicated Patient 27 did not have an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) and that “information was requested.” The CIM stated upon admission on 9/25/2024, Patient 27 did not have an AD. During a concurrent interview and record review on 10/3/2024 at 10:23 a.m. with the Medical Social Worker (MSW), the MSW confirmed that Patient 27 had an order for Social Services Advance Directive Consult on 9/26/2024 at 7:33 a.m. . The MSW verified the consult order was completed by the MSW on 9/26/2024 at 8:43 a.m. without the MSW note regarding the consult visit. During the same interview on 10/3/2024 at 10:23 a.m., the MSW stated “order completed” means the consult occurred and that she (MSW) completed the task needed as indicated on the order. The MSW stated Patient 27’s record did not have the MSW note to indicate the consult occurred with Patient 27 regarding AD. During a review of the facility’s policy and procedure (P&P) titled, “Advanced Healthcare Directives (AHCD),” dated 05/2022, the P&P indicated the following: -“If the Advanced Healthcare Directives (AHCD) Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient’s family/significant other and document the attempt in the chart.” -“Social Services will follow-up with patients indicating an interest in further information regarding AHCD.” -“When a patient who lacks present decision-making capacity is admitted to the hospital, family or friend will be asked if the patient has an AHCD.” -“If the patient is unaccompanied information about AHCD will be asked of the surrogate decision-maker as soon as possible.” 4. During a review of Patient 29’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/1/2024, the H&P indicated, Patient 29 was admitted to the facility for fever with vomiting and productive cough. During a concurrent interview and record review on 10/3/2024 at 4:47 p.m. with the Admitting Director, Patient 29’s “Consent for Treatment (COT - patient’s permission to receive medical treatment, tests, or examinations)) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient’s responsibilities for the hospital services they receive),” dated 10/1/2024, indicated Patient 29 had an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) and that a copy of AD was provided to the facility. The Admitting Director verified the facility did not have a copy of Patient 29’s AD. The Admitting Director stated there was no documentation of an attempt to obtain Patient 29’s AD. During a review of the facility’s policy and procedure (P&P) titled, “Advanced Healthcare Directives,” dated 5/2022, the “P&P” indicated, “This hospital shall provide each adult patient over 18 years of age, at the time of his/her admission as an inpatient, written information describing ...The hospital’s policies regarding these rights to make healthcare decisions and to formulate AHCD (Advanced Healthcare Directives) and regarding the way such decisions and directives will be implemented in the hospital ... Nursing will confirm the information on the AHCD Questionnaire Form with the patient when completing the Initial Assessment. If the AHCD Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient’s family/significant other and document the attempt in the chart.”

“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: 50516 Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 23), Patient 23’s care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) for the use of restraint (chemical or physical device that prevents a person from freely moving) was developed in accordance with the facility’s policy and procedure regarding restraints use. This deficient practice had the potential to result in in delayed provision of care to the patients by not identifying Patients 23’s needs and risks. Findings: During a concurrent observation and interview on 10/2/2024 at 10:20 a.m. with Registered Nurse 6 (RN) 6, Patient 23 was observed in bed with bilateral (both sides) wrist restraints (chemical or physical device that prevents a person from freely moving). RN 6 stated Patient 23 was confused but aware of herself. During a review of Patient 23’s “Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital),” dated 10/2/2024, the discharge summary indicated Patient 23 was admitted on 9/27/2024, for shortness of breath (difficulty breathing), urinary tract infection (UTI, urine infection), agitation (mix of emotions that can make someone feel irritable, tense, or confused) and had a history of depression (constant feelings of sadness and/or loss of interest in usual activities) and fibular fracture (broken lower leg bone). During a concurrent interview and record review on 10/3/2024 at 2:13 p.m. with the Clinical Educator (CE), the CE verified Patient 23 had an order for bilateral soft wrist restraints from 9/29/2024 through 10/2/2024. The CE stated the record indicated Patient 23 was on bilateral wrist restraints for interfering with incision wound healing, and for pulling on medical devices (intravenous [IV, through the vein] lines, tubes). The CE stated Patient 23 was on bilateral wrist restraints from 9/29/2024 to 10/2/2024. During the same interview and record review on 10/3/2024 at 2:13 p.m., with the CE and the ST Segment Elevation Myocardial Infarction (STEMI, deadly type of heart attack) Coordinator (SC), the SC verified Patient 23 did not have a care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) for the use of restraints when it was initiated on 9/29/2024. The CE stated Patient 23’s restraint care plan was developed on 10/1/2024 (2 days after Patient 23’s restraint was applied). During an interview on 10/3/2024 at 5:20 p.m. with the Director of Telemetry (DT), the DT stated Patient 23’s care plan for the use of restraint was important for the nurses to know what needed to be managed, such as looking at skin integrity, and evaluating the need for restraints. The DT stated Patient 23’s restraint care plan should have been started within four to six hours after the patient’s restraint application. During a review of the facility’s policy and procedure (P&P) titled, “Restraints and Seclusion (involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving),” dated 6/2024, the P&P indicated, “When Restraint or Seclusion is used, there must be documentation in the patient’s medical record of the following ...Use of Restraint or Seclusion in the Plan of Care.” During a review of the facility’s P&P titled, “Planning of Care,” dated 2/2022, the P&P indicated, “Nursing assessments and associated care plans should be documented in the medical record within 24 hours of inpatient admission or the initiation of observation status.””

“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: 46333 Based on interview and record review, the facility failed to: 1. Ensure three of five sampled patients (Patients 1, 11, and 12) were screened, in accordance with the facility’s policy and procedure using the Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening in which the answers help users identify whether someone is at risk for suicide [death caused by injuring oneself with the intent to die], determine the severity and immediacy of that risk, and gauge the level of support that the person needs) tool: 1.a. For Patient 1, there was no C-SSRS completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered by Registered Nurse (RN) 1 as “no” but should have been answered “yes,” and no C-SSRS was completed when Patient 1’s mental status condition worsened. This deficient practice led to undetected suicidal ideation (thoughts of killing oneself) and/or plans, delayed treatment, and compromised Patient 1’s safety. Patient 1 eloped (when a patient leaves an area they are expected to stay within, for their safety) from the facility and jumped from the second floor of the parking structure and sustained injury. 1.b. For Patient 11, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as “no” but should have been answered “yes.” This deficient practice led to incomplete screening of Patient 11 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 11’s safety. 1.c For Patient 12, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as “no” but should have been answered “yes.” This deficient practice led to incomplete screening of Patient 12 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice also had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 12’s safety. 2. Ensure one of five sampled patient’s (Patient 1) change in behavior (emotions and behaviors that affect individual overall well-being) was communicated to the physician, in accordance with the facility’s policy and procedure regarding assessment and physician notification about change of condition. This deficient practice likely led to Patient 1’s elopement (when a patient leaves an area they are expected to stay within, for their safety) from the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital) and ran into the facility’s parking structure and jumped from the second floor, sustained injuries to the face and forehead and requiring transport to a trauma specialized hospital. 3. Ensure the pain level of two of 31 sampled patients (Patients 6 and Patient 30) was reassessed after pain medication was administered, in accordance with the facility’s policy and procedure regarding pain management standard of care. This deficient practice had the potential for Patient 6’s and Patient 30’s pain to not be managed effectively and in a timely manner and may result in delayed treatment, which could worsen the patients (Patient 6 and 30) pain level. 4. Ensure one of 31 sampled patients (Patient 25) was reassessed (reevaluated), in accordance with the nursing standard of care and the facility’s policy and procedure regarding reassessment, after Ativan (medication used for relaxation), ordered as needed (PRN) for anxiety, was administered, in order to determine the effectiveness of the medication or the patient’s (Patient 25) response to the medication (Ativan). This deficient practice had the potential to cause a delay in determining Patient 25’s change of condition and/or a delay in the provision of care needed which could worsen the patient’s condition. 5. Ensure one of 31 sampled patients (Patient 26) was reassessed, in accordance with the facility’s policy and procedure regarding reassessment, after Hydralazine (medication used for lowering blood pressure [BP, amount of force blood uses to move through the body]), ordered PRN (as needed) for systolic (SBP, maximum amount of pressure the blood uses to move through the body) greater than 160 mmHg (millimeters of mercury, a unit of measure), was administered. This deficient practice had the potential to cause a delay in determining Patient 26’s change of condition and/or a delay in the provision of care needed which could worsen the patient’s condition. Findings: 1a. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the “H&P” indicated, Patient 1 “presented status post (after) seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) clearance workup (a medical exam to make sure that a patient’s psychiatric symptoms are not caused by a medical condition) was initiated, and at the time of elopement (when a patient leaves an area they are expected to stay within, for their safety), the patient (Patient 1) was pending psychiatric evaluation.” The H&P further indicated that “on reevaluation/repeat exam, the current time (when Patient 1 eloped) the patient is pending psychiatric evaluation for suicidal ideation.” During a review of Patient 1’s “Neurologic Assessment (evaluate function of the brain, involves a series of tests that assesses mental status, reflexes, and movements),” dated 9/11/2024 at 5:45 p.m., the exam indicated Patient 1 was “calm, stares into space, flat affect (emotional flattening, not expressing emotions), coherent (is logical and clear), and alert.” The following exam on 9/12/2024 at 6:30 a.m. indicated, “patient (Patient 1) is now euphoric [intense happiness and excitement], not oriented to the situation [the inability to correctly acknowledge the current time, place, one’s role, and personal identity], confused [disturbed in mind or purpose], disjointed [unorganized or disconnected thoughts], and easily distracted.” During a concurrent interview and record review on 10/1/2024 at 2:56 p.m. with the Clinical Informatics Manager (CIM), Patient 1’s “ED Triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms),” dated from 9/11/2024 through 9/12/2024, was reviewed. The triage indicated Patient 1 arrived at the ED on 9/11/2024 at 4:53 p.m. Patient 1 received a C-SSRS pre-screener (C-SSRS, supports suicide risk screening in which the answers help users identify whether someone is at risk for suicide [death caused by injuring oneself with the intent to die], determine the severity and immediacy of that risk, and gauge the level of support that the person needs) on 9/12/2024 at 12:17 a.m., seven hours and 24 minutes after admission to the ED. CIM confirmed that there was only one C-SSRS completed for Patient 1, and likewise, Patient 1 did not have a C-SSRS pre-screener completed during initial triage. The CIM confirmed that Patient 1’s triage report did not indicate at the time of triage that Patient 1 was not able to answer questions. During an interview on 10/1/2024 at 4:00 p.m. with Registered Nurse (RN) 1, RN 1 stated that Patient 1’s behavior was initially calm and quiet and progressed to becoming strange and asking strange questions. RN 1 stated, Patient 1’s behavior worsened towards the end of the shift, it became more frequent when he (Patient 1) would say things like “are we on a space station?” RN 1 stated the C-SSRS Pre-Screen question indicating “Patient present with self-harm intent or signs and/or symptoms of self-harm in the initial assessment or a behavioral health chief complaint,” was answered with “no.” RN 1 stated, “I should have answered “yes” because the patient has behavioral health as chief compliant.” RN 1 further stated when a patient’s mental status changed, the RN has to do another CSSRS. During an interview on 10/1/2024 at 5:15 p.m. with Registered Nurse (RN) 2, RN 2 stated, “The patient (Patient 1) has mood swing, up and down, and around 6:30 he sprinted to the bathroom. Closed his eyes and talked to himself.” During the same interview on 10/1/2024 at 4:00 p.m., RN 2 stated around 8:00 a.m. a code gray (a rapid response in the event a need occurs to help control a combative patient, or incident involving violence or impending violence where assistance in the part of other hospital employees may be necessary) was called because Patient 1 was standing up at the edge of the bed.” RN 1 confirmed that after the code gray, another psychiatric assessment (assess the individual to establish a diagnosis and formulation of the individual’s problems, and to plan their care and treatment) and neurological assessment (collecting subjective and objective data through an interview and detailed physical examination of the individual’s function) were to be completed. However, these (referring to another psychiatric assessment and neurological assessment) were not completed. During a concurrent interview and record review on 10/2/2024 at 10:24 a.m. with the Emergency Department Director (DED), the Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the person needs), was reviewed. The DED stated answering yes to the prescreen question will prompt the staff to complete CSSR questions 1-7, and answering yes to questions 3,4,5,or 7 will trigger interventions such as to initiate a self-harm observation, initiate suicide precaution (set of interventions to reduce access to lethal means of suicide among individuals with identified suicide risk), initiate environment checklist, and notify QMP (a provider approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists) or QMHP (Qualified Mental Health Professional, an individual who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness) for a full suicide assessment, and notify provider. The DED confirmed that for Patient 1, the interventions were not triggered because the answer provided by RN 1 was “no.” During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Intervention,” dated November 2022, the P&P indicated, “(name of the facility) will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ...A registered nurse will pre-screen all patients, >= 12 years of age upon admission. If a registered nurse cannot assess the patient upon arrival due to the patient’s medical status, they will perform the pre-screening as soon as the patient’s condition permits. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. If the patient screens positive using C-SSRS, which is defined as providing a “Yes” response to questions 3,4,5, or 7, the nursing staff will complete the following: 1. Send an order request for one-to-one observation to the attending physician. 2. Send a referral for consult to case management, social services, and a BHP. 3. Immediately place the patient on a one-to-one observation by a CHP and obtains a physician’s order as soon as possible. 4. Implement at a minimum the following precautions: a. Place patient in safe hospital attire, preferably green safety scrubs. b. Provide safe patient food trays. c. Complete environmental checklist. d. Where practical, place patient in a preferred room or closest to the main nurse’s station. The nursing staff will use the Constant Observation Flowsheet to document observation. Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed. If the patient screens positive using C-SSRS, then the facility designated QMHP will complete an evidenced based full suicide risk assessment within 24 hours... (name of the facility) will require an initial C-SSRS suicide screening if, at any time, a patient who has screened negative for suicide ideations expresses new thoughts of self-harm or suicidal ideation.” 1.b During a review of Patient 11’s “ED (Emergency Department) Note,” dated 9/7/2024, the “ED Note” indicated, Patient 11 was presented for an evaluation of auditory hallucination (the perception of hearing sounds or voices that are not there). The ED Note also indicated that patient (Patient 1) stated he had been hearing voices, felt depressed, thought people want to hurt him (Patient 1), and had suicidal ideations (thoughts of killing oneself). The patient (Patient 1) had attempted to hurt himself in the past by cutting his wrists. He was willing to go voluntarily to a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) facility. During a concurrent interview and record review on 10/2/2024 at 10:24 a.m. with the Emergency Department Director (DED), the “Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the person needs), was reviewed. The DED stated answering yes to the prescreen question will prompt the staff to complete CSSR questions 1-7, and answering yes to questions 3,4,5,or 7 will trigger interventions such as to initiate a self-harm observation, initiate suicide precaution (set of interventions to reduce access to lethal means of suicide among individuals with identified suicide risk), initiate environment checklist, and notify QMP (a provider approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists) or QMHP (Qualified Mental Health Professional, an individual who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness) for a full suicide assessment, and notify provider. During a concurrent interview and record review on 10/3/2024 at 2:17 p.m. with the Clinical Informatics Manager (CIM), Patient 11’s “ED Triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms),” dated 9/7/2024, was reviewed. The triage indicated Patient 11 arrived at the ED on 9/7/2024 at 10:34 a.m. Patient 11 received a C-SSRS pre-screener on 9/7/2024 at 10:37 a.m. CIM confirmed that the C-SSRS Pre-Screen question indicating “Patient present with self-harm intent or signs and/or symptoms of self-harm in the initial assessment or a behavioral health chief complaint” was answered with “no.” CIM stated, “it should have been answered “yes” because the patient presented with self-harm intent and was diagnosed with suicidal ideation. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Intervention,” dated November 2022, the P&P indicated, “(name of the facility) will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ...A registered nurse will pre-screen all patients, >= 12 years of age upon admission. If a registered nurse cannot assess the patient upon arrival due to the patient’s medical status, they will perform the pre-screening as soon as the patient’s condition permits. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. If the patient screens positive using C-SSRS, which is defined as providing a “Yes” response to questions 3,4,5, or 7, the nursing staff will complete the following: 1. Send an order request for one-to-one observation to the attending physician. 2. Send a referral for consult to case management, social services, and a BHP. 3. Immediately place the patient on a one-to-one observation by a CHP and obtains a physician’s order as soon as possible. 4. Implement at a minimum the following precautions: a. Place patient in safe hospital attire, preferably green safety scrubs. b. Provide safe patient food trays. c. Complete environmental checklist. d. Where practical, place patient in a preferred room or closest to the main nurse’s station. The nursing staff will use the Constant Observation Flowsheet to document observation. Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed. If the patient screens positive using C-SSRS, then the facility designated QMHP will complete an evidenced based full suicide risk assessment within 24 hours... (name of the facility) will require an initial C-SSRS suicide screening if, at any time, a patient who has screened negative for suicide ideations expresses new thoughts of self-harm or suicidal ideation.” 1.c. During a review of Patient 12’s “ED (Emergency Department) Note,” dated 9/22/24, the “ED Note” indicated, Patient 12 was a 25 years old female, was brought in by ambulance from home for evaluation after drinking cleaning fluid. “Patient did ingest the cleaning fluid with the intention of harming herself.” Patient (Patient 12) was placed on a 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) prior to arrival. During a concurrent interview and record review on 10/2/2024 at 10:24 a.m. with the Emergency Department Director (DED), the “Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the person needs), was reviewed. The DED stated answering yes to the prescreen question will prompt the staff to complete CSSR questions 1-7, and answering yes to questions 3,4,5,or 7 will trigger interventions such as to initiate a self-harm observation, initiate suicide precaution (set of interventions to reduce access to lethal means of suicide among individuals with identified suicide risk), initiate environment checklist, and notify QMP (a provider approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists) or QMHP (Qualified Mental health Professional, an individual who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness) for a full suicide assessment, and notify provider. During a concurrent interview and record review on 10/3/2024 at 3:31 p.m. with the Clinical Informatics Manager (CIM), Patient 12’s “ED Triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms),” dated 9/22/2024, was reviewed. The triage indicated Patient 12 arrived at the ED on 9/22/2024 at 11:22 p.m. Patient 12 received a C-SSRS pre-screener on 9/22/2024 at 11:30 p.m. CIM confirmed that the C-SSRS Pre-Screen question indicating “Patient present with self-harm intent or signs and/or symptoms of self-harm in the initial assessment or a behavioral health chief complaint,” was answered with “no.” CIM stated, “it should have been answered “yes” because the patient presented with self-harm intent and was diagnosed with suicidal ideation. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Intervention,” dated November 2022, the P&P indicated, “(name of the facility) will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ...A registered nurse will pre-screen all patients, >= 12 years of age upon admission. If a registered nurse cannot assess the patient upon arrival due to the patient’s medical status, they will perform the pre-screening as soon as the patient’s condition permits. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. If the patient screens positive using C-SSRS, which is defined as providing a “Yes” response to questions 3,4,5, or 7, the nursing staff will complete the following: 1. Send an order request for one-to-one observation to the attending physician. 2. Send a referral for consult to case management, social services, and a BHP. 3. Immediately place the patient on a one-to-one observation by a CHP and obtains a physician’s order as soon as possible. 4. Implement at a minimum the following precautions: a. Place patient in safe hospital attire, preferably green safety scrubs. b. Provide safe patient food trays. c. Complete environmental checklist. d. Where practical, place patient in a preferred room or closest to the main nurse’s station. The nursing staff will use the Constant Observation Flowsheet to document observation. Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed. If the patient screens positive using C-SSRS, then the facility designated QMHP will complete an evidenced based full suicide risk assessment within 24 hours ... (name of the facility) will require an initial C-SSRS suicide screening if, at any time, a patient who has screened negative for suicide ideations expresses new thoughts of self-harm or suicidal ideation.” 2. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the “H&P” indicated, Patient 1 “presented status (after) post seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) clearance workup (a medical exam to make sure that a patient’s psychiatric symptoms are not caused by a medical condition), was initiated, and at the time of elopement (an act or instance of running off secretly against medical advice), the patient was pending psychiatric evaluation.” The H&P further indicated that on reevaluation/repeat exam, the current time (when Patient 1 eloped) the patient (Patient 1) was pending psychiatric evaluation for suicidal ideation (thoughts of killing oneself). During a review of Patient 1’s “Neurologic Exam (evaluate function of the brain, involves a series of tests that assesses mental status, reflexes, and movements),” dated 9/11/2024 at 5:45 p.m., the exam indicated Patient 1 was “calm, stares into space, flat affect (emotional flattening, not expressing emotions), coherent (is logical and clear), and alert.” The following exam on 9/12/2024 at 6:30 a.m. indicated Patient 1 was euphoric (intense happiness and excitement), not oriented to the situation (the inability to correctly acknowledge the current time, place, one’s role, and personal identity), confused (disturbed in mind or purpose), disjointed (unorganized or disconnected thoughts), and easily distracted. During an interview on 10/1/2024 at 3:10 p.m. with the certified nursing assistant (CNA, an entry-level role that provides vital support to both patients and nurses) 1, CNA 1 stated, he (CNA 1) received report from RN 1 that the patient (Patient 1) was suicidal. CNA 1 further stated that on 9/12/2024 at about 8:00 a.m. “because the Patient (Patient 1) was standing on top of the gurney with his eyes closed, a code gray (a rapid response in the event a need occurs to help control a combative patient, or incident involving violence or impending violence where assistance in the part of other hospital employees may be necessary) was called.” CNA 1 stated, “the charge nurse and I have to hold the patient shoulder, we put him back to bed.” During an interview on 10/1/2024 at 4:00 p.m. with Registered Nurse (RN, a licensed medical professional who provides hands-on care in different medical and community settings) 1, RN 1 stated that Patient 1’s behavior was initially calm and quiet and progressed to becoming strange and asking strange questions. RN 1 stated, Patient 1’s behavior worsened towards the end of the shift, it became more frequent when he (Patient 1) would say things like “are we on a space station?” RN 1 stated on 9/11/2024 at around 10:00 p.m. the physician (MD)1 spoke to the patient (Patient 1) for about 25 minutes. RN 1 stated the physician came back and informed RN 1 that now the patient was “Passive SI (when an individual’s thinks about or wishes for death without actually planning to end their life) and we will hold him overnight and need to do PET (Psychiatric Emergency Team, perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others as a result of mental disorder) eval (evaluation).” RN 1 stated, “The patient behavior worsens toward the end of the shift. The doctor (name of MD 1) was aware of this, but he (MD 1) left a few hours after we decided to keep the patient (Patient 1) that night after we started to take over. The doctor (name of MD 2) took over care, I did not report this (change in Patient 1’s behavior) to him.” During an interview on 10/2/2024 at 11:15 a.m. with the Emergency Department Medical Director (MD) 3, MD 3 stated, “If the patient become more aggressive, and behavior changes, the nurse will communicate to the physician and the physician would assess the patient, may give medication to control behavior issues, and may call PET (Psychiatric Emergency Team) and give (discuss) situation that patient is not giving urine for test and the patient’s condition changed.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment Patient Care,” dated November 2023, the P&P indicated, “To ensure that each patient’s physical, psychological and social status is assessed to determine the patient’s care needs and to ensure patient’s changing needs are reassessed in response to treatment and care provided. All patients at (name of the facility) receiving inpatient, outpatient, or emergency services will have a timely, initial assessment of pertinent medical and psychosocial variables by qualified, privileged, interdisciplinary health care providers. The scope of assessment performed is dependent upon the patient’s status, diagnosis, location, response to treatment, and the assessing discipline ... Reporting Abnormal Guidelines for calling MD: Reporting Abnormal Guidelines for calling MD: Any changes in patient baseline vital signs that may cause concerns. All abnormal vital signs should be reported following the guidelines below to the patient’s physician unless the physician has ordered specific notification parameters. All interventions should be documented in the outcome notes: Failure to respond to treatment for an acute problem/symptom; Any other concern when there is a change from the patient’s baseline or change in condition ...” 3.a. During a review of Patient 6 ‘s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/1/2024, the “H&P” indicated, Patient 6’s past medical history included hip surgery in 2023. The H&P further indicated, “Patient 6 came in with abdominal pain ...patient underwent incarceration (the contents of the hernia cannot be reduced) right hernia (a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it) repair.” During a concurrent interview and record review on 10/3/2024 at 3:44 p.m. with the Director of Clinical Quality Improvement (DCQI), Patient 6’s “Medication Administration Records (MAR),” was reviewed. The MAR indicated a physician order of Morphine (Morphine sulfate, a drug used to treat moderate to severe pain) 2 milligrams (mg, a unit of measurement) per 1 milliliter (mL, unit of fluid measurement) injection, PRN (as needed) for severe pain (pain scale 8-10). DCQI verified in the MAR that Patient 6 was administered Morphine 2 mg on 10/2/2024 at 9:02 p.m. The DCQI stated there was no documentation of Patient 6’s pain re-assessment after the pain medication was given. During an interview on 10/4/2024 at 10:20 a.m. with the Director of the Emergency Department (DED), DED stated pain medication after it was given should be reassessed; “there is no policy, but this is a nursing standard of care to see if the medication is effective.” During a review of the facility’s policy and procedure (P&P) titled, “Pain management,” dated July 2022, the P&P indicated, “Provide guidelines for the effective relief and management of acute pain for all patients using an individualized interdisciplinary approach to pain management. Enhance patient comfort and satisfaction. Reduce acute pre-procedure, post-procedure, and post-traumatic pain severity and incidence. Educate patients and staff about the process of pain assessment, evaluation, and treatment ...If interventions are ineffective, alternative measures must be considered. Alternative measures may include but are not limited to: Dosage adjustment and/or new medications. Notification of the physician for new or alternate orders. Implementation of other non-pharmacological measures such as responding, music therapy, massage or immobilization. A reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment for inpatients and following any intervention intended to lessen the patient’s pain (e.g., administration of pain medications, application of cold packs, repositioning). Such reassessment is a dynamic and ongoing process which shall take place within a clinically appropriate time frame, depending on the type of intervention, the route of medication administration and the clinical condition of the patient. Staff should document the reassessment of a pain intervention must occur by the end of shift.” 3.b. During a review of Patient 30s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/26/2024, the H&P indicated Patient 30 was admitted to the facility for fever (a body temperature that is higher than normal) of three days, nausea (a feeling of sickness with an inclination to vomit), vomiting, dysuria (a symptom that describes the sensation of pain, burning, stinging, or itching when urinating), and increased urinary frequency related to sepsis (a life-threatening medical emergency that occurs when the body’s immune system has an extreme response to an infection or injury) and pyelonephritis (a kidney infection). During a concurrent interview and record review on 10/3/2024 at 4:48 p.m. with the Clinical Educator (CE), the CE verified Patient 30’s “Medication Administration Record (MAR),” dated 9/26/2024, included a physician’s order of Norco (pain medication) 325/5 milligram (mg, a unit of measurement) 1 tablet, to be given by mouth, every four hours as needed (PRN) for moderate pain (pain score of 4 to 6), with a start date of 9/26/2024. During the same interview and record review on 10/3/2024 at 4:55 p.m. the CE verified Patient 30’s MAR, which indicated Patient 30 was given Norco 325/5 mg 1 tablet on the following dates and times: - On 9/29/2024 at 5:17 a.m., Norco was given for Patient 30’s pain score of 5. Patient 30’s next pain assessment, score of 0, was at 8 a.m. (3 hours after administering the Norco); and, - On 9/30/2024 at 4:12 p.m., Norco was given for Patient 30’s pain score of 5. Patient 30’s next pain assessment, score of 0, was at 8:06 p.m. (4 hours after administering the Norco). During an interview on 10/4/2024 at 11:20 a.m., with the Director of Telemetry (DT), the DT stated as a nursing standard of care, the patient’s pain should be reassessed in 30 minutes to one hour after administering oral pain medications and 15 minutes after administering intravenous (IV - within the veins) pain medication. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 07/2022, the P&P indicated, “A reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment for inpatients and following any intervention intended to lessen the patient’s pain...e.g., administration of pain medications ...Such reassessment is a dynamic and ongoing process which shall take place within a clinically appropriate time frame, depending on the type of intervention, the route of medication administration and the clinical condition of the patient.” During a review of the facility’s “Policy and Procedure” (P&P), titled “Medication Administration of,” dated 8/2022, the P&P indicated, “All medications and IV’s are recorded in eMAR (electronic Medication Administration Record) or other designated areas of the patient’s permanent medical chart record...Responses to all “PRN” medications must be noted either on the pain flow sheet, Nursing clinical documentation tool, or in the progress notes.” 4. During a review of Patient 25’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/22/2024, the “H&P” indicated, Patient 25 was admitted for a fall (an unintentional event that results in a person coming to rest on the ground or other lower level) and altered mental status (confusion). During a concurrent interview and record review on 10/3/2024 at 4:52 p.m. with ST Segment Elevation Myocardial Infarction (STEMI, deadly type of heart attack) Coordinator (SC), the SC verified Patient 25’s “Medication Administration Record (MAR),” dated 9/30/2024, had a physician’s order for Patient 25, to administer Ativan 1 milligram (mg, a unit of measure) one tablet by mouth every six hours PRN (as needed) for anxiety. The SC stated the MAR further indicated Patient 25 was given Ativan at 10:59 a.m. During the same interview and record review on 10/3/2024 at 4:52 p.m. the SC verified Patient 25 did not have an assessment after Ativan was given on 9/30/2024 at 10:59 a.m. The SC stated Patient 25’s assessment was completed on 9/30/2024 at 8:00 a.m. and 8:00 p.m., and no other assessments were documented. During an interview on 10/3/2024 at 5:31 p.m. with the Clinical Manager of Med-Surg (CMMS), the CMMS stated it was important to reassess (reevaluation) and monitor the patient after giving PRN medication to know if the medication was effective. The CMMS said the patient should be reassessed within 30 minutes to one hour after PRN medication was given. The CMMS stated Patient 25 should be monitored for any changes in breathing, mental status, and for sleepiness after receiving PRN Ativan. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Medication Administration,” dated 8/2022, the P&P indicated, “All medications and IV’s are recorded in eMAR (electronic Medication Administration Record) or other designated areas of the patient’s permanent medical chart record ... Responses to all “PRN” medications must be noted either on the pain flow sheet, Nursing clinical documentation tool, or in the progress notes.” During a review of the facility’s “Policy and Procedure (P&P)” titled, “Assessment and Reassessment Patient Care,” dated 10/2023, the P&P indicated, “Reassessment is a component of the patient plan of care and is conducted at key determinate events as well as throughout the care continuum. Reassessment is the evaluation of patient’s response to treatment and care in order to determine the appropriateness and effectiveness of care decision. The goal of the assessment and reassessment process is to provide the patient with the best and most appropriate individualized care and treatment.” 5. During a review of Patient 26’s “Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital),” dated 10/2/2024, the discharge summary indicated, Patient 26 was admitted on 9/23/2024 for back pain, and had a medical history of high blood pressure (BP, amount of force blood uses to move through the body). During a review of Patient 26’s “Order Information,” dated 9/23/2024, the order indicated for Patient 26 to be given Hydralazine (medication used for lowering BP) 10 milligram (mg, unit of measure) intravenously (IV, through the vein), every six hours PRN (as needed) for systolic (SBP, maximum amount of pressure the blood uses to move through the body) greater than 160 mmHg (millimeters of mercury, a unit of measure). During a concurrent interview and record review on 10/3/2024 at 5:42 p.m. with the Clinical Manager of Med-Surg (CMMS), the CMMS verified that Patient 26’s “Medication Administration Record (MAR),” dated 9/23/2024 and 9/25/2024, Patient 26 was given Hydralazine 10 mg IV on the following dates and time: -On 9/23/2024 at 10:53 p.m., for BP of 177/62 mmHg -On 9/25/2024 at 4:13 a.m., for BP of 172/53 mmHg The CMMS verified Patient 26’s record had no documentation of the patient’s BP reassessment after PRN Hydralazine 10 mg IV was given on 9/23/2024 at 10:53 p.m., and on 9/25/2024 at 4:13 a.m. During the same interview and record review on 10/3/2024 at 5:42 p.m. with the CMMS, the CMMS stated Patient 26’s BP should have been rechecked 30 minutes after Hydralazine was given because the medication was given through the IV. The CMS further stated BP reassessment was important to ensure the medication was effective, and if the patient’s BP was still high, the physician should be notified. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Medication Administration of,” dated 8/2022, the P&P indicated, “All medications and IV’s are recorded in eMAR (electronic Medication Administration Record) or other designated areas of the patient’s permanent medical chart record...Responses to all “PRN” medications must be noted either on the pain flow sheet, Nursing clinical documentation tool, or in the progress notes.” During a review of the facility’s “Policy and Procedure (P&P)” titled, “Assessment and Reassessment Patient Care,” dated 10/2023, the P&P indicated, “Reassessment is a component of the patient plan of care and is conducted at key determinate events as well as throughout the care continuum. Reassessment is the evaluation of patient’s response to treatment and care in order to determine the appropriateness and effectiveness of care decision. The goal of the assessment and reassessment process is to provide the patient with the best and most appropriate individualized care and treatment...Vital signs and pain scale occurs routinely every 8 hours and more frequently as needed based on patient care and responses to care and treatment.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22’s care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), was developed in accordance with the accepted standards of nursing practice and the facility’s policy and procedure regarding care planning. This deficient practice resulted in Patient 22 not having an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for Patient 22’s care. In addition, this deficient practice had the potential for Patient 22’s needs and risks to not be addressed. Findings: During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/17/2024, the H&P indicated Patient 22 was admitted for low oxygen levels. Patient 22 had a history of End Stage Renal Disease (ESRD, poor kidney function) and was on dialysis (procedure that cleans the blood by removing extra fluids and waste). During a review of Patient 22’s “Hemodialysis (procedure that cleans the blood by removing extra fluids and waste) Treatment,” dated 10/1/2024, the record indicated Patient 22 had an order to receive dialysis. During a concurrent interview and record review on 10/3/2024 at 12:21 p.m. with Charge Nurse 5 (CN) 5, CN 5 stated Patient 22’s “Care Plans” did not include a plan addressing Patient 22’s dialysis. CN 5 stated Patient 22 should have a developed care plan that addressed the patient’s goals and needs for dialysis treatment. During a review of the facility’s policy and procedure (P&P) titled, “Planning of Care,” dated 2/2022, the P&P indicated, “Nursing assessments and associated care plans should be documented in the medical record within 24 hours of inpatient admission or the initiation of observation status.””

“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: 46333 Based on observation, interview, and record review, the facility failed to: 1. Ensure two of 31 sampled patients’ (Patients 1 and 2), who were admitted to the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), focused reassessment at a minimum of every four hours, were completed, in accordance with the facility policy and procedure regarding frequency of focused reassessment in the ED. This deficient practice had the potential for missed changes in condition, delay in care, and treatment which may compromise Patient 1 and Patient 2’s safety. 2. Ensure one of 31 sampled patient’s (Patient 1’s) refusal to take Keppra (Levetiracetam, medication used to treat seizures) medication was properly documented when Patient 1 did not take the medication, in accordance with the facility’s policy and procedure regarding medication administration documentation. This deficient practice had the potential to result in mismanagement of Patient 1’s treatment and affect patient’s (Patient 1) safety, as Patient 1 was brought into the facility’s Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) for suspected seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). 3. Ensure one of 31 sampled patient’s (Patient 3) IV (Intravenous, through the vein) catheter was changed after 96 hours (4 days) instead of 192 hours (8 days), in accordance with the facility’s policy and procedure regarding IV catheter management. This deficient practice had the potential to increase Patient 3’s risk for catheter-related bloodstream infection, inflammation of the vein due to blood clot (thrombophlebitis), and discomfort. 4. Ensure one of 31 sampled patient’s (Patient 8) IV (Intravenous, through the vein) catheter was removed after discovering a hematoma (collection of blood that pools outside the blood vessel) at the catheter site, and notify the physician, in accordance with the facility’s policy and procedure regarding IV catheter site maintenance. This deficient practice resulted in Patient 8’s left inner arm, from the armpit to above the elbow, to develop swelling and with dark purple discoloration. 5. Ensure one of 31 sampled patient’s (Patient 4) medication was not left unattended in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) room in the back of gurney, in accordance with the facility’s policy and procedure regarding medications brought from home. This deficient practice had the potential to compromise Patient 4’s safety due to the risk of the medications being lost as well as the risk for a mental health patient in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) who may unintentionally ingest the medications. 6. Ensure one of 31 sampled patient’s (Patient 11)constant observation, due to risk of self-harm, was properly carried out and documented, while Patient 11 was in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), in accordance with the facility’s policy and procedure regarding Suicide (death caused by injuring oneself with the intent to die) risk assessment and intervention. This deficient practice had the potential to compromise Patient 11’s safety and may result in Patient 11 causing self-harm. 7. Ensure Patients 22 and 31’s wound photos were documented in accordance with the facility’s policy and procedure regarding wound care, when Patients 22 and 31’s wound photos did not have wound measurement. This deficient practice had the potential to result in an inaccurate assessment of Patients 22 and 31’s wounds and staff may not be able to monitor for signs and symptoms of the patients’ wound deterioration. Findings: 1.a. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the “H&P” indicated, Patient 1 “presented status post (after) seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient (Patient 1) was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) clearance workup (a medical exam to make sure that a patient’s psychiatric symptoms are not caused by a medical condition) was initiated, and at the time of elopement (an act or instance of running off secretly against medical advice), the patient was pending psychiatric evaluation.” The H&P further indicated that on “reevaluation/repeat exam, the current time the patient is pending psychiatric evaluation for suicidal ideation.” During a concurrent interview and record review on 10/3/2024 at 2:50 p.m. with the ED Manager (EDM) and the ED Director (DED), Patient 1’s “ED Neurological Assessment (Neuro assessment, evaluate function of the brain, involves a series of tests that assess mental status, reflexes, and movements),” was reviewed. There was no neuro assessment completed on admission on 9/11/2024 at 4:54 p.m. There was a neuro assessment on 9/11/2024 at 5:45 p.m. and (over 12 hours and 45 minutes later) another assessment done on 9/12/2024 at 6:30 a.m. EDM confirmed that Patient 1 was admitted to the ED on 9/11/2024 at 4:54 p.m. until Patient 1 eloped on 9/12/2024 at 9:00 a.m., only two neuro assessments were completed. The DED stated, “In the ED, we chart by exception, and a focus assessment on the patient chief of complaint is done; it should be completed a minimal q (every) shift (12 hours).” During a concurrent interview and record review on 10/3/2024 at 2:50 p.m. with the DED, the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment Patient Care,” dated November 2023, was reviewed. The P&P indicated, “To ensure that each patient’s physical, psychological and social status is assessed to determine the patient’s care needs and to ensure patient’s changing needs are reassessed in response to treatment and care provided ...Emergency Department: An evaluation is initiated by an RN within 10 minutes of arrival for emergent patients, 30 minutes for urgent patients, and 45 minutes for non¿urgent patients utilizing preset triage criteria. Triage and initial assessment will include data related to patient’s chief complaint upon entering Emergency Department and shall include ... Glasgow Coma Scale ... Reassessment: Patients are reassessed based upon the triage priority. A focused reassessment occurs minimally every 4 hours and at regular intervals, the frequency and content of which is based on changes in patient condition or diagnosis, standards of care, policies and procedures for ED, response to treatment or procedure, changes in level of care, and progress toward patient outcomes and patient goal attainment.” The DED verified that the ED staff are not completing a focused reassessment at a minimal every 4 hours, they are completing every shift. 1.b. During a review of Patient 2’s “Medical Screening Exam (MSE, a provider initial exam performed when a patient presents to a dedicated emergency department and requests care),” dated 9/24/2024, the “MSE” indicated, Patient 2 presenting to the ED for complaints of hearing auditory hallucinations (the perception of hearing sounds or voices that are not there) telling him to walk into traffic and to kill himself.” During a concurrent interview and record review on 10/3/2024 at 2:40 p.m. with the ED Manager (EDM) and the ED Director (DED), Patient 2’s “ED timeline,” was reviewed. The patient (Patient 2) arrived in the ED on 9/24/2024 at 8:22 p.m. The chief complaint indicated, “States he (Patient 2) has been off his psych meds (psychotropic medications are used to treat mental health disorders) for 5 days, and is now hearing voices telling him to jump into traffic.” During a concurrent interview and record review on 10/3/2024 at 2:40 p.m. with the ED Manager (EDM) and the ED Director (DED), Patient 2’s “ED Neurological Assessment,” was reviewed. The first Neurological assessment was completed on 9/24/2024 at 9:40 p.m. and then a partial assessment of behavior was completed 20 minutes later at 10:00 p.m. there was no other neuro assessment completed until 9 hours later on 9/25/2024 at 7:00 a.m. EDM verified there were no other neuro assessment until the patient was transferred more than 8 hours later. During a concurrent interview and record review on 10/3/2024 at 2:50 p.m. with the DED, the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment Patient Care,” dated November 2023, was reviewed. The P&P indicated, “To ensure that each patient’s physical, psychological and social status is assessed to determine the patient’s care needs and to ensure patient’s changing needs are reassessed in response to treatment and care provided ...Emergency Department: An evaluation is initiated by an RN within 10 minutes of arrival for emergent patients, 30 minutes for urgent patients, and 45 minutes for non¿urgent patients utilizing preset triage criteria. Triage and initial assessment will include data related to patient’s chief complaint upon entering Emergency Department and shall include ... Glasgow Coma Scale ... Reassessment: Patients are reassessed based upon the triage priority. A focused reassessment occurs minimally every 4 hours and at regular intervals, the frequency and content of which is based on changes in patient condition or diagnosis, standards of care, policies and procedures for ED, response to treatment or procedure, changes in level of care, and progress toward patient outcomes and patient goal attainment.” The DED verified that the ED staff are not completing a focused reassessment at a minimal every 4 hours, they are completing every shift. 2. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the “H&P” indicated, Patient 1 “presented status post (after) seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient (Patient 1) was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) clearance workup (a medical exam to make sure that a patient’s psychiatric symptoms are not caused by a medical condition) was initiated, and at the time of elopement (an act or instance of running off secretly against medical advice), the patient (Patient 1) was pending psychiatric evaluation.” The H&P further indicated that “on reevaluation/repeat exam, the current time the patient is pending psychiatric evaluation for suicidal ideation.” During a review of Patient 1’s “Medication Administration Record (MAR, a report detailing the drugs administered to a patient),” dated 9/12/2024, the “MAR” indicated, Patient 1 received 750 milligrams (mg, a unit of measurement) of Keppra (Levetiracetam, medication used to treat seizures) by mouth. During an interview on 10/1/2024 at 5:15 p.m. with Registered Nurse (RN) 2, RN 2 stated, while on break, a nurse (RN 14) that took over the care of Patient 1, administered the Keppra (Levetiracetam, prescription drugs used to treat seizures) medication that is due at 8:00 a.m. but Patient 1 refused to take the Keppra medication that had been scanned by RN 14. The RN 14 reported to RN 2 that the medication was scanned. However, it was not given. RN 14 then handed RN 2 the Keppra medication. RN 2 stated, “I should have modified the medication administration record, but I forgot to do it.” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated September 2022, the P&P indicated the following: To provide guidelines for the safe and accurate administration of medications, to provide a permanent documentation of medication administration and to provide a system for licensed personnel to have access to secure, approved floor stock medication, maintain inventory control, narcotic tracking and accurate patient charging. Clinical appropriateness and patient status shall serve as the determining factors for immediacy of order processing, regardless of age ... All medications will be stored in suitable secure locations, and shall be prepared and administered in accordance with Federal and State Laws, under the orders of a licensed practitioner, as per accepted standards of practice ... Any medication(s) obtained from an ADC or secured medication floor stock location but not administered must be returned to an appropriate secured location (ADC return bin, patient cassette, controlled medication drawer) or pharmacy within 30 minutes of acquisition and may not be carried on any person beyond the 30-minute time frame (excluding procedural and operating areas) ... All medications which are refused, not given, “given by other”, etc. shall be clearly documented in the patient’s medical record (eMar) accordingly. Patients may refuse scheduled medications while admitted to the hospital and will have the risks versus benefits reviewed by the licensed health care professional (HCP) accordingly. If the patient still refuses a medication, then the HCP will document education efforts and patient refusal, chart the medication task as “not given”, and indicate the reason as “patient refused”. During a review of the facility’s policy and procedure (P&P) titled, “Medication Errors,” dated April 2023, the P&P indicated, “Definition of Medication Variance (Error): Anytime a medication is administered includes but is not limited to one of the following ... Omission, unless qualified in nursing notes ... The healthcare provider making or discovering the error is responsible for notifying the attending physician of the error and carrying out any further orders. Notify the Charge Nurse or Nursing Supervisor, Unit Director. Completing an incident report using the Electronic System for Risk Management (ESRM).” 3. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the “H&P” indicated, Patient 3 presented to the emergency department for left foot pain for three (3 ) weeks. H& P indicated, “Patient states that he notices a blister (fluid fills a space between layers of skin) on his (Patient 30 foot but now thinks his foot is turning gangrenous (occurs when a body tissue dies due to a lack of blood supply or a bacterial infection).” The H&P further indicated the plan was to start the patient (Patient 3) on Intravenous (medication administered into the vein) antibiotic (medication that inhibit or kill microorganisms). During a concurrent observation and interview on 10/3/2024 at 10:30 a.m. with the Director of Telemetry (DT), in Patient 3’s room, Patient 3’s skin at the intravenous (IV, into the vein) catheter (a thin, flexible tube is inserted into a vein to administer fluid medication) site was reddened. The catheter site did not have a label (date and initial of staff who inserted the catheter) of when the IV catheter was inserted. Patient 3 stated, “There is a little pain (pointing to the IV catheter site), but not too much.” The DT stated she will have the nurse look at the IV catheter site. DT said, generally, the IV catheter site was assessed every shift (within 12 hours) and was changed every 96 hours or as needed. During an interview on 10/3/2024 at 10:38 p.m. with Registered Nurse (RN) 13, outside the corridor, RN 13 stated, “I did not insert the IV catheter, but we do need to label the IV catheter site with date, so we know when it was inserted. IV catheter need to be replaced every 4-5 days.” During a concurrent interview and record review on 10/3/2024 at 3:45 p.m. with the Director of Clinical Quality Improvement (DCQI), Patient 3’s flowsheet (report that outlines the steps involved in managing patient care) dated 9/24/2024 to current, 10/2/2024, was reviewed. The flowsheet indicated Patient 3’s IV catheter was inserted on 9/24/2024, more than 192 hours (8 days) old. DCQI stated this was failure on the nurse to not change the IV catheter site. During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy-Central Venous Cath,” November 2022, the P&P indicated, “To provide guidelines to achieve the following goals during peripheral IV therapy: Provide standardization of care for continuous or intermittent IV therapy Administer IV Push medications. Reduce the risk of infection due to IV Therapy. Reduce the risk of clotting by establishing a standardized procedure for maintenance of peripheral saline lock therapy. IV Insertion Site Change: Every 96 hours. PRN complications (e.g. infiltration, phlebitis, clotted/resistance to flush). Initiate new venous access before discontinuing old access device. If unable to initiate access at a new site, contact the physician. Label dressings with date and time changed, and initials of person changing. Change the needleless components with routine dressing changes, when residual blood is visible, and at least as frequently as the administration set which should be changed every 96 hours.” 4. During a review of Patient 8’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the “H&P” indicated, Patient 8 was admitted to the facility for chest pain and shortness of breath (difficulty breathing). The H&P further indicated “Patient has never had chest pain before. Denies any fever, chills (a feeling of coldness and rapid muscle contractions and relaxations as the body tries to produce heat), nausea (a feeling of sickness with an inclination to vomit), vomiting. However, patient (Patient 8) does state that patient (Patient 8) had melena (black tarry stool that comes from bleeding in your upper) at the skilled nursing facility (is a type of inpatient facility that provides short or long-term skilled nursing care, and rehabilitation services) denies any previous history of melena.” During an observation and interview on 10/3/2024 at 10:30 a.m. with Registered Nurse (RN) 13 in Patient 8’ room, Patient 8’s left inner arm, from the armpit to above the elbow, was observed to have swelling and dark purple coloration. Patient 8 pointed to the left inner arm and stated, “Last night at 1 or 12, It was here and here no good.” RN 13 stated IV (Intravenous, through the vein) to the left upper arm was removed at 4:19 a.m. due to infiltration (when the IV fluid or medication accidentally leaks into the surrounding tissues outside the intended vein). RN 13 stated, “I will call the physician for an order for ultrasound.” During a concurrent interview and record review on 10/3/2024 At 4:35 p.m. with the Director of Clinical Quality Improvement (DCQI), Patient 8’s “flowsheet,” dated 10/2/2024 and 10/3/2024, was reviewed. The flowsheet indicated an IV catheter to the left upper arm assessed on 10/2/2024 at 8:00 a.m. indicated site/condition with hematoma (collection of blood that pools outside the blood vessel). However, DCQI verified that the IV catheter was not removed. Instead, the IV catheter was discontinued the following day on 10/3/2024 at 4:19 a.m. During an interview on 10/4/2024 at 10:12 a.m. with the DT, DT stated the bruise on Patient 8’s arm was not communicated to the provider. DT said, “The IV site, if discovered with hematoma, even if flushable, should be removed. Also, take the picture (of the site) and notify the physician.” During a review of the facility’s policy and procedure (P&P) titled, “IV Therapy-Central Venous Cath,” November 2022, the P&P indicated the following: To provide guidelines to achieve the following goals during peripheral IV therapy: Provide standardization of care for continuous or intermittent IV therapy Administer IV Push medications. Reduce the risk of infection due to IV Therapy. Reduce the risk of clotting by establishing a standardized procedure for maintenance of peripheral saline lock therapy. Site Assessment - Inspect visually and palpate site for signs of infusion-related complications upon admission, every shift, with dressing change and PRN. If patient admitted with IV in place and insertion site not visible, remove dressing to inspect site. Notify physician for any of the following signs: 1. Infiltration - swelling, coolness, pain, fluid leaking, proximal or distal to the insertion site, resistance met during infusion attempt. 2. Phlebitis - erythema, warmth, drainage, pain, streaking, palpable venous cord 3. Inflammatory process - pain, discomfort to palpation 5.. During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the “H&P” indicated, Patient 4 presented to the ED (Emergency Department) for shortness of breath (difficulty breathing) and also “experiencing dizziness upon climbing half a flight of stairs and becoming short of breath and having to stop.” The H&P further indicated the plan was to admit Patient 4 to the telemetry unit (a floor in a hospital where patients undergo continuous heart monitor). During a concurrent observation and interview on 10/1/2024 at 11:38 a.m. with the Director of ED (DED) in the Emergency Department, room 3, a translucent plastic bag with three bottles of medication without any label was left in the back of the gurney unattended. There was no patient or staff in room 3. The DED opened the plastic bag and retrieved the three medications. The medications were: Eliquis (apixaban, a prescription medication to prevent and treat blood clots), Lipitor (atorvastatin, a prescription medicine that contains a cholesterol-lowering property), and Amiodarone (a prescription drug used to treat certain types of abnormal heart rhythms). DED stated, “This should not be here unless the patient refuses to hand it over to staff, then we will ask them to have it sent home.” The DED further stated, “The nurse is not here right now; we will find out where the patient is.” During an interview on 10/1/2024 at 12:15 p.m. with Pharmacist (PH) 1, PH 1 stated, “The medication should be left with the patient all the time. Medication brought from home should be checked into pharmacy if the patient refused to have a family member pick up the medication. It should be in a secure area until the family picks it up for patient safety.” During a review of the facility’s policy and procedure (P&P) titled, “Medications Brought to the Hospital by Patient,” dated January 2024, the P&P indicated the following: This policy applies to (name of the facility) and to all employees, Medical Staff members, contractors, patients, and visitors regardless of service location or category of patient. The purposes of this policy are (a) to provide for patient safety, continuity of care, and appropriate patient billing in circumstances when the patient brings his or her own medications to the Hospital; and (b) to provide safe and effective administration ...Handling of Medications Brought to the Hospital by the Patient: If a patient brings his or her own medications to the Hospital, the nurse shall request that a responsible family member or patient representative take the medications home. If the medications are unable to be removed from the Hospital, the admitting nurse shall be responsible for removing the medications from the patient’s possession and taking the following steps: 1. The nurse will place all medications into a clear plastic “security bag” (see Attachment A) in the patient’s presence. 2. The name of any medications placed into the bag shall be documented on the outside of the bag. 3. The RN will verify the medications with the charge nurse prior to delivery to pharmacy 4. The RN and Pharmacist will perform another check upon delivery to the Pharmacy. 5. Charge RN and patient will check the list of medications upon return to the patient prior to discharge. 6. The patient’s name, unit, ID#, date and nurse’s name are to be documented on the bag in the appropriate spaces. The patient and nurse shall initial the bag on the line titled “prepared by.” If the patient is unable to initial, two nurses will initial the bag. 6. During a review of Patient 11’s electronic medical record (EMR, digital version of the paper chart), the EMR indicated, Patient 11 presented in the ED (Emergency Department) on 9/7/2024 at 10:34 a.m. for evaluation of auditory hallucination (the perception of hearing sounds or voices that are not there). The EMR also indicated that “patient (Patient 11) states he has been hearing voices, feels depressed, thinks people want to hurt him (Patient 11), and has suicidal ideations (thoughts of killing oneself). The patient (Patient 11) has attempted to hurt himself in the past by cutting his wrists. Patient (Patient 11) is willing to go voluntarily to a psychiatric facility. Patient was transferred to a Behavioral Health Facility on 9/8/2024 at 6:05 a.m.” During a concurrent interview and record review on 10/3/2024 at 2:17 p.m. with the Clinical Informatics Manager (CIM), Patient 11’s “Constant Observer Flowsheet (a document used by healthcare providers to record observations of a patient who is under constant observation),” dated 9/7/2024, was reviewed. The flowsheet indicated that patient (Patient 11) observation started at 10:45 a.m., patient (Patient 11) was continuously monitored until 7:00 p.m. CIM stated that Patient 11 had an order to be placed on constant observation because patient (Patient 11) was at risk for self-harm. CIM verified there was no entry in the flowsheet that patient (Patient 11) was observed from 9/7/2024 7:00 p.m. to 9/8/2024 6:05 a.m., which was the date and time of discharge. CIM stated, per Policy, staff who was assigned as constant observer must document patient observation every 15 minutes on the flowsheet. During a review of the facility’s policy and procedure (P&P) titled, “Suicide Risk Assessment and Intervention,” dated November 2022, the P&P indicates the following: -“(Name of the Facility) conducts an annual self-harm environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide, and (Name of the Facility) will take the necessary action to minimize the risk(s). This applies to all inpatient psychiatric units and outpatient psychiatric programs.” -“The nursing staff will use the Constant Observation Flowsheet to document observation.” 7.a. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/17/2024, the H&P indicated Patient 22 was admitted for low oxygen levels and had a history of End Stage Renal Disease (ESRD, poor kidney function), on dialysis (procedure that cleans the blood by removing extra fluids and waste), and a Stage III Pressure Injury (Full-thickness loss of skin, with dead and black tissue that may be visible). on the sacrum (lower back bone, part of the pelvis). During a review of Patient 22’s “Wound Care Note,” dated 9/26/2024, the note indicated Patient 22 had several wounds: - Stage III PI (Pressure Injury) on the sacrum and right upper buttock (rear); - Bruises (leaking blood vessels causing purple/blue skin discoloration) and skin tears on the right and left arms; and, -Multiple blood blisters (skin bubble filled with blood), bruises, and scabs (dry, crusted blood over a wound) on both legs. During a concurrent interview and record review on 10/3/2024 at 11:55 a.m. with the Wound Care Nurse 1 (WCN 1), WCN 1 verified Patient 22’s “Wound and Impaired Skin Assessment Form,” dated 9/17/2024, indicated the following: - Patient 22’s right buttock wound, and sacrum (lower back bone, part of the pelvis) wound photos did not include wound measurements; and, -Patient 22’s left thigh, right thigh, left arm, and lower extremities (both legs) did not include wound measurements and the nurse’s name/signature of who took the photos. During the same interview and record review on 10/3/2024 at 11:55 a.m., WCN 1 verified Patient 22’s “Wound and Impaired Skin Assessment Form,” dated 9/18/2024, indicated Patient 22’s left leg and sacrum wound photos were missing wound measurements. During the same interview and record review on 10/3/2024 at 11:55 a.m., WCN 1 verified Patient 22’s “Wound and Impaired Skin Assessment Form,” dated 9/25/2024, indicated Patient 22’s left hand, left knee, left lower leg, right and left legs, right buttock, and sacrum wound photos were missing wound measurements. During an interview on 10/3/2024 at 11:55 a.m. with WCN1, WCN 1 stated wound photograph documentation should include a site, measurements, the nurse’s name and signature, and the date and time (when the wound photo was taken). WCN 1 stated wound measurement should be included with the wound photo to monitor for improvement or deterioration of the wound. During a review of the facility’s policy and procedure (P&P) titled, “Tissue and Pressure Ulcer Prevention and Management Policy,” dated 11/2023, the P&P indicated, “Documentation to accompany photograph includes: Wound dimensions and Wound descriptors as noted in the wound assessment.” 7.b. During a review of Patient 31’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/12/2024, the H&P indicated Patient 31 was admitted to the facility for alcohol intoxication (a condition associated with drinking too much alcohol in a short amount of time) with sepsis (a life-threatening medical emergency that occurs when the body’s immune system has an extreme response to an infection or injury), rhabdomyolysis (a serious medical condition that occurs when muscle tissue breaks down and releases harmful substances into the blood), cirrhosis (a chronic liver disease that occurs when the liver is damaged over time and scar tissue replaces healthy liver tissue) of liver and on mechanically assisted ventilation (a medical procedure that uses a machine to help a patient breathe or breathe for them). During a concurrent interview and record review on 10/3/2024 at 11:51 a.m. with Wound Care Nurse 1 (WCN 1), Patient 31’s “Wound and Impaired Skin Assessment,” dated 9/18/2024, was reviewed. The assessment included the following wound photo of Patient 31: -right lower extremity wound, the wound photo did not include wound measurement; and, right upper extremity wound, the wound photo did not include wound measurement. During the same interview on 10/2/2024 at 11:51 a.m., WCN 1 stated Patient 31’s wound photos taken on 9/18/2024 did not have wound measurements. WCN 1 stated the wound photos should have wound measurements to indicate if the wound was getting better or worse. During a review of the facility’s policy and procedure (P&P) titled, “Tissue and Pressure Ulcer Prevention and Management Policy,” dated 11/2023, the P&P indicated, “Documentation to accompany photograph includes: Wound dimensions and Wound descriptors as noted in the wound assessment.””

“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: 50632 Based on interview and record review, the facility failed to ensure for two of 31 sampled patients (Patients 26 and 29) the following: 1. Patient 26’s Hydralazine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 26’s health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient. 2. Patient 29 received the first dose of cefepime (antibiotic, use for treatment of an infection) in a timely manner, in accordance with the facility’s Policy and Procedure regarding medication administration. This deficient practice resulted in a delay in treatment and had the potential for the antibiotic to be ineffective in the treatment of Patient 29’s infection. Findings: 1. During a review of Patient 26’s “Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital),” dated 10/2/2024, the discharge summary indicated, Patient 26 was admitted to the facility on 9/23/2024 for back pain. Patient 26 had a medical history of high blood pressure (BP, amount of force blood uses to move through the body). During a review of Patient 26’s “Order Information,” dated 9/23/2024, the order indicated for Patient 26 to be given Hydralazine (medication used for lowering BP) 10 milligram (mg, unit of measure) intravenously (IV, through the vein), every six hours as needed (PRN) for systolic (SBP, maximum amount of pressure the blood uses to move through the body) greater than 160 mmHg (millimeters of mercury, a unit of measure). During a concurrent interview and record review on 10/4/2024 at 10:40 a.m. with Clinical Manager of Med-Surg (CMMS), the CMMS verified Patient 26’s “Vital Sign Flowsheet” dated 9/23/2024 at 9:10 p.m., Patient 26’s BP was 177/62. During the same interview and record review, on 10/4/2024 at 10:40 a.m., the CMMS verified Patient 26’s “Medication Administration Record (MAR),” indicated the PRN Hydralazine 10 mg IV was given to Patient 26 on 9/23/2024 at 10:53 p.m. (1 hour and 43 minutes since Patient 26’s BP of 177/62 was taken). CMMS stated Patient 26 should have been given the PRN Hydralazine when the patient’s BP was 177/62 at 9:10 p.m. During a review of the facility’s “Policy and Procedure (P&P)” titled, “Medication Administration of,” dated 8/2022, the P&P indicated, “All medications...will be administered in a safe manner following “The Five Rights” ...Prior to obtaining medications for administration, validate orders entered into the patient’s electronic medical record (EMR) by comparing against written or electronic orders, and documenting accordingly... The licensed personnel will assure that the drug is delivered at the appropriate time.” 2. During a review of Patient 29’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/1/2024, the H&P indicated Patient 29 was admitted to the facility for fever (a body temperature that is higher than normal) associated with vomiting and productive cough. During a concurrent interview and record review on 10/3/2024 at 3:30 p.m., with Clinical Manager of Medical Surgical (CMMS), CMMS stated Patient 29’s “Medication Administration Record (MAR),” dated 10/2/2024, included a physician’s order for Patient 29 to receive cefepime (antibiotic), 1 gram in 50 milliliters (mL, a unit of measurement), intravenous (IV - within the veins), to start on 10/2/2024 at 6 p.m. During the same interview and record review on 10/3/2024 at 3:30 p.m., CMMS stated Patient 29’s MAR indicated Patient 22’s first dose of cefepime was given on 10/2/2024 at 9:50 p.m. (3 hours and 50 minutes after it was ordered to be given at 6 p.m.). CMMS stated antibiotics should be given within one hour of scheduled time. CMMS further stated Patient 29’s first dose of cefepime was given late because it was not available. CMMS stated two high priority requests were made to pharmacy regarding Patient 29’s cefepime. The CMMS stated the antibiotic not given on time could delay treatment of the patient’s infection. During an interview on 10/4/2024 at 12:16 p.m. with the Director of Pharmacy (DP), the DP confirmed two high priority medication request was received for Patient 29’s IV cefepime, 1 gram in 50 mL, due to missing medication on 10/2/2024 at 6:05 p.m. and 7:55 p.m. The DP stated there was no note entered by the pharmacy staff indicating the reason for the late refill and processing of Patient 29’s cefepime. During the same interview on 10/4/2024 at 12:16 p.m., The PD stated Patient 29’s cefepime was delivered to the unit on 10/2/2024 at 8:27 p.m., and cefepime was scheduled to be given on 10/2/2024 at 6 p.m. The DP stated after a high priority medication was requested, the medication should be refilled, processed and ready for pick up or delivery to the unit within an hour. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration of,” dated 08/2022, the P&P indicated, “antibiotic first doses should be given within 30 minutes of the order.””