Kaiser Foundation Hospital - Orange County - Anaheim

“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: 45560 Based on interview and record review, the hospital failed to ensure pain management was addressed for one of eight sampled patients (Patient 1) as per the hospital’s P&P. This failure increased the risk of substandard health outcomes to the patient. Findings: During a review of the hospital’s P&P titled, “Pain Assessment and Management,” dated August 2025, the P&P showed pain management is a continuous process, which involves assessment and reassessment after each intervention. Assessment of pain is based on the patient’s report of intensity, timing, duration, character, and contributing factors for verbal patients and on physiological and/or behavioral changes for non-verbal patients. Appropriate treatment options consist of both pharmacological and/or non-pharmacological interventions. During a review of Patient 1’s medical records on 3/4/26 at 1450 hours, Patient 1’s medical record showed Patient 1 arrived at the ED on 1/26/26 at 0612 hours and was discharged from the ED at 1422 hours. During a review of Patient 1’s Patient Care Timeline dated 1/26/26, the Patient Care Timeline showed Patient 1 presented to the ED with several symptoms including neck pain, eye pain, and back pain. The Patient Care Timeline showed on 1/26/26 at 0620 hours, Patient 1 was experiencing 9/10 (on the pain scale from zero to 10, zero indicates the patient has no pain and 10 indicate the patient has the worst pain) sharp continuous pain in their head and back. During a review of Patient 1’s Patient Care Timeline dated 1/26/26 at 0645 hours, the Patient Care Timeline showed Patient 1 was experiencing pain 9/10 level to their back that was sharp and continuous. The timeline also showed the patient’s acceptable level of pain was 5/10. The assessment showed the patient’s alleviating factor for pain was medication. During a review of Patient 1’s Patient Care Timeline dated 1/26/26 at 0800 hours, the Patient Care Timeline showed Patient 1 was experiencing 9/10 level of pain to their back that was sharp and continuous. The pain interventions at that time showed that the patient was repositioned and the patient requested to speak to their medical provider regarding pain medications. During a review of Patient 1’s Patient Care Timeline dated 1/26/26 at 1000 hours, the Patient Care Timeline showed Patient 1 was experiencing 9/10 sharp continuous back pain. The pain interventions at that time showed the patient was repositioned, requested “pain infusion” and that the provider was made aware. During a review of Patient 1’s Patient Care Timeline dated 1/26/26 at 1055 hours, the Patient Care Timeline showed a physician’s order was placed to discharge the patient to home. During a review of Patient 1’s Patient Care Timeline dated 1/26/26 at 1100 hours, the Patient Care Timeline showed Patient 1 was experiencing 9/10 sharp, continuous back pain. The pain interventions at that time showed the patient was repositioned. During a review of Patient 1’s physician’s orders dated 1/26/26 at 1132 hours, the physician’s orders showed an order to administer acetaminophen (a pain medication) 1000 mg IV solution. During an interview on 3/5/26 at 0930 hours with Physician 1, Physician 1 stated pain medication had not been offered to Patient 1 earlier because the physician was unaware of the level of pain that the patient was experiencing until the order for discharge was placed. During a concurrent interview and review of Patient 1’s medical record on 3/5/26 at 1245 hours, with the Emergency Department Director. The Emergency Department Director acknowledged although Patient 1 had complained of 9/10 pain on presentation to the ED on 1/26/26 at 0620 hours, no pain medication was offered until 1/26/26 at 1132 hours. During an interview with the Director of Regulatory Services on 3/5/26 at 1545 hours, the Director Regulatory Services was notified of the above findings, and acknowledged the findings.”

“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: 38660 Based on interview and record review, the hospital failed to implement the P&P for wound assessment and wound care for one of eight sampled patients (Patients 3) as evidenced by: * The nursing staff failed to perform an ongoing accurate assessment and evaluations of Patient 3’s wound as per the hospital’s P&P. * The nursing staff did not follow the physician’s order and Wound Care Nurse’s recommendations for Patient 3’s dressing changes. These failures created the risk of substandard health outcomes to the patients. Findings: During a review of the hospital’s P&P titled “Skin Care in Infants,” dated August 2024, the hospital’s P&P showed: * The Skin Risk Assessment and Management Tool (SRAMT) will be used to assess all infants in the NICU (Neonatal Intensive Care Unit) upon admission, once every shift and as needed. * Any skin breakdown, pressure sore or open wound resulting immobility, devices, or IV infiltration/extravasation will be documented and photographed. A clear photograph will be taken and uploaded in the infant’s Health Connect electronic medical record (EMR) at the time the skin breakdown is first noted, with any changes or at a minimum of every seven days and on transfer to another facility or discharge to home. * Assess/measurement - Assess characteristics of skin breakdown including color or color changes, type and amount of exudate/drainage, edges/markings, swelling. Measure skin breakdown in centimeters. - Take photos of affected area(s). Subsequent photos should be taken weekly (every Monday) to track healing progress until the affected area is healed. * Documentation - Document specific procedure/interventions performed in the appropriate section of the infant’s Health Connect EMR. - Document SRAMT skin risk assessment findings. Intervention(s) provided and response of infant to intervention(s) should be documented in the EMR under skin interventions. During a concurrent interview and review of Patient 3’s medical record on 3/4/26 at 1430 hours, with the Director of Quality and the Manager of NICU and Pediatrics. Patient 3’s medical record showed Patient 3 was admitted to the hospital on 9/27/25. Patient 3 was a newborn at 23 weeks gestation with intact skin. During a review of the Skin Flowsheet dated 10/16/25 at 1600 hours, the Skin Flowsheet showed the RN documented Patient 3 had a wound on the anterior left foot measuring 1 cm (length) x 1 cm (width). The open wound bed appearance was left blank, the periwound/ surrounding skin was clear and intact. During a review of the Wound/Ostomy Progress Note dated 10/20/25 at 1503 hours, the Wound/Ostomy Progress Note showed the WOCN 1 documented Patient 3 had a partial-thickness MARSI (medical adhesive-related skin injury) on the left anterior ankle with 100% smooth pink/red non granular tissue. The periwound was clear and intact, and the wound edge was irregular. The wound measured 0.5 cm (length) x 0.2 cm (width) X 0.1 (depth). The recommended treatment was to cleanse wound with normal saline (a wound cleanser), pat dry, cover with Mepitel One (clear, porous dressing) for protection, apply Aquaphor over Mepitel One to moisturize wound base. Mepitel One could be in place for three days; cleanse and moisturize the wound base once per shift/twice daily. During a review of the physician’s order dated 10/20/25 at 1508 hours, the order showed to cleanse wound on Patient 3’s left anterior ankle with normal saline, pat dry, cover with Mepitel One for protection, apply Aquaphor over Mepitel One to moisturize wound base. Mepitel One could be in place for three days; cleanse and moisturize the wound base once per shift/twice daily. During a review of the Skin Flowsheet from 10/21 to 12/9/25, no documentation showed the nurses assessed Patient 3’s partial thickness MARSI and provided treatment as ordered by the physician. During a concurrent interview and review of Patient 3’s medical record on 3/5/26 at 1022 hours, with WOCN 1, WOCN 2, the Director of Quality, and the Manager of NICU and Pediatrics. WOCN 1 stated the wound on patient’s left anterior ankle should be cleaned and covered with Mepitel One, with the dressing change every three days. Aquaphor could be applied on top of the dressing each shift to moisturize the wound base. WOCN 1 confirmed she delegated the wound care to nursing staff. During an interview on 3/5/26 at 1100 hours, with the Director of Quality and the Manager of ICU and Pediatrics, they acknowledged, the nurses did not perform the wound assessment daily, apply Aquaphor every shift and change the dressing every three days as ordered by the physician and the hospital’s P&P.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by:”

“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: 22553 Based on interview and record review, the hospital failed to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases and failed to ensure the ED staff implemented its P&Ps for seven of 20 sampled patients (Patients 1, 6, 8, 15, 17, 18, and 20) as evidenced by: 1. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for Patients 1, 6, 8, and 20. 2. The hospital failed to ensure the ED staff implemented its P&Ps for Patients 15, 17, and 18. a. For Patient 15, there was no documented evidence the ED staff weighed the patient as per the hospital ’ s P&P. The ED staff performed the Pasero sedation scale assessment when there was no documented evidence to show the patient received narcotic for pain management. b. For Patient 17, the ED staff failed to complete the FLACC Pain Assessment when triaging the patient. c. For Patient 18, the ED staff failed to accurately assign the ESI priority level for the patient. These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving the ED services. Findings: 1. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for Patients 1, 6, 8, and 20. Cross reference to A2407. 2. During a review of the hospital’s P&P titled, “Patient Triage Process,” dated November 2022, the P&P showed the following: * The Triage RN will determine through the interview assessment process the presenting complaint of each patient ... The person’s condition based on the presenting complaint will be assigned an acuity level and be seen in the Emergency Department. * Initial assessment will be done by a Registered Nurse which shall include making decision as to need for immediate care on the basis of gross observation; documentation of triage category with the time the category is established; obtaining ongoing triage history; performing initial focused assessment, using the appropriate computer triage screen based on the patient’s chief complaint, including vital signs. Review of the computer triage screen for ESI level showed Decision B section showing severe pain/ distress that is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale (one a pain scale from 0 to 10, 0 is no pain and 10 is the worst pain), is assigned to Level 2 on the Priority row. During a review of the hospital’s P&P titled, “Standardized Emergency Registered Nurse Procedures,” dated November 2022, the P&P showed: * The authorized ED RN shall perform a patient assessment including subjective and objective information to determine the appropriateness for initiating the standardized procedure prior to ED physician evaluation. * 6.2.2. Acuity ESI Priority 2 (Emergent -High risk situation), “Inform physician of ESI priority. Patient to be seen within 15 minutes.” * 6.11.3 Pediatric: “obtain weight in kilograms.” During a review of the hospital’s P&P titled, “Scope of Care in ED,” dated November 2022, the P&P showed: * All patients will be weighed in kilograms. * Weights are documented. * Pain and comfort are assessed on arrival, and minimally every two hours if applicable (indicating location, type, duration, aggravating or alleviating factors and intensity) using the functional pain score of 0-10; or the Wong -Baker scale. Review of the hospital’s P&P titled Pain Assessment and Management dated August 2025 showed * Pain Management is a continuous process, which involves assessment and reassessment after each intervention. Assessment of pain is based on the patient’s report of intensity, timing, duration, character, and contributing factors for verbal patients and on physiological and/or behavioral changes for non-verbal patients. Appropriate treatment options consist of both pharmacological and non-pharmacological interventions. * Pain is assessed initially on admission, at least as often as routine vital signs are collected, - “ 6.2.3.1 Initial Assessment .... 6.2.3.1.1. Perform PASERO Sedation Scale for patients receiving narcotics for pain managementDuration. “ * 6.3.1 pain assessments and reassessments shall be documented in the electronic medical record. * 6.3.2 documentation occurs as soon as possible preferably before leaving the patient’s room. Review of Appendix C of the hospital’s P&P titled Pain Assessment and Reassessment showed for the FLACC Scale (recommended for infant to 3 years of age), the assessment category include face (F), legs (L), activity (A), cry (C), and consolability (C). Each of the five categories face (F), legs (L), activity (A), cry (C), and consolability (C) is scored from 0 to 2 which results in a total score between 0 and 10. a. A concurrent interview and review of Patient 15’s closed medical was conducted on 9/5/25 at 1015 hours, with the Informatics Nurse. Patient 15’s closed medical record showed Patient 15 (a pediatric patient) presented to the ED on 5/29/25 at 1130 hours, with the chief of complaint of fever, diarrhea, vomiting, given Tylenol (a medication used to treat pain or fever), loss of appetite, and abdominal pain. Review of the Patient Care Timeline dated 5/29/25, showed at 1131 hours, the nursing staff documented “Pain Assessment .... Pasero Opiate Induced Sedation Scale: Awake and Alert.” the Decision B section showed the patient had “no” severe pain. The patient’s ESI level priority was 3 or Urgent. Patient 15’s medical record did not show documented evidence that the patient was receiving narcotics for pain management when the Pasero sedation scale assessment was performed for the patient. In addition, there was no documented evidence to show the patient was weighed upon arrival. The Informatics Nurse confirmed the findings. b. During a concurrent interview and record review on 9/5/25 at 1415 hours, with the Informatics Nurse, Patient 17’s medical record was reviewed. Patient 17’s medical record showed Patient 17, a pediatric patient who came to the ED on 9/3/25 at 0855 hours, with a chief complaint of foot injury. Review of the Patient Care Timelines showed the following: * At 0857 hours, the Chief Complaints Updated event showed Patient 17 had “left foot injury yesterday while playing with ... Pt walked on own normally but has been avoiding putting weight on LLE.” * At 0857 hours, the Rapid Triage Intake VS event showed the “Pain Assessment ... FLACC (++) .... FLACC Assessment ... Legs... Activity...Crying...Consolability.” The FLACC assessment did not include the assessment of the patient’s face. did not include Face (F). * At 0857 hours, the patient’s ESI level priority was assigned as 4 (Non-Urgent). On 9/5/25 at 1642 hours, the ED Nurse Manager confirmed the ESI level was assigned without a complete FLACC assessment. c. During a concurrent interview and record review on 9/4/25 at 1439 hours with the Informatics Nurse, Patient 18’s closed medical record was reviewed. Review of the Patient Care Timeline dated 10/11/24, showed the following: * At 0701 hours, Patient 18 arrived in the ED with the chief complaint of sharp abdominal pain in the right lower quadrant for one hour, accompanied by nausea and vomiting. The patient stated the patient had two episodes of yellow-colored emesis. * At 0703 hours, the patient’s pain was assessed. The patient’s pain level was 8 out of 10 (severe pain). The patient’s acceptable pain level was 2 out of 10. * At 0703 hours, the Decision B section of the ESI (Emergency Severity Index) event showed “No” as the response to a question “Arrived....or severe pain/distress?” The patient was assigned an ESI priority level of 3 (Urgent). Review of the ED Provider Note dated 10/11/24 at 0820 hours (1 hour and 17 minutes later), showed Patient 18 was seen by the provider Further review of the Patient Care Timeline dated 10/11/24, showed at 0824 hours, Patient 18 received hydromorphone (a pain medication), 0.5 mg IV. During an interview on 9/5/25 at 1642 hours, the ED Nurse Manager reviewed the hospital’s P&P and stated Patient 18 should have been triaged as ESI priority level 2 as per the hospital’s P&P.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 37663 Based on interview and record review, the hospital failed to ensure the hospital’s central log was accurately maintained for the patient’s disposition for one of 20 sampled patients (Patient 4). This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED for treatment for an emergency medical condition. Findings: During a review of the hospital’s P&P titled “Emergency Medical Screening Examination, Treatment, and Transfer” dated 1/9/23, the P&P indicated, “Central (EMTALA) Log ... Logs will be maintained by the emergency and the labor and delivery departments on each person who comes to the hospital seeking emergency care.... The log shall be maintained and shall contain ... individual’s disposition (e.g., ... LWBS ... and leaving against advice).” Review of the ED central log for August 2025 showed Patient 4 arrived in the ED on 8/7/25 at 2024 hour. The ED Disposition section showed Patient 4 was “LWBS.” During a review of Patient 4’s medical record on 9/4/25, the medical record indicated Patient arrived in the ED on 8/7/25. Review of the Patient Care Timeline showed on 8/7/25, Patient 4 arrived in the ED at 2024 hours. The disposition section showed at 2140 hours, the patient was LWBS; Patient 4 was called three times, and the ED was searched. The RN documented the patient’s family reported that they would take the patient to a different hospital location to see the patient’s personal physician. During a review of the “ED Provider Triage Note” dated 8/7/25 at 2036 hours, the ED Provider Triage Note showed the ED physician performed a medical screening exam assessment in the Triage, including a brief chart review and ordered tests. Patient 4 was informed that this was a preliminary evaluation in order to expedite care and was instructed not to leave the ED before formal evaluation by the treating physician. . An interview and concurrent record review was conducted with the ED Nurse Manager on 9/4/25 at 1123 hours. The ED Nurse Manager stated the LWBS was an error in the patient’s disposition. Patient 4 was seen by the ED physician, tests were ordered and completed, and then Patient 4 left. The ED Nurse Manager stated the correct disposition should have been AMA.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 22553 Intakes: CA00974104 Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for four of 20 sampled patients (Patients 1, 6, 8, and 20) as evidenced by: 1. The ED staff failed to ensure the pain assessment and management for Patients 1, 8, and 20 as per the hospital’s P&P. 2. The ED nursing staff failed to follow the physician’s order for IV fluid administration for Patient 6. These failures created the increased risk of substandard health outcomes for the patients and an unsafe patient care environment. Findings: 1. During a review of the hospital’s P&P titled “Scope of Care in ED” dated November 2022, the P&P showed “6.12 Vital signs, including a pain score if applicable (HR, BP, RR, and Temperature) are measured upon arrival, ... at least every two hours, or more often as patient condition warrants....6.17 Pain and comfort are assessed on arrival, and minimally every two hours if applicable (indicating location, type, duration, aggravating or alleviating factors and intensity) using the functional pain score of 0-10; or the Wong -Baker scale. Additional pain assessments are done as follows... 6.17.2 The patient’s response to an intervention (i.e. pain medication) is evaluated as appropriate and documented ... per policy... 6.17.3 Physician is notified for pain that is not controlled ... 6.21.5 Discharge instruction will be reviewed by the ED provider/RN at the time of discharge. Printed instructions are provided.” During a review of the hospital’s P&P titled, “Pain Assessment and Management” reviewed August 2025, the P&P showed “2.3 Pain Management is a continuous process, which involves assessment and reassessment after each intervention. Assessment of pain is based on the patient’s report of intensity, timing, duration, character, and contributing factors for verbal patients and on physiological and/or behavioral changes for non-verbal patients. Appropriate treatment options consist of both pharmacological and non-pharmacological interventions ... 3.0 .... This policy applies to ... Emergency Department ... 6.2.1 Pain is assessed initially on admission; at least as often as routine vital signs are collected ... 6.2.2 Assessment is repeated and documented: ... within 30 minutes after each IV push medication dose and 60 minutes for each ... PO pain medication dose or non - pharmacological intervention.... 6.2.7 When patient’s pain is not controlled within tolerable pain level ... Notify physician.... 6.3.1 Pain assessments and reassessments shall be documented in the electronic medical record ... 6.3.2 Documentation occurs as soon as possible preferably before leaving the patient’s room.” a. During a review of Patient 1’s closed medical record on 9/3/25, Patient 1’s closed medical record showed Patient 1 arrived in triage on 8/3/25 at 2111 hours. The patient’s chief complaints were tingling or numbness in bilateral upper and lower extremities, progressively getting worse for several days. Review of the Patient Care Timeline showed the following: * On 8/3/25 at 2112 hours, Patient 1’s pain level was 9 out of 10 (10 is the worst pain), and the patient’s acceptable pain level was 3 out of 10. * On 8/3/25 at 2322 hours, ED MD 1 ordered acetaminophen 1000 mg IV. The acetaminophen was administered to the patient at 2341 hours, with the infusion rate of 400 mg/hr, and completed at 2356 hours. * On 8/4/25 at 0241 hours, ED MD 2 ordered dexamethasone (a steroid) 10 mg IV. At 0242 hours, the “ ED Disposition set to Home” was ordered. * On 8/4/25 at 0312 hours, RN 4 administered dexamethasone 10 mg IV to the patient. * On 8/4/25 at 0433 hours, the patient was discharged. There was no documented evidence to show Patient 1’s pain was reassessed until the patient was discharged from the ED on 8/4/25 at 0433 hours (or for 7 hours and 21 minutes) Review of the ED Provider Notes dated 8/3/25 at 2245 hours, showed the following: * The Plan/Medical Decision Making section showed the patient was agreeable to Decadron (dexamethasone) treatment for pain only after imaging was completed; and agreeable to IV APAP (acetaminophen) now for pain treatment. The patient presentation was discussed with the neurology consult. * The Clinical Impression section showed a tingling sensation. * The Disposition section showed pending imaging. Review of the Sign-Out Note dated 8/4/25 at 0242 hours, showed ED MD 2’s note showing Patient 1 was informed of the MRI results and advised to follow up with the patient’s neurologist and neurosurgeons. During a concurrent interview and record review on 9/4/25 at 1323 hours, with the ED Nurse Manager, the ED Nurse Manager verified the above findings. b. During a review of Patient 8’s closed medical records on 9/8/25, Patient 8’s closed medical record showed Patient 8 arrived in the ED triage on 8/17/25 at 1732 hours, with a chief complaint of left side pain, left leg pain, unable to stand or put weight on the left leg for two days. Patient 8 also complained of “decreased urine output.” The patient’s ESI level was 3. Review of the Patient Care Timeline showed on 8/17/25 at 1815 hours, acetaminophen 1000 mg IV was ordered for the patient. The acetaminophen was administered to the patient at 1831 hours and the infusion completed at 1846 hours. Review of the physician’s order dated 8/17/25 at 1839 hours, showed to administer morphine (narcotic pain medication) 4 mg IV every 30 minutes as needed for pain, hold for RR less than or equal to 12 breaths per minute, O2 saturation less than 93%, or excessive sedation. Review of the Patient Care Timeline showed morphine 4 mg IV was given to the patient on 8/17/25 at 1848 and 2115 hours. Review of Patient 8’s Pain Management showed on 8/17/25 at 1733 hours, Patient 8’s pain level was 9 out of 10, and the patient’s acceptable pain level was 4 out of 10. There was no documentation of the pain reassessment after administering the acetaminophen and morphine to the patient. Review of Patient 8’s vital signs did not show the nursing staff assessed Patient 8’s RR when morphine 4 mg IV was administered to the patient on 8/17/25 at 2115 hours. During a concurrent interview and record review on 9/8/25 at 1405 hours, with the Quality Consultant, the above findings were verified. c. During a concurrent interview and record review on 9/3/25 at 1515 hours, with the Director of MCH, Charge RN, L&D PP Educator, and L&D Nurse Manager, the medical record for Patient 20 was reviewed and showed Patient 20 came to the hospital on 9/3/25. Review of the Multi-Discipline Progress Note dated 9/3/25 at 0927 hours, showed Patient 20 was at “31w1d .... here s/p MVA ... this morning.” The patient reported soreness in the lower abdomen. The patient complained of headache and pain in both the upper and lower back. During a review of the Flowsheet dated 9/3/25, the Flowsheet showed the following: * At 0921 hours, Patient 20 reported back pain with the pain level of 7 out of 10. Patient 20’s acceptable pain level was 2 out of 10. The pain was described as continuous, sharp and aching. * At 0922 hours, Patient 20 reported the headache with the pain level of 4 out of 10. Patient 20’s acceptable pain level was 2 out of 10. The pain was described as continuous and throbbing. Review of the MAR showed an order to administer acetaminophen 1000 mg, orally, one time to the patient. The acetaminophen was given to the patient on 9/3/25 at 0945 hours. Review of the Multi-Discipline Progress Note dated 9/3/25 at 1014 hours, showed the physician was notified that the patient “only wanted 500mg of tylenol (acetaminophen), refused the additional 500mg. 500mg tylenol po given to patient.” Review of the Flowsheet dated 9/3/25, showed the following: * At 1055 hours, the patient’s back pain was reassessed. The patient’s pain level was 7 out of 10. The pain was described as continuous and throbbing. * At 1143 hours, the patient’s headache was reassessed. The patient’s pain level was 2 out of 10. * At 1144 hours, the patient had back pain with the pain level of 7 out of 10. The pain was described as continuous, throbbing, and sharp. The alleviating factors for the patient’s back pain were medication and warm application. * At 1157 and 1203 hours, the patient had back pain with the pain level of 7 out of 10. The pain was described as continuous, throbbing, and aching. Review of the Multi-Discipline Progress Note dated 9/3/25 at 1205 hours, showed the RN documented Patient 20 was discharged in stable condition with preterm labor (PTL) and fetal kick count (FKC) precautions. The patient was educated on taking Tylenol for pain and using heat/cold applications for the back as per MD instructions. During a review of the Progress Note signed by the physician on 9/3/25 at 1211 hours, the Progress Note showed Patient 20 was observed in the triage and treated with Tylenol for a headache, which improved. The Plan section showed no additional treatment was needed, and the patient was discharged. During a review of Patient 20’s After Visit Summary, the After Visit Summary did not show documented evidence of the physician’s instructions for taking Tylenol and using cold/heat applications after discharge. During a concurrent interview and record review on 9/3/25 at 1515 hours, with the L&D Nurse Manager, the L&D Nurse Manager stated the record showed Patient 20 received only half of the prescribed dose of Tylenol because the patient was concerning about the safety of Tylenol to the unborn baby. The L&D Nurse Manager was unable to locate documentation the RN notified the physician regarding Patient 20’s back pain with the pain level of 7 out of 10. Additionally, there was no documentation from the physician regarding taking Tylenol and applying heat/cold therapy after discharge. 2. Review of Patient 6’s closed medical record was initiated on 9/4/25. Patient 6’s medical record showed the patient was admitted to the ED on 8/28/25 at 0000 hours and discharged on 8/28/25 at 0235 hours. Review of the Patient Care Timeline showed on 8/28/25 at 0044 hours, the physician ordered to administer sodium chloride 0.9% (salt water) IV bolus. Review of the MAR showed sodium chloride 0.9% IV bolus with the ordered dose of 10 ml/kg/dose, ordered infusion rate of 128 ml/hr, and infused over 60 minutes, was started on 8/28/25 at 0115 hours and ended on 8/28/25 at 0147 hours (or 128 ml sodium chloride infusion was completed in 32 minutes). On 9/4/25 at 1525 hours, the findings were verified by the Quality Consultant and Nurse Manager ED.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 35310 Based on interview and record review, the hospital failed to ensure the nursing staff followed the physician’s order and the hospital’s P&P for a blood transfusion for one of four sampled patients (Patient 4). The physician ordered Patient 4’s blood transfusion to be completed over four hours, but it was completed over two hours. The failure had the potential for complications, including transfusion reactions. Findings: Review of the hospital’s P&P titled Blood Administration and Transfusion dated 11/16/22, showed the transfusion duration ordered by the ordering practitioner is used as a guideline; the actual transfusion duration may vary within 30 minutes. On 7/14/25, Patient 4’s medical record was reviewed. Patient 4’s medical record showed Patient 4 was admitted to the hospital on 7/12/25. Review of the physician’s order dated 7/13/25 at 1042 hours, showed an order to transfuse Red Blood Cells (PRBC) over four hours. Review of the Transfusion Report dated 7/13/25, showed the blood transfusion was initiated at 1216 hours, and ended at 1428 hours. On 7/14/25 at 1342 hours, Nurse Manager 1 verified the above findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 22553 Based on interview and record review, the hospital failed to ensure the nursing staff checked the blood glucose levels after administering the medications for one of three sampled patients (Patient 1). This failure created the risk of poor health outcomes to the patient. Findings: On 2/28/25 at 0930 hours, Patient 1’s closed medical record was reviewed with the Director Regulatory Services. Patient 1’s closed medical record showed the patient was admitted to the hospital on 5/26/24. Review of the H&P examination dated 5/26/24, showed Patient 1 had DM and was on insulin (a medication used to treat high blood sugar). Review of the Medication Detail showed the physician’s order for regular insulin (a short-acting insulin) injection 0-16 units before meals and at bedtime starting on 5/26/24. The instructions included the following: * If the blood glucose level was less than 70 mg/dL: - If taking orally and alert, give juice or glucose oral gel or snack/meal. - Repeat blood glucose and above treatment every 15 minutes until the blood glucose was greater than 80 mg/dL. Once the blood glucose was greater than 80 mg/dL, recheck blood glucose in one hours. - Review insulin administrations with the physician, obtain additional orders (including when to recheck glucose and for dose adjustment of any scheduled insulin) as necessary. Do not administer any scheduled insulin doses until after consulting physician. * If the blood glucose level was 201-250 mg/dL, give 8 units regular insulin. * If insulin coverage was given for bedtime blood glucose POCT and recheck blood glucose POCT four hours later. Review of the Glucose POCT Device Integrated Values - Adult/Child, the medication administration record, and the patient’s meal record showed the following: * On 5/26/24 at 0841 hours, the patient’s blood glucose was 57 mg/dL. At 0842 hours, RN 1 administered dextrose 40% oral gel 15 g (Glutose, a medication used to treat low blood sugar) to the patient. However, there was no documented evidence the nursing staff checked the patient’s blood glucose level 15 minutes after administering dextrose 40% oral gel as per the physician’s order after * On 5/26/24 at 0909 hours, the patient’s blood glucose was 69 mg/dL. At 0912 hours, RN 1 administered the dextrose 40% oral gel 15 g (Glutose) to the patient. There was no documented evidence the nursing staff checked the patient’s blood glucose level every 15 minutes after administering dextrose 40% oral gel as per the physician’s order. * On 5/26/24 at 0942 hours, the patient’s blood glucose was 79 mg/dL. The meal record showed the patient consumed 100% breakfast at 1030 hours. There was no documented evidence the nursing staff performed a repeat blood glucose in every 15 minutes per physician’s order. * On 5/26/24 at 1124 hours, the patient’s blood glucose was 100 mg/dL. * On 5/26/24 at 2256 hours, the patient’s bedtime blood glucose was 208 mg/dL, and the patient received eight units of regular insulin subcutaneously. There was no documented evidence the nursing staff checked the patient’s blood glucose level four hours later as per the physician’s order. During the concurrent interview, the Director Regulatory Services confirmed the above findings.”