Cedars-Sinai Medical Center

“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: 36206 Based on interview and record review, the facility failed to provide an appropriate transfer for two of twenty (20) sampled patients (Patients 7 and 19), who presented to the Emergency Department (ED, a specialized hospital facility staff 24 hours a day / 7 days a week to provide immediate, unscheduled care for acute, life-threatening, or severe injuries and illnesses), when: 1. For Patient 7, the facility failed to notify Patient 7 that he (Patient 7) was being transferred to another acute care facility including the reason for the transfer. In addition, the facility failed to complete the required transfer forms titled, “Patient Transfer Acknowledgement,” and the “Physician Authorization for Transfer Progress Note,” in accordance with the facility’s policies and procedures regarding Emergency Medical Treatment and Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay). This deficient practice had the potential for unsafe and inappropriate transfer of Patient 7 and had the potential to violate Patient 7’s right to participate in decisions regarding care including transferring to another facility. Uninformed transfers can potentially lead to decisions that are not aligned with Patient 7’s goal of care. (Refer to C-2409) 2. For Patient 19, the facility failed to complete the required transfer forms titled, “Physician Authorization for Transfer Progress Notes, and the “Physician Certification for Patient Transfer,” when Patient 19 was transferred to another facility. The forms were not completed in accordance with the facility’s policy and procedures regarding EMTALA transfers. The forms were missing required information, including physician’s names, date, time etc. In addition, the mode of transportation was not documented. This deficient practice of failing to properly complete transfer forms, when Patient 19 was transferred to another facility, had the potential to place Patient 19 at risk of harm including increased mortality, delays in care and diagnosis, medication errors and patient safety concerns. (Refer to C-2409) Findings: 1. During a review of Patient 7’s “ED Triage Note,” dated 1/3/2026 at 9:59 a.m., the ED Triage note indicated the following: “Patient (Patient 7) from street BIBA (brought in by ambulance) due to agitation and overdose (taking an excessive and dangerous amount of a drug) unknown amount. Patient (Patient 7) was banging on cars and running on the street. LAPD (Los Angeles Police Department) was already on scene and spit hood (or spit guard, is a mesh or fabric bag placed over a person’s head to prevent them from biting or spitting others) was already placed. Hx (history): Overdose.” During a review of Patient 7’s “ED Provider Notes,” dated 1/3/2026 at 10:24 a.m., the ED Provider Note indicated the following: Patient 7 presented with suicidal (deeply unhappy or depressed and likely to kill oneself intentionally) ideation. “Patient (Patient 7) was brought into [the facility] from the street secondary to agitation. Patient is on some unknown medication. Patient (Patient 7) was jumping on cars. Patient comes in on a hold (5150 hold, a legal procedure allowing for involuntary 72-hour psychiatric [relating to mental illness] hospitalization of an individual deemed a danger to themselves, others, or gravely disabled). Patient received Versed (a potent, short-acting medication used for sedation and anxiety reduction) in the field.” During a review of Patient 7’s “ED Provider Notes,” dated 1/3/2026 at 10:24 a.m., the ED Provider Notes indicated the following: “Patient (Patient 7) was spitting on people and had a spit bag.” The ED Provider Notes further indicated: “Neurological Comments: Patient (Patient 7) is sedated (calm, relaxed, or sleepy state) but responsive to pain. Laboratory, Urine, reviewed: Cocaine (a powerful addictive stimulant drug) screen: Positive, Amphetamine (a medication that stimulates the central nervous system) screen: Positive, Benzodiazepine (central nervous system depressants): Positive, Cannabinoid (a type of chemical found in marijuana or weed) screen: Positive. Medical Decision Making: Summary/Discussion/ED Course: Patient (Patient 7) comes in altered, [on] hold. Patient received Versed (a sedative) in the field ...Patient (Patient 7) on numerous drugs. Patient (Patient 7) is medically cleared. Diagnoses: Psychosis (a mental health condition characterized by a loss of contact with reality, where an individual experiences hallucinations [seeing/hearing things not there] or delusions [false, fixed beliefs]), aggressive behavior, polysubstance abuse (use of two or more drugs or substances to get high).” The ED Progress Note also indicated: Disposition: “Transferred to Other Psych (Psychiatric facility) [on] 5150.” During a review of Patient 7’s document titled, “Patient Transfer Acknowledgement (Form 3392-A),” dated 1/5/2026, the document indicated the following: “I understand that I have the right to receive a medical screening examination, and evaluation by a physician, other appropriate personnel, without regard to my ability to pay, prior to any transfer from this hospital and that I have a right to be informed of the reasons for any transfer. I acknowledge that I have received a medical screening examination and evaluation by a physician, or other appropriate personnel, and that I am being transferred for the following reasons: -Box Checked for “Specialized care not available at CSMC.” (Complete “Physician Authorization for Transfer Progress Note” Form 3392-B and “Physician Certification for Patient Transfer” Form 3392) Section titled, “Signature of patient or legal representative,” indicated “Involuntary Hold.” However, the form was not signed by Patient 7 nor a legal representative. There was no reason documented as to why Patient 7 did not sign the form. During a review of Patient 7’s note titled, “Physician Authorization For Transfer Progress Note (Form 3392-B),” dated 1/5/2026, the Physician Authorization For Transfer Progress Note indicated the following: Section 1 (Check one of the following), Box A or Box B. -Box A (not checked) indicated “The patient’s emergency medical condition has been stabilized such that within reasonable medical probability, no material deterioration in the condition of the patient is likely to result from or occurring during transfer.” -Box B (not checked) indicated “The patient’s emergency medical condition has not been stabilized.” Section 3 (Check below as appropriate). Note: The patient may not be transferred unless each of the following requirements are met.) -Box A (not checked) - indicated the hospital has provided medical treatment within its capacity that minimized the risks to the patient’s health ... -Box B (not checked) - indicated the receiving facility’s name (Hospital B). -Box C (not checked) - indicated the receiving facility has agreed to accept transfer and to provide appropriate medical treatment. Name of person accepting transfer: position and title: MD, Date accepted: 1/5/2026. Time accepted 8:29 a.m. -Box D (not checked) - indicated the name of the accepting physician. -Box E (not checked) - indicated the receiving facility will be provided with appropriate copies of medical records related to the emergency condition of the patient. -Box F (not checked) indicated the patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support. Section 5 (Completed by transferring physician), dated 1/5/2026 at 10 a.m., indicated “Updated status of patient’s condition: unchanged, stable,” and was signed by the physician (MD 2). Section 7 (Transfer Checklist): indicated copies provided: Medical records: Yes. Notification of significant others: N/A (not applicable). During a review of Patient 7’s form titled, “Physician Certification for Patient Transfer (Form 3392),” dated 1/5/2026, the Physician Certification for Patient Transfer Form indicated the following: Reason for transfer, including summary of risk and benefits: Further evaluate and management of acute psychosis. During a concurrent interview and record review on 3/18/2026 at 3:10 p.m. with the Assistant Nurse Manager (ANM 1), ANM 1, Patient 7’s medical record, was reviewed. ANM 1 stated the following regarding Patient 7: Patient 7 was brought in by ambulance for agitation and overdose and was on a 5150 hold for danger to self on 1/3/2026. Patient 7 was diagnosed with psychosis. Patient 7 was transferred to another hospital on 1/5/2026, because the hospital did not have an inpatient psychiatric unit. Patient 7 did not sign the “Patient Transfer Acknowledgement” form, which indicated that the patient (Patient 7) was informed of the reason for transferring to another acute care hospital. ANM 1 stated that the form should have been signed by the patient, regardless of Patient 7 being on a 5150 Hold, and unable to consent to the transfer. ANM 1 stated Patient 7 had the right to be informed of where he (Patient 7) would be transferred to and the reason for the transfer. ANM 1 stated if Patient 7 was unable to sign the form, the reason for the lack of Patient 7’s signature should have been documented. ANM 1 verified that the “Physician Authorization for Transfer Progress Note,” was not completed in its entirety. Section 1 did not indicate whether Patient 7’s emergency medical condition was stable (Box A) or unstable (Box B). Section 3’s requirements for transfer Boxes A, B, C, D, E, and F were not checked off, as indicated on the form. The Boxes A - F to be checked off should have included information that Patient 7 was provided treatment within the hospital’s capacity, the receiving facility had space available and qualified personnel to treat the patient, the receiving facility agreed to the transfer, name of the accepting physician, the receiving facility would be provided copies of the medical records and the patient would be transferred by qualified personnel. During a concurrent interview and record review on 3/19/2026 at 12:16 p.m. with the Assistant Nurse Manager (ANM 2), Patient 7’s “Physician Authorization For Transfer Progress Note,” dated 1/5/2026, was reviewed. ANM 2 verified the form was not completely filled out, per the facility’s policy and procedure. ANM 2 said that Section 1 should have been checked off, per Patient 7’s condition, whether stable or unstable. In addition, in Section 3, none of the boxes A through F were checked off, as indicated on the form and per the facility’s policy and procedure regarding transfers. ANM 2 stated that all transfer forms needed to be completely filled out regardless of the type of patient being transferred. In addition, ANM 2 verified that Patient 7’s “Patient Transfer Acknowledgement,” form was not signed by Patient 7, nor did it indicate the reason for lack of Patient 7’s signature. ANM 2 stated the reason why Patient 7 did not sign should be documented. ANM 2 stated it was unknown as to whether or not Patient 7 was given the opportunity to sign and acknowledge the transfer. ANM 2 also verified that there was no other documentation in the medical record indicating that Patient 7’s responsible party was notified of the transfer. During a concurrent interview and record review on 3/19/2026 at 2:17 p.m. with the Director of Office Licensing, Accreditation and Regulatory (DOLAR), the DOLAR reviewed Patient 7’s transfer documentation and verified that the forms were incomplete. The DOLAR said that patients should sign the reviewed forms to indicate acknowledgement that they (the patients) have been notified of the reason for being transferred. If the forms were not signed, the reason why the forms were not signed should be documented. All transfer forms should be completed in accordance with the facility’s policy and procedures to ensure safe and appropriate transfer of patients. During a review of the facility’s policy and procedure (P&P) titled, “Transfers from [name of Transferring facility] to other Healthcare Facilities: Transfer Center Policy: Clinical Administrative,” dated 10/1/2025, the P&P indicated the following: [name of transferring facility] will comply with all State and Federal laws regarding patient transfers including the Emergency Medical Treatment & Labor Act (EMTALA). “Prior to any transfer, the physician shall complete the: -Patient Transfer Acknowledgement Form (Form No. 3392-A) -Physician Authorization for Transfer Progress Note (Form No. 3392-B) Transfers to Other Healthcare Facilities from CSMC: The following procedures will be done by the Transfer Center for psychiatric patients and patients with emergency medical conditions (higher level of care transfers), or by the Emergency Department Administrator for patients who do not have an emergency medical condition (lateral transfers) ...Collect appropriate information (by the Transfer RN) regarding the request to transfer to another acute care facility including: 8. Patient / family informed and consented to the transfer.” 2. During a review of Patient 19’s “Patient Care Timeline,” dated 12/25/2025, the Patient Care Timeline indicated the following: -At 4:19 a.m. “Pt BIB (brought in by) law enforcement who are currently writing a 5150 hold ( 5150 is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare] which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72 hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) DTS (danger to self). -At 4:23 a.m. “Report per law enforcement, wife called as she found pt (Patient 19) with a belt around his neck ...” -At 5:08 a.m. assigned physician (MD 6) was assigned as attending. -At 6:45 a.m. “Psych MD at bedside” -At 7:00 a.m. “Psych transfer request order placed - Transfer to other facility” -At 1:21 p.m. “Patient discharged” During a review of Patient 19’s “Psych (Psychiatric) Consult (a formal assessment conducted by a psychiatrist in health care setting to evaluate a person’s mental and behavioral health),” dated 12/25/2025, the psych consult indicated Patient 19 presented to the ED on 12/25/2025, brought in by LAPD (Los Angeles Police Department) on 5150 DTS after suicide attempt with a belt. Patient 19’s psych consult further indicated, “He (Patient 19) does meet 5150 DTS criteria and requires psychiatric hospitalization for stabilization.” During a review of Patient 19’s note titled, “Physician Authorization For Transfer Progress Note,” undated, the Physician Authorization For Transfer Progress note indicated the following sections: -Section 1 “(Check one of the following)” A. (Not checked). “The patient’s emergency medical condition has been stabilized such that within reasonable medical probability, no material deterioration in the condition of the patient is likely to result from or occur during transfer (With regard to a woman in labor, the patient has already delivered, including the placenta.)” B. (Not checked). “The patient’s emergency medical condition has been stabilized.” -Section 2 “(Check on the following only if Section 1 (B) above has been checked. If 1 (B) has not been checked, proceed to Section 3.)” A. Not checked. “The patient requests transfer, (Complete “Patient Requests for Transfer or Discharge “Form 3392-C) B. Not checked. “A legally-responsible person acting on the patient’s behalf requests transfer ...” C. Not checked. “Based on the reasonable risks and benefits to the patient, and based upon the information available at the time of the patient’s examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk ...” -Section 3 “Check below as appropriate. Note. The patient may not be transferred unless each of the following requirements are met.) A. (Not checked). “[facility name] has provided medical treatment within its capacity that minimizes the risks to the patient’s health, and for patients in labor, to the health of the unborn child.” B. (Not checked). “The receiving facility has available space and qualified personnel, for the treatment of the patient ...” C. (Not checked). “The receiving facility has agreed to accept transfer and to provide appropriate medical treatment.” D. (Not checked). “Name of accepting physician ...” E. (Not checked). “The receiving facility will be provided with appropriate copies of medical records related to the emergency condition of the patient. F. (Not checked). “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures ...” -Section 4 “(If transfer is refused, check (A) or (B) below): A. Not checked. “The patient was offered transfer, but refused ...” B. Not checked. “Transfer was offered, but refused by a legally responsible person acting on the patient’s behalf ...” -Section 5 “(Complete by transferring physician) -“Time” (was blank) Updated status of patient’s condition: Stable ... I Certify that I have answered the above questions, based upon the information available to me at the time of the patient’s examination.” Name of the physician authorizing transfer (please print) was blank, signature of physician (was blank, not signed by the physician), ID# (blank), and date signed (blank),” The Note was missing the date, the time, the name of the physician, the physician’s signature, and the physician’s identification number (ID). -Section 6 “(Mode of transport: report of patient’s status during transport attached)” Not checked. “Paramedic Unit (Advanced Life Support)” Not checked. “Emergency Medical Technician (Basic Life Support)” Not checked. “Critical Care Transport (personnel, i.e. physician, RN, and/or respiratory therapist)” Not checked. “Pediatric Advance Life Support” Not checked. “Air Transport” Not checked, “Police car” Not checked, “Other” The mode of transportation was not documented. During a review of Patient 19’s “Physician Certification For Patient Transfer,” undated, the Physician certification for patient transfer indicated, “I (Name of Physician, was blank), the undersigned physician, have examined and evaluated Patient 19. Based on this examination, the information available to me at this time, and the reasonable risks and benefits to the patient ...Reason for transfer, including summary of risk and benefits: 5150. Updated Status of Patient’s Condition: Stable ...Name of Physician (Please Print) was blank ...ID# (blank) ...Date Signed (blank),” The form did not indicate the physician’s name, ID number, or the date signed. During an interview on 3/17/2026 at 10:56 a.m. with the Medical Director of Emergency Department (MD 1), MD 1 stated the following: Patients who needed to be admitted for psychiatric treatment were transferred to another facility because the facility did not offer psychiatric treatment. Transfer arrangements included: the psych team would communicate with transfer center, to identify a facility with a bed available for the patients. Physicians conducted hand off report to the receiving physician. Transportation would be arranged for the patient. The type of transportation, whether BLS (Basic Life Support) or ACLS (Advanced Cardiac Life Support), was based on the medical needs and the condition of the patient. Furthermore, MD 1 stated there were four pages (of notes) that needed to be completed by the physician prior to the transfer of a patient. During a concurrent interview and record review on 3/19/2026 at 11:17 a.m. with Assistant Nurse Manager (ANM) 2, Patient 19’s, “Physician Authorization for Transfer Progress Note and the Physician Certification for Patient Transfer,” undated forms, were reviewed. ANM 2 verified that Patient 19’s, “Physician Certification for Patient Transfer,” indicated that the name of the physician, was not written. ANM 2 verified there was a physician’s signature, however, the identity of the signer could not be determined. In addition, ANM 2 verified Patient 19’s, “Physician Authorization For Transfer Progress Note,” indicated that the name of the physician, signature of physician, ID#, and date signed, were not documented on the note. During a concurrent interview and record review on 3/19/2026 at 12:37 p.m. with ANM 2, Patient 19’s “Physician Authorization For Transfer Progress Note,” undated, was reviewed. ANM2 verified that in section 6, none of the modes of transport were checked or documented on the note. The mode of transportation options included, Paramedic unit (Advanced Life Support or ALS [ambulance that is staffed and equipped to provide advanced medical intervention]), emergency medical technician (Basic Life Support or BLS [ambulance that transports patient who do not require invasive care), Critical care transport (specialized ambulance services for critically ill or injured patients) personnel (i.e. physician, registered nurse, and / or respiratory therapist), Air transport, Police car, and other options. During a concurrent interview and record review on 3/19/2026 at 3:18 p.m. with MD 1, Patient 19’s, “Physician Authorization For Transfer Progress Note and Physician Certification For Patient Transfer,” undated forms, were reviewed: -For Patient 19’s “Physician Authorization For Transfer,” [undated form], MD 1 verified that the form was incomplete, name of the physician authorizing the transfer was unfilled, signature of physician was unfilled, ID# was unfilled and date signed was unfilled. MD 1 stated the form should be completed with physician’s name, physician’s signature, ID #, and most specially the time on top of section 5. MD 1 stated the form should be completed as part of the facility’s standard practice. MD 1 verified that in section 6, the mode of transportation, was not checked. MD 1 stated the physician could add a comment, and usually the last physician to see the patient would complete the form and document how the patient would be transported. -For Patient 19’s “Physician Certification For Patient Transfer,” [undated form], MD 1 verified the form was incomplete. The name of physician was unfilled, the ID# was unfilled, and date signed was unfilled. During a review of the facility’s policy and procedures (P&P) titled, “Transfer from [facility name] to other Healthcare Facilities: Transfer Center Policy: Clinical Administrative,” effective date 10/1/2025, the P&P indicated, “Prior to any transfer, the physician shall complete the: ...Physician Authorization for Transfer Progress Note ...Where it has been determined that a patient has an emergency medical condition, [facility name] shall: With certification. The patient may be transferred if the on-duty Emergency Department physician has documented that the medical benefits expected from transfer outweigh the risks ...The following procedures will be done by the Transfer Center for psychiatric patients ...Collect appropriate information (by Transfer Center RN) regarding the request to transfer to another acute facility including: ...Mode of transportation as determined by [facility name] MD ...Assemble and assure that the following completed document are sent with the patient to the receiving facility (by Unit RN/NCT) ...’Physician Authorization for Transfer Progress Note’ form (form No. 3392-B) ...2. With Certification .... Complete and check the appropriate boxes must be checked on the: ...Physician Authorization for Transfer Progress notes ...The transfer must be made through the qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.””

“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: 36206 Based on interview and record review, the facility failed to provide an appropriate transfer for two of twenty (20) sampled patients (Patients 7 and 19), who presented to the Emergency Department (ED, a specialized hospital facility staff 24 hours a day / 7 days a week to provide immediate, unscheduled care for acute, life-threatening, or severe injuries and illnesses), when: 1. For Patient 7, the facility failed to notify Patient 7 that he (Patient 7) was being transferred to another acute care facility including the reason for the transfer. In addition, the facility failed to complete the required transfer forms titled, “Patient Transfer Acknowledgement,” and the “Physician Authorization for Transfer Progress Note,” in accordance with the facility’s policies and procedures regarding Emergency Medical Treatment and Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be treated and stabilized, regardless of their insurance status or ability to pay). This deficient practice had the potential for unsafe and inappropriate transfer of Patient 7 and had the potential to violate Patient 7’s right to participate in decisions regarding care including transferring to another facility. Uninformed transfers can potentially lead to decisions that are not aligned with Patient 7’s goal of care. 2. For Patient 19, the facility failed to complete the required transfer forms titled, “Physician Authorization for Transfer Progress Notes, and the “Physician Certification for Patient Transfer,” when Patient 19 was transferred to another facility. The forms were not completed in accordance with the facility’s policy and procedures regarding EMTALA transfers. The forms were missing required information, including physician’s names, date, time etc. In addition, the mode of transportation was not documented. This deficient practice of failing to properly complete transfer forms, when Patient 19 was transferred to another facility, had the potential to place Patient 19 at risk of harm including increased mortality, delays in care and diagnosis, medication errors and patient safety concerns. Findings: 1. During a review of Patient 7’s “ED Triage Note,” dated 1/3/2026 at 9:59 a.m., the ED Triage note indicated the following: “Patient (Patient 7) from street BIBA (brought in by ambulance) due to agitation and overdose (taking an excessive and dangerous amount of a drug) unknown amount. Patient (Patient 7) was banging on cars and running on the street. LAPD (Los Angeles Police Department) was already on scene and spit hood (or spit guard, is a mesh or fabric bag placed over a person’s head to prevent them from biting or spitting others) was already placed. Hx (history): Overdose.” During a review of Patient 7’s “ED Provider Notes,” dated 1/3/2026 at 10:24 a.m., the ED Provider Note indicated the following: Patient 7 presented with suicidal (deeply unhappy or depressed and likely to kill oneself intentionally) ideation. “Patient (Patient 7) was brought into [the facility] [from] the street secondary to agitation. Patient is on some unknown medication. Patient (Patient 7) was jumping on cars. Patient comes in on a hold (5150 hold, a legal procedure allowing for involuntary 72-hour psychiatric [relating to mental illness] hospitalization of an individual deemed a danger to themselves, others, or gravely disabled). Patient received Versed (a potent, short-acting medication used for sedation and anxiety reduction) in the field.” During a review of Patient 7’s “ED Provider Notes,” dated 1/3/2026 at 10:24 a.m., the ED Provider Notes indicated the following: “Patient (Patient 7) was spitting on people and had a spit bag.” The ED Provider Notes further indicated: “Neurological Comments: Patient (Patient 7) is sedated (calm, relaxed, or sleepy state) but responsive to pain. Laboratory, Urine, reviewed: Cocaine (a powerful addictive stimulant drug) screen: Positive, Amphetamine (a medication that stimulates the central nervous system) screen: Positive, Benzodiazepine (central nervous system depressants): Positive, Cannabinoid (a type of chemical found in marijuana or weed) screen: Positive. Medical Decision Making: Summary/Discussion/ED Course: Patient (Patient 7) comes in altered, [on] hold. Patient received Versed (a sedative) in the field ...Patient (Patient 7) on numerous drugs. Patient (Patient 7) is medically cleared. Diagnoses: Psychosis (a mental health condition characterized by a loss of contact with reality, where an individual experiences hallucinations [seeing/hearing things not there] or delusions [false, fixed beliefs]), aggressive behavior, polysubstance abuse (use of two or more drugs or substances to get high).” The ED Progress Note also indicated: Disposition: “Transferred to Other Psych (Psychiatric facility) [on] 5150.” During a review of Patient 7’s document titled, “Patient Transfer Acknowledgement (Form 3392-A),” dated 1/5/2026, the document indicated the following: “I understand that I have the right to receive a medical screening examination, and evaluation by a physician, other appropriate personnel, without regard to my ability to pay, prior to any transfer from this hospital and that I have a right to be informed of the reasons for any transfer. I acknowledge that I have received a medical screening examination and evaluation by a physician, or other appropriate personnel, and that I am being transferred for the following reasons: -Box Checked for “Specialized care not available at CSMC.” (Complete “Physician Authorization for Transfer Progress Note” Form 3392-B and “Physician Certification for Patient Transfer” Form 3392) Section titled, “Signature of patient or legal representative,” indicated “Involuntary Hold.” However, the form was not signed by Patient 7 nor a legal representative. There was no reason documented as to why Patient 7 did not sign the form. During a review of Patient 7’s note titled, “Physician Authorization For Transfer Progress Note (Form 3392-B),” dated 1/5/2026, the Physician Authorization For Transfer Progress Note indicated the following: Section 1 (Check one of the following), Box A or Box B. -Box A (not checked) indicated “The patient’s emergency medical condition has been stabilized such that within reasonable medical probability, no material deterioration in the condition of the patient is likely to result from or occurring during transfer.” -Box B (not checked) indicated “The patient’s emergency medical condition has not been stabilized.” Section 3 (Check below as appropriate). Note: The patient may not be transferred unless each of the following requirements are met.) -Box A (not checked) - indicated the hospital has provided medical treatment within its capacity that minimized the risks to the patient’s health ... -Box B (not checked) - indicated the receiving facility’s name (Hospital B). -Box C (not checked) - indicated the receiving facility has agreed to accept transfer and to provide appropriate medical treatment. Name of person accepting transfer: position and title: MD, Date accepted: 1/5/2026. Time accepted 8:29 a.m. -Box D (not checked) - indicated the name of the accepting physician. -Box E (not checked) - indicated the receiving facility will be provided with appropriate copies of medical records related to the emergency condition of the patient. -Box F (not checked) indicated the patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support. Section 5 (Completed by transferring physician), dated 1/5/2026 at 10 a.m., indicated “Updated status of patient’s condition: unchanged, stable,” and was signed by the physician (MD 2). Section 7 (Transfer Checklist): indicated copies provided: Medical records: Yes. Notification of significant others: N/A (not applicable). During a review of Patient 7’s form titled, “Physician Certification for Patient Transfer (Form 3392),” dated 1/5/2026, the Physician Certification for Patient Transfer Form indicated the following: Reason for transfer, including summary of risk and benefits: Further evaluate and management of acute psychosis. During a concurrent interview and record review on 3/18/2026 at 3:10 p.m. with the Assistant Nurse Manager (ANM 1), Patient 7’s medical record, was reviewed. ANM 1 stated the following regarding Patient 7: Patient 7 was brought in by ambulance for agitation and overdose and was on a 5150 hold for danger to self on 1/3/2026. Patient 7 was diagnosed with psychosis. Patient 7 was transferred to another hospital on 1/5/2026, because the hospital did not have an inpatient psychiatric unit. Patient 7 did not sign the “Patient Transfer Acknowledgement” form, which indicated that the patient (Patient 7) was informed of the reason for transferring to another acute care hospital. ANM 1 stated that the form should have been signed by the patient, regardless of Patient 7 being on a 5150 Hold, and unable to consent to the transfer. ANM 1 stated Patient 7 had the right to be informed of where he (Patient 7) would be transferred to and the reason for the transfer. ANM 1 stated if Patient 7 was unable to sign the form, the reason for the lack of Patient 7’s signature should have been documented. ANM 1 verified that the “Physician Authorization for Transfer Progress Note,” was not completed in its entirety. Section 1 did not indicate whether Patient 7’s emergency medical condition was stable (Box A) or unstable (Box B). Section 3’s requirements for transfer Boxes A, B, C, D, E, and F were not checked off, as indicated on the form. The Boxes A - F to be checked off should have included information that Patient 7 was provided treatment within the hospital’s capacity, the receiving facility had space available and qualified personnel to treat the patient, the receiving facility agreed to the transfer, name of the accepting physician, the receiving facility would be provided copies of the medical records and the patient would be transferred by qualified personnel. During a concurrent interview and record review on 3/19/2026 at 12:16 p.m. with the Assistant Nurse Manager (ANM 2), Patient 7’s “Physician Authorization For Transfer Progress Note,” dated 1/5/2026, was reviewed. ANM 2 verified the form was not completely filled out, per the facility’s policy and procedure. ANM 2 said that Section 1 should have been checked off, per Patient 7’s condition, whether stable or unstable. In addition, in Section 3, none of the boxes A through F were checked off, as indicated on the form and per the facility’s policy and procedure regarding transfers. ANM 2 stated that all transfer forms needed to be completely filled out regardless of the type of patient being transferred. In addition, ANM 2 verified that Patient 7’s “Patient Transfer Acknowledgement,” form was not signed by Patient 7, nor did it indicate the reason for lack of Patient 7’s signature. ANM 2 stated the reason why Patient 7 did not sign should be documented. ANM 2 stated it was unknown as to whether or not Patient 7 was given the opportunity to sign and acknowledge the transfer. ANM 2 also verified that there was no other documentation in the medical record indicating that Patient 7’s responsible party was notified of the transfer. During a concurrent interview and record review on 3/19/2026 at 2:17 p.m. with the Director of Office Licensing, Accreditation and Regulatory (DOLAR), the DOLAR reviewed Patient 7’s transfer documentation and verified that the forms were incomplete. The DOLAR said that patients should sign the reviewed forms to indicate acknowledgement that they (the patients) have been notified of the reason for being transferred. If the forms were not signed, the reason why the forms were not signed should be documented. All transfer forms should be completed in accordance with the facility’s policy and procedures to ensure safe and appropriate transfer of patients. During a review of the facility’s policy and procedure (P&P) titled, “Transfers from [name of Transferring facility] to other Healthcare Facilities: Transfer Center Policy: Clinical Administrative,” dated 10/1/2025, the P&P indicated the following: [name of transferring facility] will comply with all State and Federal laws regarding patient transfers including the Emergency Medical Treatment & Labor Act (EMTALA). “Prior to any transfer, the physician shall complete the: -Patient Transfer Acknowledgement Form (Form No. 3392-A) -Physician Authorization for Transfer Progress Note (Form No. 3392-B) Transfers to Other Healthcare Facilities from CSMC: The following procedures will be done by the Transfer Center for psychiatric patients and patients with emergency medical conditions (higher level of care transfers), or by the Emergency Department Administrator for patients who do not have an emergency medical condition (lateral transfers) ...Collect appropriate information (by the Transfer RN) regarding the request to transfer to another acute care facility including: 8. Patient / family informed and consented to the transfer.” 2. During a review of Patient 19’s “Patient Care Timeline,” dated 12/25/2025, the Patient Care Timeline indicated the following: -At 4:19 a.m. “Pt BIB (brought in by) law enforcement who are currently writing a 5150 hold ( 5150 is the number of the section of the Welfare and Institutions Code [establishes programs and public social services for promoting the public welfare] which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72 hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) DTS (danger to self). -At 4:23 a.m. “Report per law enforcement, wife called as she found pt (Patient 19) with a belt around his neck ...” -At 5:08 a.m. assigned physician (MD 6) was assigned as attending. -At 6:45 a.m. “Psych MD at bedside” -At 7:00 a.m. “Psych transfer request order placed - Transfer to other facility” -At 1:21 p.m. “Patient discharged” During a review of Patient 19’s “Psych (Psychiatric) Consult (a formal assessment conducted by a psychiatrist in health care setting to evaluate a person’s mental and behavioral health),” dated 12/25/2025, the psych consult indicated Patient 19 presented to the ED on 12/25/2025, brought in by LAPD (Los Angeles Police Department) on 5150 DTS after suicide attempt with a belt. Patient 19’s psych consult further indicated, “He (Patient 19) does meet 5150 DTS criteria and requires psychiatric hospitalization for stabilization.” During a review of Patient 19’s note titled, “Physician Authorization For Transfer Progress Note,” undated, the Physician Authorization For Transfer Progress note indicated the following sections: -Section 1 “(Check one of the following)” A. (Not checked). “The patient’s emergency medical condition has been stabilized such that within reasonable medical probability, no material deterioration in the condition of the patient is likely to result from or occur during transfer (With regard to a woman in labor, the patient has already delivered, including the placenta.)” B. (Not checked). “The patient’s emergency medical condition has been stabilized.” -Section 2 “(Check on the following only if Section 1 (B) above has been checked. If 1 (B) has not been checked, proceed to Section 3.)” A. Not checked. “The patient requests transfer, (Complete “Patient Requests for Transfer or Discharge “Form 3392-C) B. Not checked. “A legally-responsible person acting on the patient’s behalf requests transfer ...” C. Not checked. “Based on the reasonable risks and benefits to the patient, and based upon the information available at the time of the patient’s examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk ...” -Section 3 “Check below as appropriate. Note. The patient may not be transferred unless each of the following requirements are met.) A. (Not checked). “[facility name] has provided medical treatment within its capacity that minimizes the risks to the patient’s health, and for patients in labor, to the health of the unborn child.” B. (Not checked). “The receiving facility has available space and qualified personnel, for the treatment of the patient ...” C. (Not checked). “The receiving facility has agreed to accept transfer and to provide appropriate medical treatment.” D. (Not checked). “Name of accepting physician ...” E. (Not checked). “The receiving facility will be provided with appropriate copies of medical records related to the emergency condition of the patient. F. (Not checked). “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures ...” -Section 4 “(If transfer is refused, check (A) or (B) below): A. Not checked. “The patient was offered transfer, but refused ...” B. Not checked. “Transfer was offered, but refused by a legally responsible person acting on the patient’s behalf ...” -Section 5 “(Complete by transferring physician) -“Time” (was blank) Updated status of patient’s condition: Stable ...I Certify that I have answered the above questions, based upon the information available to me at the time of the patient’s examination.” Name of the physician authorizing transfer (please print) was blank, signature of physician (was blank, not signed by the physician), ID# (blank), and date signed (blank),” The Note was missing the date, the time, the name of the physician, the physician’s signature, and the physician’s identification number (ID). -Section 6 “(Mode of transport: report of patient’s status during transport attached)” Not checked. “Paramedic Unit (Advanced Life Support)” Not checked. “Emergency Medical Technician (Basic Life Support)” Not checked. “Critical Care Transport (personnel, i.e. physician, RN, and/or respiratory therapist)” Not checked. “Pediatric Advance Life Support” Not checked. “Air Transport” Not checked, “Police car” Not checked, “Other” The mode of transportation was not documented. During a review of the Patient 19’s “Physician Certification For Patient Transfer,” undated, the Physician certification for patient transfer indicated, “I (Name of Physician, was blank), the undersigned physician, have examined and evaluated Patient 19. Based on this examination, the information available to me at this time, and the reasonable risks and benefits to the patient ...Reason for transfer, including summary of risk and benefits: 5150. Updated Status of Patient’s Condition: Stable ...Name of Physician (Please Print) was blank ...ID# (blank) ...Date Signed (blank),” The form did not indicate the physician’s name, ID number, or the date signed. During an interview on 3/17/2026 at 10:56 a.m. with the Medical Director of Emergency Department (MD 1), MD 1 stated the following: Patients who need to be admitted for psychiatric treatment are transferred to another facility because the facility does not offer psychiatric treatment. Transfer arrangements included: the psych team would communicate with transfer center, to identify a facility with a bed available for the patients. Physicians conducted hand off report to the receiving physician. Transportation would be arranged for the patient. The type of transportation, whether BLS (Basic Life Support) or ACLS (Advanced Cardiac Life Support), was based on the medical needs and the condition of the patient. Furthermore, MD 1 stated there were four pages (of notes) that needed to be completed by the physician prior to the transfer of a patient. During a concurrent interview and record review on 3/19/2026 at 11:17 a.m. with Assistant Nurse Manager (ANM) 2, Patient 19’s, “Physician Authorization for Transfer Progress Note and the Physician Certification for Patient Transfer,” undated forms, were reviewed. ANM 2 verified that Patient 19’s “Physician Certification for Patient Transfer,” indicated that the name of the physician, was not written. ANM 2 verified there was a physician’s signature, however, the identity of the signer could not be determined. In addition, ANM 2 verified Patient 19’s, “Physician Authorization For Transfer Progress Note,” indicated that the name of the physician, signature of physician, ID#, and date signed, were not documented on the note. During a concurrent interview and record review on 3/19/2026 at 12:37 p.m. with ANM 2, Patient 19’s “Physician Authorization For Transfer Progress Note,” undated, was reviewed. ANM2 verified that in section 6, none of the modes of transport were checked or documented on the note. The mode of transportation options included, Paramedic unit (Advanced Life Support or ALS [ambulance that is staffed and equipped to provide advanced medical intervention]), emergency medical technician (Basic Life Support or BLS [ambulance that transports patient who do not require invasive care), Critical care transport (specialized ambulance services for critically ill or injured patients) personnel (i.e. physician, registered nurse, and / or respiratory therapist), Air transport, Police car, and other options. During a concurrent interview and record review on 3/19/2026 at 3:18 p.m. with MD 1, Patient 19’s, “Physician Authorization For Transfer Progress Note and Physician Certification For Patient Transfer,” undated forms, were reviewed: -For Patient 19’s “Physician Authorization For Transfer,” [undated form], MD 1 verified that the form was incomplete, name of the physician authorizing the transfer was unfilled, signature of physician was unfilled, ID# was unfilled and date signed was unfilled. MD 1 stated the form should be completed with physician’s name, physician’s signature, ID #, and most specially the time on top of section 5. MD 1 stated the form should be completed as part of the facility’s standard practice. MD 1 verified that in section 6, the mode of transportation, was not checked. MD 1 stated the physician could add a comment, and usually the last physician to see the patient would complete the form and document how the patient would be transported. -For Patient 19’s “Physician Certification For Patient Transfer,” [undated form], MD 1 verified the form was incomplete. The name of physician was unfilled, the ID# was unfilled, and date signed was unfilled. During a review of the facility’s policy and procedures (P&P) titled, “Transfer from [facility name] to other Healthcare Facilities: Transfer Center Policy: Clinical Administrative,” effective date 10/1/2025, the P&P indicated, “Prior to any transfer, the physician shall complete the: ...Physician Authorization for Transfer Progress Note ...Where it has been determined that a patient has an emergency medical condition, [facility name] shall: With certification. The patient may be transferred if the on-duty Emergency Department physician has documented that the medical benefits expected from transfer outweigh the risks ...The following procedures will be done by the Transfer Center for psychiatric patients ...Collect appropriate information (by Transfer Center RN) regarding the request to transfer to another acute facility including: ...Mode of transportation as determined by [facility name] MD ...Assemble and assure that the following completed document are sent with the patient to the receiving facility (by Unit RN/NCT) ...’Physician Authorization for Transfer Progress Note’ form (form No. 3392-B) ...2. With Certification .... Complete and check the appropriate boxes must be checked on the: ...Physician Authorization for Transfer Progress notes ...The transfer must be made through the qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure that one (1) of 39 sampled patients (Patient 20) had their grievance (a formal or informal complaint from a patient or their representative to a hospital about issues that require an investigation or further action to resolve) addressed and resolved, in accordance with the facility’s “Patient Complaints and Grievances: Resolution” policy. This deficient practice resulted in Patient 20’s concern regarding unrelieved pain remaining unresolved and not addressed through the facility’s formal grievance process. (Refer to A-0118) 2. The facility failed to ensure one of the 39 sampled patient’s (Patient 7) exercise of patient rights (Patient rights refer to the legal and ethical rules that ensure patients are treated with respect, given clear information, and receive compassionate care) was met, when: 2.a. An assessment for pain was not done every two hours, while Patient 7 was in the Emergency Department (ED, a medical area that provided urgent and emergency care), as required by the facility’s policy on vital signs (Vital signs include basic body functions such as temperature, pulse, breathing rate, and blood pressure). This deficient practice resulted in Patient 7 potentially experiencing prolonged and unrelieved pain, negatively impacting their overall hospital experience and potentially delaying their treatment and recovery process. (Refer to A-0129) 2.b. A pain assessment was not repeated within 30 minutes before Patient 7 was discharged from the facility, in accordance with the facility’s policy regarding Vital Sign standards. This deficient practice had the potential for Patient 7 to experience uncontrolled or severe pain at home which can impede recovery, interfere with daily activities, and emotional distress. (Refer to A-0129) 3. The facility failed to ensure that one (1) of 39 sampled patients (Patient 20) was provided the opportunity to participate in the development and implementation of their pain management plan. The facility did not escalate ongoing, severe pain, rated between 6 and 10 on a 0-10 pain scale (0 being no pain and 10 being the worst pain), experienced by Patient 20 (after 9/5/2025 through 9/20/2025) to the pain management team or to the physician and did not revise the plan of care to address the patient’s persistent pain. This deficient practice resulted in Patient 20 experiencing unrelieved pain throughout the hospital stay. (Refer to A-0130) 4. The facility failed to ensure all patients (individuals receiving care) with serious illness (a health condition that significantly impacts daily function or quality of life) were offered the opportunity to participate in palliative care planning (planning for specialized medical care focused on relief from symptoms and stress of serious illness), and failed to ensure that palliative care eligibility and access were consistent with facility policy, public information, and regulatory requirements for one (1) of 39 sampled patients (Patient 20). The facility restricted palliative care access by not offering palliative care to patients with serious illness and advanced illness (a health condition that significantly impacts daily function or quality of life) who did not have a terminal illness (an illness expected to result in death within a limited period) or cancer (a disease caused by uncontrolled division of abnormal cells), which was not consistent with its own policy and public statements. The facility did not ensure that all patients with serious illness were able to participate in care planning as required. This deficient practice resulted in the potential for patients with serious illness (a health condition that significantly impacts daily function or quality of life), including Patient 20, to be denied their right to participate in the development and implementation of their plan of care (the plan for medical treatment and support), and to be denied access to palliative care (specialized medical care for relief from symptoms and stress of serious illness) that could improve their quality of life. (Refer to A-0130) 5. The facility failed to ensure one of 39 sampled patient’s (Patient 26) designated representatives (RP 1, RP 2 and RP 3), were notified of Patient 26’s deep tissue (maroon and/or purple colored underlying tissue damage that occurs before the skin breaks) pressure injury (PI, localized damage to the skin and/or underlying tissue), in accordance with the facility’s policy regarding Patient rights (Patient rights refer to the legal and ethical rules that ensure patients are treated with respect, given clear information, and receive compassionate care). This deficient practice led to Patient 26’s representatives to not be fully informed of Patient 26’s condition and may potentially hinder Patient 26’s designated representatives from engaging actively in the care process that ensures Patient 26’s well-being. (Refer to A-0131) 6. The facility failed to provide access to medical records for one of 39 sampled patient’s (Patient 18) authorized health-care representative, despite a valid durable power of attorney (DPOA, a legal document that lets the principal appoint someone (the agent) to manage financial, legal, or healthcare decisions if the principal becomes unable to do so) on file and a request for records, in accordance with the facility’s policy regarding protected health information (any health-related data that can identify an individual, including demographics, medical histories, diagnoses, treatments, and payment info, safeguarded under patient privacy law). This deficient practice prevented Patient 18’s authorized healthcare representative from obtaining necessary clinical information, hindering their ability to make informed decisions (a collaborative process where patients, empowered with understandable, evidence-based information, actively participate with their providers to choose treatments or care plans that align with their personal values, goals, and preferences, considering risks, benefits, and alternatives) on behalf of Patient 18 and undermining the patient’s right to access and confidentiality of records. (Refer to A-0148) 7. The facility failed to ensure that nursing staff performed and documented restraint (any physical, chemical, or mechanical method, device, material, or equipment that immobilizes or reduces a patient’s ability to move or access any part of their body) monitoring every two (2) hours for one of 39 sampled patients (Patient 25), as required by the facility’s policy and procedure on restraints, when there was no documented restraints monitoring for seven (7) hours on 10/27/2025 from 3 p.m. to 10 p.m. This deficient practice had the potential to put Patient 25 at risk for skin breakdown (damage to the skin and underlying tissue typically caused by prolonged pressure that restricts blood flow to the area) and other needs including hydration (the process of ensuring a patient has enough fluids in their body by drinking water and consuming foods with high water content) not being met while on restraints. (Refer to A-0175) 8. The facility failed to ensure that for one of 39 sampled patients (Patient 25), there was evidence indicating that less restrictive options were implemented before escalating to the use of multiple types of restraints (used to stop a patient from moving freely when they might hurt themselves or others), in accordance with the facility’s policy regarding restraints use. The behavioral justification for using multiple restraints (Four bed rails up [considered a restraint when used to prevent a patient from voluntarily getting out of bed], Bilateral wrist restraints [devices applied to both wrists to limit arm movement], and Bilateral ankle restraints [devices applied to both ankles to restrict leg movement]), was not documented. This deficient practice had the potential to result in violations of Patient 25’s rights (the basic rules of care that ensure patients are treated with dignity, respect, and safety, including the right to make decisions about their care and to be free from unnecessary restraints), which undermines the patient’s right to be free from unnecessary restraint. In addition, the deficient practice had the potential to result in physical harm to Patient 25, such as nerve damage (injury to the nerves caused by prolonged or improper use of physical restraints, such as wrist or ankle strap), emotional suffering, and delayed clinical reassessment (a failure to evaluate a patient’s condition in a timely manner after an intervention). (Refer to A-0186) 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: 48212 Based on interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure that a registered nurse (RN) supervised and evaluated the nursing care for one (1) of 39 sampled patients (Patient 1), in accordance with the facility’s policies and procedures, when: 1.a. Patient 1 was not reassessed after showing signs of disorientation (a state of confusion about surroundings, time, or identity) on 3/11/2025 at 7:41 a.m., even though, at the time of admission to the medical-surgical unit on 3/8/2025, Patient 1 was alert and oriented ×4 (aware of person, place, time, and situation). On 3/11/2025 at 7:41 a.m., Registered Nurse (RN) 2 documented Patient 1 was disoriented to time (unable to correctly identify the current time or date). No follow-up neurological (a check to see how well the brain and nerves are working, including memory, alertness, movement, and how the body reacts to touch or sound) or focused assessment (a targeted evaluation of the patient’s mental and physical condition) was documented, until the Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration) was activated at 9:30 p.m. on the same day (3/11/2025). This deficient practice resulted in Patient 1 not receiving timely clinical evaluation, delayed recognition of deterioration, and a missed opportunity for early intervention, likely contributed to Patient 1’s continued decline and eventual death on 3/12/2025 at 11:57 p.m. (Refer to A-0395) 1.b. Patient 1 did not receive continuous monitoring of oxygen saturation levels or escalation of care in response to increasing oxygen requirements, despite a physician’s order for continuous pulse oximetry (a non-invasive method used to measure the level of oxygen in the blood) dated 3/8/2025. On 3/11/2025, the patient’s (Patient 1) oxygen needs increased from 2 liters per minute (L/min) via nasal cannula (a small tube placed in the nostrils to deliver low-flow oxygen) to 3L at 9:26 a.m., then to 5L at 12:24 p.m., followed by the use of Bilevel Positive Airway Pressures (BiPAP, a non-invasive machine that helps a person breathe by pushing air into the lungs), and ultimately a non-rebreather mask at 15L (NRM, a face mask that delivers high-flow oxygen in emergency situations). Despite these escalating oxygen needs, there was no documentation of continuous oxygen saturation monitoring, reassessment, or physician notification during this period. During an interview on 11/18/2025 at 11:00 a.m., Registered Nurse (RN) 1 confirmed that no additional monitoring or interventions were performed. This deficient practice resulted in Patient 1 not receiving timely recognition of respiratory decline, delayed escalation of care, and likely contributed to the patient’s deterioration. (Refer to A-0395) 1.c. The physician was not notified of Patient 1’s altered mental status or increasing oxygen requirements during a 12-hour period on 3/11/2025. Documentation indicated that Patient 1 became disoriented to time at 7:41 a.m. and required escalating oxygen support throughout the day. Review of Patient 1’s medical record indicated no documentation of physician notification between 7:41 a.m. and 7:47 p.m., until the RRT was activated. During an interview on 11/18/2025 at 11:00 a.m., RN 1 confirmed that the physician was not notified during this time. This deficient practice delayed medical evaluation and intervention by the physician, resulting in Patient 1 continuing to deteriorate without timely medical oversight. (Refer to A-0395) 1.d. No nursing interventions or activation of the Rapid Response Team (RRT) or Code Brain (a hospital protocol for suspected stroke [occurs when blood flow to a part of the brain is interrupted, causing brain cells to die] or acute neurological changes) occurred between 7:41 a.m. and 7:47 p.m. on 3/11/2025. Patient 1 exhibited sign of clinical deterioration beginning at 7:41 a.m., including disorientation to time and escalating oxygen requirements. Patient 1’s oxygen support increased from 2L via nasal cannula to 3L at 9:26 a.m., 5L at 12:24 p.m., followed by BiPAP, and ultimately a non-rebreather mask at 15L. Review of the medical record showed no documentation of nursing interventions (actions taken to address a patient’s clinical needs) or activation of the RRT or Code Brain until 7:47 p.m. This deficient practice resulted in Patient 1 not receiving timely clinical response to neurological and respiratory decline. These failures resulted in a delay in care and likely contributed to a fatal outcome. Patient 1 died on 3/12/2025 at 11:57 p.m. (Refer to A-0395) 2. The facility failed to ensure one of 39 sampled patient’s (Patient 13) pain level was reassessed within one hour after administering a medication to relieve pain or after performing interventions to relieve pain, in accordance with the facility’s policies and procedures regarding pain management. This deficient practice had the potential for Patient 13’s pain to be unrelieved or ineffectively managed. (Refer to A-0395) 3. The facility failed to ensure that nursing staff completed the required wound assessments, including measurements of pressure injuries for one of 39 sampled patients (Patient 4), in accordance with the facility’s policy regarding wound assessment and documentation. This deficient practice placed Patient 4 at risk for delayed wound treatment, deterioration of the wounds, and infection. (Refer to A-0395) 4. The facility failed to Ensure its nursing staff assessed/re-assessed one (1) of 39 sampled patient’s (Patient 25) change of condition (any significant change, declining, or otherwise altering, from their usual health and functional status, requiring observation, documentation, and often a revised care plan) and provide interventions in a timely manner, in accordance with facility’s policies and procedures regarding hypoglycemia (low blood sugar, a condition where the blood glucose levels drop below the normal range, typically below 70 mg/dL [unit of measurement]) protocol and assessment/re-assessment, when: 4.a. Patient 25 had a blood glucose (sugar) of 49 mg/dL (milligram per deciliter, a unit of measurement) on 10/27/2025 at 8:50 a.m. (blood sugar was not re-checked, hypoglycemia protocol [a standardized set of steps for treating low blood sugar], not followed, and Dextrose [a sterile solution used to provide the body with extra water and sugar] not administered until 3 p.m.) 4.b. Patient 25 had a change of respiratory status on 10/27/2025 at 8 p.m. (Respiratory rate [breath per minute] was in 30’s from 8 p.m. to 9:43 p.m.). This deficient practice resulted in Patient 25’s condition declining without immediate intervention. A Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration) was eventually called on 10/27/2025 at 9:43 p.m. Patient 25 was intubated (a procedure in which a tube is inserted into the airway to assist with breathing). As of 11/20/2025, Patient 25 was in the facility’s Intensive Care Unit (ICU, a special hospital department for patients with life-threatening illnesses or injuries that require constant, intensive medical care) and remained intubated. (Refer to A-0398) 5. The facility failed to ensure one of 39 sampled patient’s (Patient 32) complete head-to-toe (an evaluation of the body system to establish a baseline, identify current health status and detect potential or existing problems) assessment, was accurately documented, in accordance with facility’s policy and procedure titled, “Documentation: Patient Care Process Policy Clinical Administrative.” This deficient practice had the potential to result in a delay of necessary care and treatment for Patient 32, when critical assessment information is not properly documented to properly guide treatment decisions. (Refer to A-0398) 6. The facility failed to ensure nursing staff notified the physician and document one of 39 sampled patient’s (Patient 29) physician notification of heart rhythm (the pattern of the heart’s electrical activity, which controls its beating) changes, when Patient 29 had premature ventricular contractions (PVCs, extra heartbeat) and ventricular tachycardia (V-tach, fast heart rhythm that does not allow the heart to fill with blood and pump well throughout the body), in accordance with the accepted standards of nursing practice regarding documentation and the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative.” This deficient practice had the potential for crucial patient information not to be communicated, which could cause a delay in implementing necessary medical interventions for Patient 29 and for the care team to not know what had occurred for Patient 29. (Refer to A-0398) 7. The facility failed to ensure one of 39 sampled patient’s (Patient 4) pressure injury treatments were consistently implemented and documented by the nurses, including a timely evaluation by the Wound Ostomy Care Nurse (WOCN) after a consultation was ordered, in accordance with the facility’s policy regarding wound care treatment. This deficient practice placed Patient 4 at increased risk for worsening of pressure injury which may result in possible prolonged hospitalization, delayed recovery and/or infection. (Refer to A-0398) 8. The facility failed to ensure nursing service staff’s compliance with the facility’s established standing orders (a pre-written, physician-approved directive allowing nurses or other qualified staff to provide specific treatments, assessments, or medications [like pain relief] without needing an individual doctor’s order for every patient, improving efficiency and immediate care, especially for common situations or emergencies) policy for pain management when a staff registered nurse ordered 1000 milligrams (mg, measuring unit) of Tylenol (an over-the-counter medication commonly used to relieve pain and reduce fever ) for one of 39 sampled patients (Patient 7), which was outside the Emergency Department’s standing orders protocol for pain management. The standing order protocol only permits 650 mg for pain. This deficient practice had the potential to result in either an overdose (too much medication) resulting in complications such as organ damage or underdose (too little medication) leading to uncontrolled pain and/or emotional distress for Patient 7. (Refer to A-0406) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 48212 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that a pain medication, documented as administered on 6/11/2025 at 8:53 p.m., in the pain assessment record was also accurately documented in the MAR for one of 39 sampled patients (Patient 13), in accordance with the facility’s policies regarding pain management and documentation. There was no documented medication being administered at 8:53 p.m. on 6/11/2025 in Patient 13’s MAR. This deficient practice had the potential to result in delayed or inappropriate treatment including poor care coordination for patient 13 due to lack of documentation. (Refer to A-0438) 2. The facility failed to ensure nursing documentation was accurate for one of 39 sampled patients (Patient 27), in accordance with Federal regulatory requirement regarding medical records that must be accurately written, when Patient 27’s nursing note indicated Patient 27 threw themselves onto the floor contrary to what was observed from a security camera footage in which Patient 27 was observed being assisted onto the floor within the Emergency Department (ED) triage waiting room. This deficient practice resulted in an inaccurate description of Patient 27’s visit to the ED which could have affected Patient 27’s appropriate type of care provided, and emotional wellbeing. (Refer to A-0438) 3. The facility failed to ensure the nursing staff documented the evaluation and reassessment for one of 39 sampled patients (Patient 25), in response to Patient 25’s sudden increase in respiration rate (number of breaths per minute) on 10/27/2025 at 8 p.m., in accordance with the facility’s policy and procedure pertaining to reassessment and documentation. This deficient practice resulted in Patient 25’s medical record not reflecting Patient 25’s clinical presentation when Patient 25 had an increased respiration rate. This deficient practice also had the potential to result in leading to other healthcare team members not being able to evaluate the cause of Patient 25’s change of condition (change from baseline status, usually refer to worsening from baseline status and required medical attention) which may potentially lead to delay of treatment and care. (Refer to A-0449) 4. The facility failed to ensure the Emergency Department (ED) physician completed one of 39 sampled patient’s (Patient 8) ED physician notes (a medical note written by a physician that includes important details about the patient’s condition, treatment decisions, and care provided during the visit) regarding Patient 8’s ED visit on 11/17/2025, in accordance with the facility’s Medical Staff Rules and Regulations. This deficient practice had the potential to negatively impact Patient 8’s safety and continuity of care as it may have limited other providers’ access to critical medical information that are vital for accurate diagnosis and treatment planning and safe discharge. (Refer to A-0449) 5. The facility failed to ensure its nursing staff documented rechecking of blood sugar every fifteen (15) minutes for one of 39 sampled patients (Patient 25), in accordance with the facility’s hypoglycemia (low blood sugar) protocol (a standardized set of steps for treating low blood sugar), when Patient 25’s blood sugar was 49 milligrams per deciliter (mg/dL, unit of measure) on 10/27/2025 at 8:50 a.m. This deficient practice could lead to Patient 25’s hypoglycemia being unassessed, delaying recognition of worsening condition and increasing risk of adverse events (unfavorable medical events), including death. (Refer to A-0467) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure that one (1) of 39 sampled patients (Patient 20) had their grievance (a formal or informal complaint from a patient or their representative to a hospital about issues that require an investigation or further action to resolve) addressed and resolved, in accordance with the facility’s “Patient Complaints and Grievances: Resolution” policy. This deficient practice resulted in Patient 20’s concern regarding unrelieved pain remaining unresolved and not addressed through the facility’s formal grievance process. Findings: During a review of Patient 20’s “History and Physical” (H&P, a medical document summarizing a patient’s health history and current condition), dated 9/2/2025, the H&P indicated the patient’s (Patient 20) medical history included May-Thurner syndrome (a condition where a vein in the pelvis is compressed, which can lead to blood clots), status post (meaning after) placement of a stent (a small tube used to keep the vein open) in the left iliac vein (a large vein in the pelvis), and chronic pain (persistent or recurrent pain). The patient (Patient 20) presented to the facility on 9/2/2025 with abdominal pain and fever. During a concurrent observation and interview on 11/17/2025 at 11:30 a.m. with Patient 20 at the bedside, Patient 20 was observed grimacing and stated they were experiencing pain in their knee and abdomen. Patient 20 stated that their pain medication regimen had improved since their last visit in September; however, they reported that their pain was never fully relieved. They described their current pain level as 5 out of 10 on a pain scale where 0 indicated no pain and 10 indicated the worst possible pain. Patient 20 stated that their tolerable pain level is 3 out of 10. During a concurrent interview and record review on 11/21/2025 at 11:04 a.m. with Associate Director of Patient Advocacy (AD 4), emails from Patient 20 to the facility’s Patient Advocacy Office, dated between 9/3/2025 and 9/5/2025, were reviewed. AD 4 stated the following: - On 9/3/2025, an email from Patient Advocacy was sent to the Director of Acute Pain Anesthesia (MD 4), indicating, “Patient Advocacy was contacted by (Patient 20).” The email indicated Patient 20 had “concerns and requests for reassessment of her pain regimen. Patient requesting follow-up from the Pain Team.” AD 4 stated there was no documented response to Patient 20’s concern. -On 9/4/2025 at 7:33 a.m., an email sent from Patient 20 to the facility’s Patient Advocacy Office of Patient Experience indicated, “I still need help and would like to get this escalated. I never received help yesterday with getting reassessed by pain team.” AD 4 stated the office of Patient Experience would make referral to appropriate team, but there was no follow up whether the patient’s (Patient 20) concern regarding unrelieved pain was resolved. -On 9/4/2025, at 4:19 p.m., an email sent from Patient 20 to the facility’s Patient Advocacy, Office of Patient Experience indicated, “I beg the doctors for pain medication and was refused.” -On 9/5/2025 an email sent by the facility’s Patient Advocacy to Director of Acute Pain Anesthesia (MD) 4, indicated Patient 20 was “Requesting following: Re-assessment of pain regimen with the Pain Team along with her personal Patient Advocate,” and “Current Meds aren’t working, ok with changing home meds and changing acute meds.” AD 4 stated the office of Patient Experience would make referral to the appropriate team, but there was no follow up whether the patient’s (Patient 20) concern regarding unrelieved pain was resolved. - On 9/5/2025, at 3:53 a.m., an email sent from Patient 20 to the facility’s Patient Advocacy Office of Patient Experience indicated, “I wanna document in writing that I’ve been here since Tuesday that I’ve reached out to you multiple times that at no point in time has (name of facility’s) patient advocate or case manager ever come to my room to speak to me or my personal patient advocate as we have been begging ... I beg the doctors for pain medication and was refused.” During an interview on 11/21/2025 at 11:04 a.m. with AD 4, AD 4 stated Patient 20’s concern was treated as a complaint and not a grievance. AD 4 stated the facility defined a complaint as a concern resolved at the point of care, and a grievance as one that occurred post-discharge or involved escalated safety issues. AD 4 confirmed that Patient 20’s concern was not resolved at the time of the incident and was not documented in the facility’s grievance log. During a concurrent interview and record review on 11/21/25 at 3:56 p.m. with the Lead Coordinator, Patient Advocacy (LAD) 1, LAD 1 confirmed that Patient 20’s concern was not escalated through the formal grievance process, nor was a written response provided to the patient or their representative. During a concurrent interview and record review on 11/21/25 at 3:56 p.m. with the Lead Coordinator, Patient Advocacy (LAD) 1, the facility’s policy and procedure (P&P) titled, “Patient Complaints and Grievances: Resolution Policy,” dated 4/7/025, was reviewed. The P&P indicated the following: Patient Complaint (“complaint): a patient complaint is any statement or indication of concern by a patient, or the patient’s representative, regarding the care and/or services provided by (name of the facility) which can be effectively addressed and/or resolved in a relatively short period of time by (name of the facility) staff present at the time of the complaint. Patient Grievance: a patient grievance is any statement or indication of concern by a patient, or the patient’s representative, made in writing (e.g., emails or FAXs) or verbally (e.g., in person or by phone), 1. During or subsequent to an inpatient or outpatient admission. 2. Regarding care and/or services provided by (name of the facility). 3. For which any one of the following is true: It is not possible to resolve the concern in a relatively short period of time, but in no case longer than twenty-four (24) hours of the concern being first expressed to (name of the facility) staff present at the time; the resolution of the concern is postponed by (name of the facility) to a later time or day ...Staff must refer all patient complaints that have not been or could not be resolved to the satisfaction of the patient, or the patient’s representative, within 24 hours to the Patient Advocacy Department within the Office of Patient Experience for determination of whether the complaint needs to be addressed as a grievance. Patient Grievances: Patient Advocacy will acknowledge receipt of the grievance and will conduct an investigation. Patient Advocacy will issue a written response to the grievance. This response will include the resolution date, a summary of the steps taken to investigate grievance, and the results of the grievance process. The LAD 1 stated the grievance was not processed in accordance with the policy and no resolution was communicated to the patient. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy: Clinical Manual/ Administrative,” dated 5/9/2025, the P&P indicated, “Patients has the right to: Considerate and respectful care, and to be made comfortable. The patient has the right to respect his/her personal values and beliefs. Have a family member (or other representative of his/her choosing) and his/her own physician notified promptly of his/her admission to the hospital. Receive information about his/her health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms he/she can understand. The patient has the right to effective communication and to participate in the development and implementation of his/her plan of care. The patient has the right to participate in ethical questions that arise in the course of his/her care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life sustaining treatment. Make decisions regarding medical care and receive as much information about any proposed treatment or procedure as he/she may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. Request or refuse treatment, to the extent permitted by law. Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions. Request or reject the use of any or all modalities to relieve pain, including opiate medication, if the patient suffers from severe chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform the patient that there are physicians who specialize in the treatment of severe chronic pain with methods that include the use of opiates.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure one of the 39 sampled patient’s (Patient 7) exercise of patient rights (Patient rights refer to the legal and ethical rules that ensure patients are treated with respect, given clear information, and receive compassionate care) was met, when: 1. An assessment for pain was not done every two hours, while Patient 7 was in the Emergency Department (ED, a medical area that provided urgent and emergency care), as required by the facility’s policy on vital signs. (Vital signs include basic body functions such as temperature, pulse, breathing rate, and blood pressure.) This deficient practice resulted in Patient 7 potentially experiencing prolonged and unrelieved pain, negatively impacting their overall hospital experience and potentially delaying their treatment and recovery process. 2. A pain assessment was not repeated within 30 minutes before Patient 7 was discharged from the facility, in accordance with the facility’s policy regarding Vital Sign standards. This deficient practice had the potential for Patient 7 to experience uncontrolled or severe pain at home which can impede recovery, interfere with daily activities, and emotional distress. Findings: 1. During a review of Patient 7’s History of Present Illness (HPI, a detailed account of the patient’s current health issue, including the onset, characteristics, and progression of symptoms), dated 9/14/2025, the HPI indicated that Patient 7 visited the Emergency Department (ED) due to generalized body aches, headache, and runny nose after receiving the COVID-19 vaccine (a medical intervention designed to protect individuals from the SARS-CoV-2 virus, which causes COVID-19). During a concurrent interview and record review on 11/18/2025 at 11:24 a.m. with assistant nurse manager (NM 2), Patient 7’s pain assessment flowsheet (a form used to record how much pain a patient is feeling and when it was checked), dated 9/14/2025, was reviewed. The flowsheet indicated that there was no documentation of pain assessments done every 2 hours after Patient 7 was triaged (the process of checking a patient’s condition to decide how quickly they need care) on 9/14/2025 at 6:01 p.m. and had pain level documented to be 0/10 (scale used to measure a patient’s pain intensity ranging from 0 to 10, where 0 signifies no pain, and 10 represents the worst pain imaginable). During the same concurrent interview and record review on 11/18/2025 at 11:24 a.m. with assistant nurse manager (NM 2), NM 2 reviewed the pain flowsheet for Patient 7 and stated that the standard practice in the Emergency Department (ED) was to reassess Vital Signs (VS) every two hours, regardless of whether the patient was in the waiting area or in a room. NM 2 also said that if Patient 7 did not report experiencing pain, then a pain assessment was not required, even though vital signs (VS) were taken and recorded (on 9/14/2025 and 9/15/2025) every two hours in Patient 7’s chart: -At 6:01 p.m. (Triage), pain was documented as 0/10. -At 8:28 p.m., pain was not documented along with other vital signs (VS). -At 10:45 p.m., pain was not documented along with other VS. -At 1:05 a.m., pain was not documented along with other VS. -At 1:21 a.m., the patient (Patient 7) was discharged. During an interview on 11/19/2025, at 2:35 p.m. with Nurse Manager (NM 9), NM 9 stated that ED nurses were not required to reassess pain every two hours. NM 9 reviewed the Vital Sign (VS) Standard protocol, which mandated pain assessments every two hours in the ED, and said: “This policy needs to be changed. We only reassess pain if the patient complains after the initial triage assessment.” During an interview on 11/19/2025 at 2:35 p.m. with Nurse Manager (NM 9), NM 9 said that the pain was subjective, and the best efforts were made to explain the scale to patients. NM 9 then also said, “Pain is one of the primary reasons patients seek medical care and is often being linked to the chief complaint and significantly influencing patient satisfaction.” NM 9 did not discuss the potential implications for Patient 7 when pain levels were not regularly assessed. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy,” dated May 2025, the P&P indicated the following: “Patients have the right to: appropriate assessment and management of your (Patient’s) pain, information about pain, pain relief measures, and participation in pain management decisions...” During a review of the facility’s policy and procedure (P&P) titled, “Vital Sign Standards,” dated 3/2025, the P&P indicated the following: “Vital Signs (VS) include ... Pain Assessment ... required to be obtained every 2 hours per the Emergency Department (ED) standard with follow-up frequency as indicated by clinical condition... and upon admission, discharge, and transfer, must be repeated within 30 minutes prior to... discharge...” 2. During a review of Patient 7’s History of Present Illness (HPI, a detailed account of the patient’s current health issue, including the onset, characteristics, and progression of symptoms), dated 9/14/2025, the HPI indicated that Patient 7 visited the Emergency Department (ED) due to generalized body aches, headache, and runny nose after receiving the COVID-19 vaccine. During a review of Patient 7’s Timeline of Care (a step-by-step summary that shows what happened to a patient during their medical visit or hospital stay) in the Emergency Department, dated 9/14/2025 through 9/15/2025, the record indicated that Patient 7 was discharged on 9/15/2025 at 1:42 a.m. with a diagnosis of “chills after vaccination” impression. During a concurrent interview and record review on 11/18/2025 at 11:06 a.m. with Assistant Nurse Manager (NM 2), Patient 7’s Medication Administration Record (MAR, a document that includes the medication given to a patient, the dosage, and the time of administration), dated 9/14/2025, was reviewed. The MAR indicated that on 9/14/2025: - At 11:01 p.m., Patient 7 received 1000 mg (milligrams, a unit of measure) of Tylenol (a common pain reliever and fever reducer), taken orally for unknown pain level. NM 2 confirmed that the pain level was not documented for this administration. - At 11:49 p.m., Patient 7 received 30 milligrams (mg, measuring unit) of Toradol (a medication used to treat moderate to severe pain) for a pain level of 7/10. (The pain level scale ranges from 0 to 10, with 0 indicating no pain and 7-10 indicating severe pain.) NM 2 confirmed that pain reassessment was documented on 9/15/2025 at 12:10 a.m., indicating a pain level of 6/10 (indicating mild to moderate pain level). -NM 2 said that no further pain reassessment was required after 12:10 a.m. on 9/15/2025, but could not confirm if a pain level of 6 was acceptable for Patient 7 because this information was not documented in the pain assessment flowsheet (a record that tracks a patient’s pain levels and responses to treatment). During a follow-up interview on 11/18/2025 at 11:06 a.m. with Assistant Nurse Manager (NM 2), NM 2 made the following statements regarding the lack of pain reassessment documentation prior to discharge, NM 2 said: -“Pain reassessment was not necessary after it was documented that a pain level was 6 out of 10 at midnight on 9/15/2025. NM 2 could not confirm whether this pain level was acceptable for the patient but still verified that no further pain reassessment was needed. NM 2 also stated that pain should not be reassessed prior to discharge, but vital signs (VS) should be taken about an hour or 30 minutes before discharge.” -NM 2 did not provide a statement regarding the implications of not assessing pain prior to discharge for Patient 7, nor did NM 2 address the potential consequences of discharging Patient 7 while possibly still in pain. NM 2 referenced the Emergency Department (ED) physician (MD) note, dated 9/15/2025, where the MD documented that after administration of Toradol, Patient 7 reported feeling better. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy,” dated May 2025, the P&P indicated the following: “Patients have the right to: appropriate assessment and management of your (Patient’s) pain, information about pain, pain relief measures, and participation in pain management decisions ...” During a review of the facility’s policy and procedure (P&P) titled, “Vital Sign Standards,” dated 3/2025, the P&P indicated the following: “Vital Signs (VS) include ... Pain Assessment ... required to be obtained every 2 hours per the Emergency Department (ED) standard with follow-up frequency as indicated by clinical condition... and upon admission, discharge, and transfer, must be repeated within 30 minutes prior to... discharge...””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to: 1. Ensure that one (1) of 39 sampled patients (Patient 20) was provided the opportunity to participate in the development and implementation of their pain management plan. The facility did not escalate ongoing, severe pain, rated between 6 and 10 on a 0-10 pain scale (0 being no pain and 10 being the worst pain), experienced by Patient 20 (after 9/5/2025 through 9/20/2025) to the pain management team or to the physician and did not revise the plan of care to address the patient’s persistent pain. This deficient practice resulted in Patient 20 experiencing unrelieved pain throughout the hospital stay. 2. Ensure all patients (individuals receiving care) with serious illness (a health condition that significantly impacts daily function or quality of life) were offered the opportunity to participate in palliative care planning (planning for specialized medical care focused on relief from symptoms and stress of serious illness), and failed to ensure that palliative care eligibility and access were consistent with facility policy, public information, and regulatory requirements for one (1) of 39 sampled patients (Patient 20). The facility restricted palliative care access by not offering palliative care to patients with serious illness and advanced illness (a health condition that significantly impacts daily function or quality of life) who did not have a terminal illness (an illness expected to result in death within a limited period) or cancer (a disease caused by uncontrolled division of abnormal cells), which was not consistent with its own policy and public statements. The facility did not ensure that all patients with serious illness were able to participate in care planning as required. This deficient practice resulted in the potential for patients with serious illness (a health condition that significantly impacts daily function or quality of life), including Patient 20, to be denied their right to participate in the development and implementation of their plan of care (the plan for medical treatment and support), and to be denied access to palliative care (specialized medical care for relief from symptoms and stress of serious illness) that could improve their quality of life. Findings: 1. During a review of Patient 20’s “History and Physical (H&P, a medical document summarizing a patient’s health history and current condition),” dated 9/2/2025, the H&P indicated the patient’s (Patient 20) medical history included May-Thurner syndrome (a condition where a vein in the pelvis is compressed, which can lead to blood clots), status post (after) placement of a stent (a small tube used to keep the vein open) in the left iliac vein (a large vein in the pelvis), and chronic pain. The patient (Patient 20) presented to the facility on 9/2/2025 with abdominal pain and fever. During a concurrent observation and interview on 11/17/2025 at 11:30 a.m. with Patient 20 at the bedside, Patient 20 was observed grimacing and stated they (Patient 20) were experiencing pain in their knee and abdomen. Patient 20 stated that their pain medication regimen had improved since their last visit in September; however, they (Patient 20) reported that their pain was never fully relieved. They described their current pain level as 5 out of 10 on a pain scale where 0 indicated no pain and 10 indicated the worst possible pain. Patient 20 stated that their tolerable pain level was 3 out of 10. Patient 20 stated, “I told the nurses every day that my pain was not getting better. I wanted to see a pain specialist or have my doctor change my medications, but nothing changed.” During a concurrent interview and record review on 11/21/2025 at 1:30 p.m. with the Associate Director of Medical Surgical (AD) 5, Patient 20’s medical record (MR) titled, “Pain Assessment,” dated from 9/6/2025 through 9/20/2025, was reviewed. The MR indicated Patient 20’s tolerable pain level was 3/10, AD 5 stated this document would change when the patient reported new tolerable pain level. The pain assessment flowsheets indicated that Patient 1 consistently reported pain levels of 6-10 out of 10 for 18 consecutive days. AD 5 stated in this situation the RN should notify the primary physician. During a review of Patient 20’s medical record (MR) titled, “Progress Note - Nursing,” dated 9/2/2025 through 9/9/2025, the notes indicated the following: -On 9/4/2025, RN 27 documented, “Pt (Patient 20) c/o (complained of) 9/10 generalized body and abdominal pain all night. Patient (Patient 20) unable to sleep. Patient (Patient 20) requesting pain consult for better pain management.” --On 9/4/2025, RN 28 documented, Patient 20 had “Returned from Procedure, Peripheral Inserted Central Cather (PICC) line removed; patient stated having 10/10 pain during procedure and did not receive any medication to alleviate pain.” - On 9/4/2025, RN 29 documented, “Met with the patient few times due to complaints of her pain medication schedule. PRN (as needed) pain meds are given almost every 1-2 hrs with breakthrough pain in between, and still continues to say her pain medications are not enough and wants to discuss this issue again with the primary team this AM.” During a concurrent interview and record review on 11/21/2025 at 2:00 p.m. with AD 5, Patient 20’s medical record (MR) titled, “Progress Note - Nursing” and “Communication,” dated from 9/5/2025 through 9/20/2025, was reviewed. AD 5 stated there was no documented evidence in the “Progress Note - Nursing” or “Communication” flowsheet that the physician was notified regarding Patient 20 continuing to experience pain rated 6-10 out of 10 after 9/4/2025, when the registered nurse (RN) 28 documented, “Patient still insisting on speaking with ‘higher up’ regarding pain medication regimen; MD made aware; message sent to patient advocacy regarding patient’s request to speak with them.” AD 5 confirmed that after this notification, there was no further documented evidence that the physicians were notified that Patient 20’s pain regimen was not effective. During a concurrent interview and record review on 11/21/2025 at 2:15 p.m. with AD 5, Patient 20’s medical record (MR) titled, “Care Plan,” dated from 9/5/2025 through 9/20/2025, was reviewed. The care plan for pain management included interventions such as medication; however, AD 5 confirmed that there had been no update to reflect the ongoing pain or to include new interventions to the care plan since 9/3/2025. During an interview on 11/17/2025 at 11:30 a.m. with Registered Nurse (RN) 26, RN 26 stated that Patient 1 frequently reported severe pain and requested additional pain relief. RN 1 stated the same pain medication regimen was continued and the pain management team or physician was not notified because the orders were already in place. RN 1 confirmed that the patient’s pain was not relieved and that Patient 20 continued to report pain. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management Adult and Pediatrics Policy, “dated 10/14/2025, the P&P indicated, “Take the following action post-pain intervention assessment when the pain rating is greater than the patient’s acceptable pain goal: Notify the provider if medication given was ineffective ...Collaborate with the provider to alter the pain management intervention(s) when the pain scores consistently remain greater than the patient’s acceptable pain/comfort goal, or when the patient’s pain consistently returns before the next dose is due. Inpatient Pain Consultation: Inpatient Acute Pain consults and makes recommendations to the requesting physician or advanced practice professional. Inpatient Acute Pain is consulted when the patient’s pain is not adequately controlled based on assessments of pain and function.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy: Clinical Manual/ Administrative,” dated 5/9/2025, the P&P indicated, “Patients has the right to: Considerate and respectful care, and to be made comfortable. The patient has the right to respect his/her personal values and beliefs. Have a family member (or other representative of his/her choosing) and his/her own physician notified promptly of his/her admission to the hospital. Receive information about his/her health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms he/she can understand. The patient has the right to effective communication and to participate in the development and implementation of his/her plan of care. The patient has the right to participate in ethical questions that arise in the course of his/her care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life sustaining treatment. Make decisions regarding medical care and receive as much information about any proposed treatment or procedure as he/she may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment. Request or refuse treatment, to the extent permitted by law. Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions. Request or reject the use of any or all modalities to relieve pain, including opiate medication, if the patient suffers from severe chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform the patient that there are physicians who specialize in the treatment of severe chronic pain with methods that include the use of opiates.” 2. During a concurrent observation and interview on 11/17/2025 at 11:30 a.m. with Patient 20 at the bedside (the patient’s hospital room), Patient 20 was observed grimacing (making a facial expression showing pain) and stated they (Patient 20) were experiencing pain in their knee and abdomen (the area of the body between the chest and hips). Patient 20 stated their pain was not relieved throughout the hospital stay (the period of time spent in the hospital, from 9/2/2025 through 9/20/2025). Patient 20 stated they (Patient 20) had questions regarding their pain management (methods to control pain) and advance directive (legal documents stating a patient’s wishes for medical care) and requested to speak with the palliative care team (specialists in relief of symptoms and stress of serious illness), but the physician (doctor) refused to refer them (Patient 20). Patient 20 stated the facility stated the reason for refusal to refer to palliative care was because they (Patient 20) were not terminally ill (not expected to die within a limited period). During a review of Patient 20’s “ISP Hospitalist Progress Note (a daily summary written by the hospital doctor),” dated 9/5/2025, the note indicated, “Patient (Patient 20) reporting pain is not being treated adequately (not enough to relieve pain) and reports after her PICC line (a long, thin tube inserted into a vein for medication or nutrition) removal yesterday, her pain was even worse post procedure (after the medical procedure). Patient (Patient 20) today requesting escalation to ‘higher ups/highest’ admin level (hospital leadership) as her palliative pain is not being managed adequately by pain team (specialists who help control pain). Does ask that pain team keeps following but patient claiming that she is being ‘retaliated’ against (treated unfairly) due to her pain regimen (pain medication plan) not being escalated (increased or changed). Requesting to speak with the higher ups in the hospital and notes that her personal SW (social worker) is involved as well. Asking for palliative team to be involved - d/w (discussed with) patient that SCM (Supportive Care Medicine, another term for palliative care) team at this time will not consult on her case given she is not terminal case (not expected to die within a limited period).” During an interview on 10/30/2025 at 1:05 p.m. with Medical Doctor (MD) 5, Director of Acute Pain, MD 5 stated supportive care medication (medicines to relieve symptoms and improve comfort) was for chronic illnesses (long-lasting health conditions), while patients with terminal conditions or cancer qualify for palliative care (specialized medical care for people living with serious illness). MD 5 stated, “Usually, yes, they must have cancer. Palliative care usually treats cancer-related pain.” MD 5 confirmed Patient 20 had multiple serious illnesses (May-Thurner Syndrome [a vein disorder], CVST [, Cerebral Venous Sinus Thrombosis, a blood clot in the brain], POTS [Postural Orthostatic Tachycardia syndrome, a condition affecting heart rate], Ehlers-Danlos Syndrome [a connective tissue disorder]) that “may impact on a person’s daily function or quality of life,” but stated the patient was not terminally ill or had cancer, and thus would be treated by the pain management team (the group of specialists who help control pain). MD 5 stated if the patient requested palliative care, the palliative team (the group of specialists providing palliative care) would review the chart (the patient’s medical record) and may cancel the consultation (meeting with a specialist) if the patient did not meet eligibility criteria (the requirements to receive a service). MD 5 stated it was not necessary to document (write in the record) the chart review or decision to decline a consult. During an interview on 11/21/2025 at 10:01 a.m. with Medical Doctor (MD) 4, the Medical Director for Supportive Care Medicine, MD 4 stated supportive care medicine (another term for palliative care) collaborated with the pain management team on a case-by-case basis (for each individual situation), for example, for patients with pancreatic cancer (a type of cancer affecting the pancreas). MD 4 acknowledged that the facility’s website (the public online information about the program) did not indicate that patients must be terminally ill to receive palliative care, but stated that “advanced illness (a serious, life-limiting health condition)” meant terminal illness (an illness expected to result in death within a limited period). During a review of the facility’s palliative care policy (Commission on Cancer Palliative Care Services Policy: Clinical Manual/General Clinical), MD 4 confirmed the policy did not indicate that palliative care was only for terminally ill patients. MD 4 stated there was also a general palliative care policy (a broader policy for palliative care), but this was not provided by the facility to the survey team (the group of health care evaluators). During a concurrent interview and record review on 10/30/2025 at 9 a.m. with the Director of Acute Pain Anesthesia (MD 4), Patient 20’s “History and Physical (H&P),” dated 9/2/2025, was reviewed. The “H&P” indicated Patient 20’s medical history included: - Lap Chole (Laparoscopic Cholecystectomy): A minimally invasive surgery to remove the gallbladder, often due to gallstones or inflammation. -May-Thurner Syndrome s/p L (left) iliac vein stent: A condition where a vein in the left leg is compressed, making it harder for blood to flow back to the heart. A stent (a small tube) was placed to keep the vein open. -CVST (Cerebral Venous Sinus Thrombosis) on Xarelto: A rare type of blood clot in the brain’s veins. The patient is taking Xarelto, a blood thinner, to prevent or treat this. -POTS (Postural Orthostatic Tachycardia Syndrome): A condition where the heart rate increases abnormally when standing up, causing dizziness or fainting. -Prior SIBO (Small Intestinal Bacterial Overgrowth): A condition where too many bacteria grow in the small intestine, leading to bloating, gas, and diarrhea. -Ehlers-Danlos Syndrome: A genetic condition that affects connective tissues, making joints very flexible and skin stretchy. It can cause digestive issues like chronic constipation. -TAC with IRA (Total Abdominal Colectomy with Ileorectal Anastomosis) in 2021: The entire colon was removed, and the small intestine was connected to the rectum to help with severe constipation. -Loop Ileostomy (2023): A temporary opening in the belly to let waste leave the body through a stoma (a small hole), bypassing the colon. -End Ileostomy with Mucous Fistula: A more permanent version of the ileostomy, with a second small opening to allow mucus from the leftover colon to drain. -Stomal Stenosis/Retraction s/p Revision x3 (most recent 2/2024): The stoma (opening) narrowed or pulled inward, requiring three surgeries to fix it, the latest in February 2024. During the same interview and record review on 10/30/2025 at 9 a.m. with the Director of Acute Pain Anesthesia (MD 4), MD 4 confirmed these (referring to the list of Patient 20’s medical history) were serious illnesses (health conditions that significantly impact daily function or quality of life). MD 4 also stated that Patient 20 was not terminally ill (not expected to die within a limited period) or had cancer (a disease caused by uncontrolled division of abnormal cells). MD 4 stated patients that were not terminal will be treated by the pain management team. When asked about when the patient had questions about advanced directives (legal documents stating a patient’s wishes for medical care) and wanted to consult on what appropriate pain management was, MD 4 stated that usually the nurse could answer these questions or the primary care team. During a review of the facility’s policy and procedure titled, “Commission on Cancer Palliative Care Services Policy: Clinical Manual/General Clinical,” dated 2020, the policy indicated, “Supportive Care Medicine (Palliative Care Services): High-quality, compassionate, and timely consultative input (specialist advice) for patients facing advanced, life-limiting illness (a serious health condition that may shorten life). ... The focus is on each person’s diagnosis (the identification of a disease), prognosis (the likely course of the disease), treatment options (choices for medical care), and holding paramount each patient’s goals, values, quality of life, and personhood (the things that matter most to the patient as a person).” The policy listed recommended criteria (suggested reasons) for palliative care consultation, including but not limited to: advanced stage disease (late-stage illness), no advance care planning (no legal documents about care preferences), complex family dynamic/poor social support (difficult family situations or lack of help at home), severe symptom burden (serious symptoms like pain or nausea), ECOG (Eastern Cooperative Oncology Group, a major cancer research organization) Performance Status of 3 or greater (a scale measuring how much a disease affects daily living), patients with questions about decision making or treatment (uncertainty about care choices), hospice candidates (patients who may qualify for end-of-life care), and high-risk transplant patients (patients at high risk from organ transplant). Depending on the needs of the patient at the time of palliative care consult, one or multiple team members of the Supportive Care Medicine· team will meet with the patient. During a concurrent interview and record review on 11/21/2025 at 10:01 a.m. with Medical Doctor (MD) 5, the Medical Director of Supportive Care Medicine, the facility’s website (public online information about the program), last updated 2025, was reviewed. The website indicated, “Palliative care, also known as supportive care medicine, focuses on improving quality of life for patients and families who are living with serious illness (a health condition that significantly impacts daily function or quality of life). ... If you have been diagnosed with a life-changing illness (a serious health condition), or have a loved one who has, and would like additional support, we are here for you. Our expert clinicians (medical professionals) collaborate with various medical teams and specialists who treat conditions like: Cancer, Advanced heart, lung or liver disease, Neurological disorders (i.e., dementia [a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking], ALS [Amyotrophic lateral sclerosis, a nervous system disease that affects nerve cells in the brain and spinal cord] and Parkinson’s disease [disease is a progressive movement disorder of the nervous system]).” The website did not state that palliative care is limited to terminal illness (an illness expected to result in death within a limited period) or cancer (a disease caused by uncontrolled division of abnormal cells). MD 5 acknowledged that the website information did not indicate that the patient must be terminally ill to receive palliative care but stated that “advanced illness” (a serious, life-limiting health condition) meant terminal illness. During a review of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, 4th edition, 2018, the guideline indicated, “Serious illness (a health condition that carries a high risk of mortality [risk of death] and either negatively impacts a person’s daily function or quality of life, or excessively strains their caregivers [people who help the patient]) is not limited to terminal illness.” (https://www.nationalcoalitionhpc.org/ncp/) During a review of the facility’s “Medical Staff Bylaws (the official rules that govern how doctors and other medical staff must act at the hospital),” dated 10/21/2024, the Bylaws indicated the following: -Medical Staff (doctors and other licensed healthcare professionals who are allowed to treat patients at the hospital) must “Demonstrate the ability to comply with these Bylaws, the Medical Staff Rules and Regulations (detailed rules for medical staff behavior), applicable Departmental Rules and Regulations (rules for each specialty department), and such other Medical Center Policies and Procedures (hospital-wide rules), as may be in effect from time to time, including, without limitation ...Medical Staff member’s Responsibilities: All Medical Staff Members with privileges (permission to perform certain procedures or care for certain patients) are required (unless specifically excused by the Executive Committee [a group of senior medical staff who make decisions for the medical staff]) to provide service in the Medical Center’s clinic(s) (outpatient care areas) in accordance with the terms of the Bylaws and the Medical Staff Rules and Regulations...” “Medical Staff Members shall provide Medical Center patients (individuals receiving care at the hospital) with quality and safe care that meets the professional standards of the Medical Staff (the expected level of care and behavior for doctors and other licensed professionals) ...” “Medical Staff Members shall continuously abide by the Medical Center Bylaws, these Bylaws, the Medical Staff Rules and Regulations, the Departmental Rules and Regulations of the Departments to which the Medical Staff Member is appointed, the Medical Center Policies and Procedures, including, without limitation, the ‘Code of Conduct’ Policy (rules for professional and respectful behavior) set forth in the Medical Staff Rules and Regulations, and Medical Staff Members shall comply with reasonable requests, including but not limited to, requests of Medical Staff representatives (leaders or committee members), in furtherance of the Medical Center’s and Medical Staff’s duties to provide quality care in a safe and effective manner (care that is both good and does not put patients at risk).””

“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 one of 39 sampled patient’s (Patient 26) designated representatives (RP 1, RP 2 and RP 3), were notified of Patient 26’s deep tissue (maroon and/or purple colored underlying tissue damage that occurs before the skin breaks) pressure injury (PI, localized damage to the skin and/or underlying tissue), in accordance with the facility’s policy regarding Patient rights (Patient rights refer to the legal and ethical rules that ensure patients are treated with respect, given clear information, and receive compassionate care). This deficient practice led to Patient 26’s representatives to not be fully informed of Patient 26’s condition and may potentially hinder Patient 26’s designated representatives from engaging actively in the care process that ensures Patient 26’s well-being. Findings: During a review of Patient 26’s “History and Physical (H&P),” dated 2/17/2025, the record indicated Patient 26 was admitted to the facility for cough, shortness of breath and fevers. Patient 26 had a medical history of myelofibrosis (cancer [uncontrolled abnormal cell growth] of the blood). During a review of Patient 26’s “Wound Care Note,” dated 3/10/2025, 3/18/2025, 3/27/2025 and 4/11/2025, the wound care notes indicated Patient 26 had developed a deep tissue (maroon and/or purple colored underlying tissue damage that occurs before the skin breaks) pressure injury (DTPI) on the sacrum (triangular bone at the base of the spine). The notes did not indicate Patient 26’s representatives were notified of the deep tissue pressure injury. During an interview on 11/17/2025 at 2:56 p.m. with Registered Nurse (RN) 18, RN 18 stated patient rights included the patient’s right to receive explanation of the care provided and the right to ask questions, and these rights also applied to the patient’s legal decision maker. During a concurrent interview and record review on 11/18/2025 at 2:55 p.m. with Nursing Professional Development Practitioner (NPDP) 5, Patient 26’s “Advance Care Planning,” undated, was reviewed. NPDP 5 confirmed Patient 26 had three emergency contacts (RP 1, 2 and 3). NPDP 5 confirmed Patient 26 did not have a durable power of attorney (DPOA, individual who can make decisions if the patient is unable to). During a concurrent interview and record review on 11/19/2025 at 10:44 a.m. with Wound Care Nurse (WOCN), WOCN stated it was important to notify the family or decision maker of wounds to have them be involved and was a holistic (addresses mental, social, physical, emotional and spiritual needs) approach. WOCN stated it was important the family or decision maker were aware of changes in a patient’s condition. WOCN stated that notification must be included in the care plan so designated patient representatives can understand the patient’s condition. WOCN also stated the family or the patient’s decision maker should be notified upon findings (of skin breakdown). During a concurrent interview and record review on 11/19/2025 at 3:30 p.m. with Nursing Professional Development Practitioner (NPDP) 6 and the Regulatory Specialist (RS) 2, RS 2 confirmed there was no family notification regarding Patient 26’s wound. NPDP 6 later confirmed another family member (not listed as the emergency contact) of Patient 26 was notified on 4/3/2025 regarding Patient 26’s DTPI. During an interview on 11/20/2025 at 3:13 p.m. with the Nursing Professional Development Practitioner (NPDP) 7, NPDP 7 stated the family member, or patient representative should be contacted as soon as able about the wound. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy: Clinical Manual/Administrative,” dated 5/9/2025, the P&P indicated, “Receive information about his/her health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms he/she can understand. The patient has the right to effective communication and to participate in the development and implementation of his/her plan of care.” During a review of the facility’s policy and procedure (P&P) titled, “Pressure Injuries: Assessment and Intervention Policy: Clinical Manual/General Clinical,” dated 4/15/2024, the P&P indicated, “Licensed nursing personnel are responsible for implementation of preventative measures and performance of pressure injury care, nursing interventions.” During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/7/2024, the P&P indicated, “Purpose: Provide a system of documentation that reflects screenings, assessment and interventions ...Documentation time frames: ...Interventions, patient education are to be documented during or immediately after performed/provided.””

“PATIENT RIGHTS: ACCESS TO MEDICAL RECORD CFR(s): 482.13(d)(2) The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual. If it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or if not, in a readable hard copy form or such other form or format as agreed by the facility and the individual, and within a reasonable timeframe. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to provide access to medical records for one of 39 sampled patient’s (Patient 18) authorized health-care representative, despite a valid durable power of attorney (DPOA, a legal document that lets the principal appoint someone (the agent) to manage financial, legal, or healthcare decisions if the principal becomes unable to do so) on file and a request for records, in accordance with the facility’s policy regarding protected health information (any health-related data that can identify an individual, including demographics, medical histories, diagnoses, treatments, and payment info, safeguarded under patient privacy law). This deficient practice prevented Patient 18’s authorized healthcare representative from obtaining necessary clinical information, hindering their ability to make informed decisions (a collaborative process where patients, empowered with understandable, evidence-based information, actively participate with their providers to choose treatments or care plans that align with their personal values, goals, and preferences, considering risks, benefits, and alternatives) on behalf of Patient 18 and undermining the patient’s right to access and confidentiality of records. Findings: During a review of Patient 18’s History and Physical (H&P), dated 3/28/2025, the H&P indicated that Patient 18 was admitted to the facility on 3/28/2025 with wound dehiscence (the partial or complete separation of a surgical incision, which can cause pain, bleeding, and an open wound) and had an extensive medical history. During a review of Patient 18’s “advance directive (a written statement of a person’s wishes regarding medical treatment)” titled, “California Advance Health Care Directive,” dated 5/29/2022, the advance directive indicated that Patient 18’s durable power of attorney (DPOA, a legal document that lets the principal appoint someone [the agent to manage financial, legal, or healthcare decisions if the principal becomes unable to do so) was appointed to make health care decisions on 5/29/2022. The document also indicated Patient 18’s initials authorized the following: -“I want my agent to make my medical care decisions now, even though I currently have the mental capacity to make my own health care decisions -My agent will be allowed to make health care decisions for me just as I make my own. For example, I give my agent my trust to make decisions ... (3) to receive or review my medical information and records, or to permit release of my records for others’ review.” During a review of the facility’s “Authorized for Use or Disclosure of Health Information,” dated 4/24/2025, the document indicated that Patient 18’s DPOA requested the following: -History and physical report -Discharge Summary -Pathology report (a pathologist’s description of a tissue sample or body fluid after looking at it through a microscope) -Other: “all images, test results, cultures-upload files given to dr, and ignored” -Radiology report (the official, written interpretation of a medical imaging test [like X-ray]) -Operative report -Consultation report -Emergency Records The DPOA indicated that the purpose for release was for: -Continuing care -Personal Use -Other: “neglect/abuses SNF (Skilled Nursing Facility, provides 24/7 nursing support for short-term recovery after hospitalization) appeal discharge” During a review of the facility’s medical records department’s email response titled, “Tracking,” dated 5/1/2025, the email response indicated, “Patient (Patient 18) is still in House (still in the hospital).” During a review of the facility’s “Authorized for Use or Disclosure of Health Information,” dated 5/7/2025, the document indicated that Patient 18’s DPOA requested the following ... -History and physical report -Discharge Summary -Pathology report -Other: “all photos in media tab” -Radiology report -Operative report -Consultation report -Laboratory report -Emergency records During a review of the facility’s “Authorized for Use or Disclosure of Health Information,” dated 5/12/2025, the documented indicated that Patient 18’s DPOA requested the following: -History and physical report -EKG/ECHO -Discharge Summary -Pathology report -Other: “all photos in media tab, images not loaded before after procedure” -Radiology report -Operative report -Consultation report -X-ray film/Images CD -Laboratory report -Emergency records During a review of the medical records department’s email response titled “Tracking,” dated 5/14/2025, the email response indicated, “For the most recent admission (Patient 18) is still in House (admitted as a patient at the hospital).” During an interview on 11/20/2025 at 10:25 a.m. with the Health Information Manager (HIM 1), HIM 1 stated the following: -HIM 1 stated that Patient’s 18’s DPOA’s request for medical records on 4/24/2025 was denied because the patient (Patient 18) was still in house (admitted in the hospital), and that the DPOA was told that she (DPOA) could request medical records once Patient 18 was discharged from the hospital. -HIM 1 stated that if patients were still admitted in the hospital, their medical records were not yet signed off by the physicians. -HIM 1 stated that Patient 18’s DPOA’s request for medical records on 5/7/2025 was denied because Patient 18 was still admitted to the hospital and his medical records had not been signed off yet by the physician. -HIM 1 stated that Patient 18’s DPOA’s request for medical records on 5/12/2025 was denied because Patient 18 was still admitted in the hospital. -HIM 1 stated that the facility’s standard practice was to not release medical records until the patient was discharged from the hospital. -HIM 1 stated that if the requester specified that the medical records were for “personal use,” the facility would not release the records. During an interview on 11/20/2025 at 2:18 p.m. with HIM 1, HIM 1 stated that the facility’s policy and procedure (P&P) did not indicate that patients must be discharged from the hospital before medical records are released to the patient’s legal representative. During a review of the facility’s policy and procedure (P&P) titled, “Advance Directive,” dated 9/13/2023, the P&P indicated ... “Unless otherwise specified in an Advanced Directive, the Agent is authorized to participate in healthcare decision making on the patient’s behalf to the same extent the patient may participate in decision-making for themselves. These include, but are not limited to: ... e. requesting, receiving, examining, copying, and consenting to the disclosure of medical or any other healthcare information ...” During a review of the facility’s policy and procedure (P&P) titled, “Use and Disclosure of PHI (protected health information) Requiring Patient Authorization Policy,” dated 1/19/2025, the P&P indicated ... “12. Upon written request by “a patient” or a “patient’s representative” and within the time limitations specified by statue, the requester is entitled to inspect and or obtain copies of all or part of the patient’s record. However, a health care provider may choose to prepare a summary of the patient’s record that complies with statutory requirements. The patient or the representative may determine whether he/she wants to inspect the summary and /or have a copy ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that nursing staff performed and documented restraint (any physical, chemical, or mechanical method, device, material, or equipment that immobilizes or reduces a patient’s ability to move or access any part of their body) monitoring every two (2) hours for one of 39 sampled patients (Patient 25), as required by the facility’s policy and procedure on restraints, when there was no documented restraints monitoring for seven (7) hours on 10/27/2025 from 3 p.m. to 10 p.m. This deficient practice had the potential to put Patient 25 at risk for skin breakdown (damage to the skin and underlying tissue typically caused by prolonged pressure that restricts blood flow to the area) and other needs including hydration (the process of ensuring a patient has enough fluids in their body by drinking water and consuming foods with high water content) not being met while on restraints. Findings: During a review of Patient 25’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 10/25/2025, the H&P indicated, Patient 25 was admitted to the facility on 10/25/2025 with diagnosis of toxic hepatic encephalopathy (a condition where a buildup of toxins, normally cleared by the liver, harms the brain’s function). During a review of Patient 25’s Order History (a chronological record of all medical orders placed for a patient, including medications, treatments, and interventions), dated 10/26/2025, the record indicated that a renewal order for non-violent restraints (any physical, chemical, or mechanical method, device, material, or equipment that immobilizes or reduces a patient’s ability to move or access any part of their body) was placed at 3:11 a.m. The order included the following types of restraints: four bed rails up (a form of restraint when it restricts a patient’s ability to voluntarily get out of bed), bilateral (both) wrist restraints, and bilateral ankle restraints (restraints applied to both wrists and both ankles to limit movement while ensuring patient safety) to prevent repeated attempts to remove medical lines and dressings. During a concurrent interview and record review on 11/20/2025 at 1:47 p.m. with the Assistant Director of the Medical-Surgical (M/S, a specialty focused on the care of patients experiencing general health conditions) Unit (AD 1), Patient 25’s restraint monitoring flowsheet (a clinical documentation tool used to record regular assessments and care provided while a patient is in restraints), was reviewed. AD 1 stated that nursing staff were required to check the restraint site for skin integrity (the state of the skin being intact and undamaged) and pulse, as well as assess the patient’s hygiene needs and provides comfort measures while the patient was restrained. AD 1 confirmed that restraint monitoring should be performed and documented every two (2) hours. AD 1 reviewed Patient 25’s restraint monitoring flowsheet and verified that there was no documentation of restraint monitoring between 3:00 p.m. and 10:00 p.m. on 10/27/2025, indicating a seven-hour gap in required monitoring. During an interview on 11/20/2025 at 2:47 p.m. with the Psychiatric Liaison Nurse (PLN), the PLN stated, “We do teach nurses here to document restraint monitoring every two hours. Patients have the right not to be restrained, and nurses are responsible for checking on their patients and ensuring their safety while under restraints.” The PLN also said that failure to monitor patients (including Patient 25) in restraints could lead to complications such as skin breakdown, nerve damage, and other complications commonly associated with restraint use (such as psychological distress, reduced blood flow, delayed recognition of medical deterioration [a failure to detect worsening clinical signs or symptoms in a timely manner, which can result in serious harm or delayed treatment]). During an interview on 11/20/2025 at 3:03 p.m. with the Assistant Director of the Medical-Surgical (M/S) Unit (AD 1), AD 1 stated: “From 3:00 p.m. to 10:00 p.m. on 10/27/2025, there is no documentation of the restraint use. If the restraint had been discontinued by the nurse, the term ‘discontinued’ would have appeared in the flowsheet. However, the flowsheet documentation ends at 3:00 p.m. and indicates ‘continued’, and then resumes at 11:00 p.m. on 10/27/2025, once Patient 25 is admitted to the ICU (Intensive Care Unit: a specialized unit that provides intensive treatment and monitoring for patients with severe or life-threatening conditions requiring constant care).” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Use Policy,” dated 4/2024, the P&P indicated: “-Assessment and documentation of restraints must be performed at a minimum of every two hours. -Discontinuing restraints: a. Restraint must be discontinued at the earliest possible time. b. Document the time restraint was discontinued in the electronic medical record.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(iii) [there must be documentation in the patient’s medical record of] Alternatives or other less restrictive interventions attempted (as applicable); This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that for one of 39 sampled patients (Patient 25), there was evidence indicating that less restrictive options were implemented before escalating to the use of multiple types of restraints (used to stop a patient from moving freely when they might hurt themselves or others), in accordance with the facility’s policy regarding restraints use. The behavioral justification for using multiple restraints (Four bed rails up [considered a restraint when used to prevent a patient from voluntarily getting out of bed], Bilateral wrist restraints [devices applied to both wrists to limit arm movement], and Bilateral ankle restraints [devices applied to both ankles to restrict leg movement]), was not documented. This deficient practice had the potential to result in violations of Patient 25’s rights (the basic rules of care that ensure patients are treated with dignity, respect, and safety, including the right to make decisions about their care and to be free from unnecessary restraints), which undermines the patient’s right to be free from unnecessary restraint. In addition, the deficient practice had the potential to result in physical harm to Patient 25, such as nerve damage (injury to the nerves caused by prolonged or improper use of physical restraints, such as wrist or ankle strap), emotional suffering, and delayed clinical reassessment (a failure to evaluate a patient’s condition in a timely manner after an intervention). Findings: During a review of Patient 25’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 10/25/2025, the H&P indicated, Patient 25 was admitted to the facility on 10/25/2025 with diagnosis of toxic hepatic encephalopathy (a condition where a buildup of toxins, normally cleared by the liver, harms the brain’s function). During a review of Patient 25’s “Order History (a section of the medical record that lists all physician orders, including those for restraints),” dated 10/25/2025 through 10/27/2025, the record indicated that Patient 25 was in restraints: Four bed rails up (considered a restraint when used to prevent a patient from voluntarily getting out of bed), bilateral wrist restraints (devices applied to both wrists to limit arm movement), and bilateral ankle restraints (devices applied to both ankles to restrict leg movement). During a concurrent interview and record review on 1/19/2025 at 1:47 p.m. with the Assistant Director of the Medical-Surgical (M/S, a specialty focused on the care of patients experiencing general health conditions) Unit (AD 1), AD 1 stated that under the restraint monitoring assessment, which was documented every 2 hours from 10/25/2025 through 10/27/2025 at 3:00 p.m., the documentation indicated justification as risk for unintentional self-harm: repeated attempts to remove or tamper with medical lines, tubes, equipment, and dressings. AD 1 also said that documentation of less restrictive alternatives (interventions or strategies used to manage a patient’s behavior or ensure safety without physically restraining them) to restraints should only be documented once at the initiation of restraints with each new order. During an interview on 1/19/2025 at 2:36 p.m. with the Assistant Director of the Medical-Surgical Unit (AD 1), AD 1 stated that the restraint order indicated the patient (Patient 25) was removing lines and dressings, which was why the patient (Patient 25) was placed in four-point restraints (refer to a type of physical restraint in which a patient’s both wrists and both ankles are secured, typically to a bed or stretcher, to restrict all limb movement) and had bedside rails up. During an interview on 11/19/2025 at 2:47 p.m. with the Psychiatric Liaison Nurse (PLN), the PLN said that restraint use was dependent on the patient’s behavior at the time. Staff were trained to use the least restrictive option and must justify restraint use based on observed behavior. PLN stated that nurses could document what behavior triggered restraint use in the free-text section of the non-violent restraint flowsheet or in progress notes. Restraints should not be used based on past behavior. If the patient was no longer showing the behavior, restraints should have been reduced or removed. During the same interview on 11/19/2025 at 2:47 p.m. with the Psychiatric Liaison Nurse (PLN), the PLN said that nurses were responsible for reassessing the patient and downgrading restraints as soon as it was safe. The PLN said that being free from restraints was a patient right. PLN stated “Restraints must not be used for staff convenience, retaliation, or punishment.” PLN also said that documentation must show that restraints were used only as a last resort after other options were considered. During an interview on 11/19/2025 at 2:56 p.m. with the Assistant Director of the Medical-Surgical Unit (AD 1), AD 1 stated that the facility’s practice was to document the specific behavior that warranted restraint use, such as “purposely being aggressive,” and that these behaviors should have been clearly documented in Patient 25’s record. AD 1 further stated, “I do not see anything documented by the nurses to justify using three different types of restraints continuously and simultaneously.” During a review of the facility’s policy and procedure (P&P) titled, “Restraint and Seclusion Use Policy,” dated 4/2024, the P&P indicated: “Clinical justification: Restraint orders include the clinical justification or patient behaviors that interferes with medical treatment and physical safety of the patient. -Initiation: In situations which may bring immediate injury to the patient, the least restrictive restraint may be applied by, or under the supervision, of a licensed provider. -Assessment and documentation: a. Patient assessment is performed at a minimum of every 2 hours and documented in the electronic medical record b. Patient plan of care reflects assessment and goal of intervention -Discontinuing restraints: a. Restraints must be discontinued at the earliest possible time b. Document the time restraint is discontinued in the electronic medical record.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to: 1. Ensure that a registered nurse (RN) supervised and evaluated the nursing care for one (1) of 39 sampled patients (Patient 1), in accordance with the facility’s policies and procedures, when: 1.a. Patient 1 was not reassessed after showing signs of disorientation (a state of confusion about surroundings, time, or identity) on 3/11/2025 at 7:41 a.m., even though, at the time of admission to the medical-surgical unit on 3/8/2025, Patient 1 was alert and oriented ×4 (aware of person, place, time, and situation). On 3/11/2025 at 7:41 a.m., Registered Nurse (RN) 2 documented Patient 1 was disoriented to time (unable to correctly identify the current time or date). No follow-up neurological (a check to see how well the brain and nerves are working, including memory, alertness, movement, and how the body reacts to touch or sound) or focused assessment (a targeted evaluation of the patient’s mental and physical condition) was documented, until the Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration) was activated at 9:30 p.m. on the same day (3/11/2025). This deficient practice resulted in Patient 1 not receiving timely clinical evaluation, delayed recognition of deterioration, and a missed opportunity for early intervention, likely contributed to Patient 1’s continued decline and eventual death on 3/12/2025 at 11:57 p.m. 1.b. Patient 1 did not receive continuous monitoring of oxygen saturation levels or escalation of care in response to increasing oxygen requirements, despite a physician’s order for continuous pulse oximetry (a non-invasive method used to measure the level of oxygen in the blood) dated 3/8/2025. On 3/11/2025, the patient’s (Patient 1) oxygen needs increased from 2 liters per minute (L/min) via nasal cannula (a small tube placed in the nostrils to deliver low-flow oxygen) to 3L at 9:26 a.m., then to 5L at 12:24 p.m., followed by the use of Bilevel Positive Airway Pressures (BiPAP, a non-invasive machine that helps a person breathe by pushing air into the lungs), and ultimately a non-rebreather mask at 15L (NRM, a face mask that delivers high-flow oxygen in emergency situations). Despite these escalating oxygen needs, there was no documentation of continuous oxygen saturation monitoring, reassessment, or physician notification during this period. During an interview on 11/18/2025 at 11:00 a.m., Registered Nurse (RN) 1 confirmed that no additional monitoring or interventions were performed. This deficient practice resulted in Patient 1 not receiving timely recognition of respiratory decline, delayed escalation of care, and likely contributed to the patient’s deterioration. 1.c. The physician was not notified of Patient 1’s altered mental status or increasing oxygen requirements during a 12-hour period on 3/11/2025. Documentation indicated that Patient 1 became disoriented to time at 7:41 a.m. and required escalating oxygen support throughout the day. Review of Patient 1’s medical record indicated no documentation of physician notification between 7:41 a.m. and 7:47 p.m., until the RRT was activated. During an interview on 11/18/2025 at 11:00 a.m., RN 1 confirmed that the physician was not notified during this time. This deficient practice delayed medical evaluation and intervention by the physician, resulting in Patient 1 continuing to deteriorate without timely medical oversight. 1.d. No nursing interventions or activation of the Rapid Response Team (RRT) or Code Brain (a hospital protocol for suspected stroke [occurs when blood flow to a part of the brain is interrupted, causing brain cells to die] or acute neurological changes) occurred between 7:41 a.m. and 7:47 p.m. on 3/11/2025. Patient 1 exhibited sign of clinical deterioration beginning at 7:41 a.m., including disorientation to time and escalating oxygen requirements. Patient 1’s oxygen support increased from 2L via nasal cannula to 3L at 9:26 a.m., 5L at 12:24 p.m., followed by BiPAP, and ultimately a non-rebreather mask at 15L. Review of the medical record showed no documentation of nursing interventions (actions taken to address a patient’s clinical needs) or activation of the RRT or Code Brain until 7:47 p.m. This deficient practice resulted in Patient 1 not receiving timely clinical response to neurological and respiratory decline. These failures resulted in a delay in care and likely contributed to a fatal outcome. Patient 1 died on 3/12/2025 at 11:57 p.m. 2. Ensure one of 39 sampled patient’s (Patient 13) pain level was reassessed within one hour after administering a medication to relieve pain or after performing interventions to relieve pain, in accordance with the facility’s policies and procedures regarding pain management. This deficient practice had the potential for Patient 13’s pain to be unrelieved or ineffectively managed. 3. Ensure that nursing staff completed the required wound assessments, including measurements of pressure injuries for one of 39 sampled patients (Patient 4), in accordance with the facility’s policy regarding wound assessment and documentation. This deficient practice placed Patient 4 at risk for delayed wound treatment, deterioration of the wounds, and infection. On 11/20/2025 at 4:35 p.m., the survey team called a second Immediate Jeopardy (IJ, a situation in which the facility’s failure to meet one or more regulatory requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Director of Licensure, Accreditation & Regulation (DLAR), Regulatory Specialist (RS) 1, and Regulatory Specialist (RS) 2. The IJ was called due to the facility’s failure to ensure that a registered nurse (RN) supervised and evaluated nursing care for Patient 1 in accordance with facility’s policies and procedures. Nursing staff failed to reassess Patient 1following a documented change in mental status (disorientation to time, meaning the patient was confused about the current time), failed to monitor and escalate care in response to increasing oxygen requirements, and failed to notify the physician of the patient’s deteriorating condition (when a patient’s condition gets worse, moving from a stable state to an unstable one that puts them at risk for serious problems like organ damage or even death). During a concurrent interview and record review with RN 1 on 11/18/2025, Patient 1’s medical record indicated a documented change in mental status on 3/11/2025 at 7:41 a.m. RN 1 confirmed that no follow-up neurological or focused assessment (a targeted evaluation of the patient’s brain function or specific symptoms) was performed until the Rapid Response Team (RRT, a group of healthcare professionals who respond quickly to signs of patient deterioration) was activated at 7:47 p.m. (12 hours after initially documented). Patient 1’s oxygen requirements escalated significantly throughout the day on 3/11/2025, from 2 liters per minute (L/min) via nasal cannula (a device that delivers oxygen through the nose) to 5 L/min, then to BiPAP (Bilevel Positive Airway Pressure, a machine that helps with breathing by providing two levels of air pressure), and ultimately to a non-rebreather mask at 15 L/min (NRM, a face mask that delivers high concentrations of oxygen). Despite these changes, there was no documentation of continuous oxygen saturation monitoring (tracking the level of oxygen in the blood), no reassessment, and no physician notification during this period. The physician was not notified of Patient 1’s altered mental status or increasing oxygen needs between 7:41 a.m. and 7:47 p.m., despite signs of clinical decline. No nursing interventions or escalation of care (such as activating the RRT or initiating a Code Brain, which is a facility-specific emergency response for neurological changes) occurred during this critical period, even though Patient 1 met the criteria for both. These omissions resulted in a failure to provide timely and appropriate care. The delayed recognition of clinical deterioration likely contributed to Patient 1’s health decline and subsequent death on 3/12/2025. On 11/212025 at 2:45 p.m., the facility submitted an Immediate Jeopardy Removal Plan (IJRP, interventions to correct the deficient practice) for review and approval. The IJRP included the following: The expectation of the nurse to perform required reassessment of patient, document changes in condition, to notify providers promptly of changes in patient’s condition, intervene as required and appropriate to the situation, and to activate the Rapid Response Team (RRT) without delay, was immediately reviewed and reinforced with nursing staff (medical-surgical, ICU, emergency department, women & children, and peri-op) from night shift (11/20/25) and day shift (11/21/2025), in person through staff huddles and 1:1. The Education Tip Sheet that addresses the nursing expectation to perform reassessment of patient, document changes in condition, to notify providers promptly of changes in patient’s condition, intervene as required and appropriate to the situation, and to activate the Rapid Response Team (RRT) without delay was sent via email to nursing staff who are scheduled to work (medical-surgical, ICU, emergency department, women & children, and peri-op) to provide the opportunity to review before they present to their scheduled shift. All nurses will receive this review and reinforcement in person during staff huddles and 1:1 until every nurse working in these departments have received this review and reinforcement. Sign in sheets are signed by the nurses to validate the nurse received the review and reinforcement of nurse’s expectation to perform reassessment of patient, document changes in condition, to notify providers promptly of changes in patient’s condition, intervene as required and appropriate to the situation, and to activate the Rapid Response Team (RRT) without delay. The unit director, assistant nurse manager, nursing professional development practitioner, and/or charge nurse will continuously monitor for documentation of reassessments, changes in condition of patient and evidence of provider notification, appropriate interventions performed and documented, and timely activation of RRT for situations warranting escalation, to validate the nurse is following policy and procedure as it pertains to the situation. If any non-compliance is observed, the unit director, assistant nurse manager, nursing professional development practitioner, and/or charge nurse will intervene immediately to ensure the safety of the patient. The expectation for nurses to intervene when patients experience changes in mentation and oxygen needs, was immediately reviewed and reinforced with nursing staff (medical-surgical, ICU, emergency department, women & children, and peri-op) from night shift (11/20/25) and day shift (11/21/2025), in person through staff huddles and 1:1. The Education Tip Sheet that addresses the expectation for the nurses to intervene when patients experience changes in mentation and oxygen needs was sent via email to nursing staff who are scheduled to work (medical-surgical, ICU, emergency department, women & children, and peri-op) to provide the opportunity to review before they present to their scheduled shift. All nurses will receive this review and reinforcement in person during staff huddles and 1:1 until every nurse working in these departments have received this review and reinforcement. Sign in sheets are signed by the nurses to validate the nurse received the review and reinforcement of expectation for the nurses to intervene when patients experience changes in mentation and oxygen needs. The unit director, assistant nurse manager, nursing professional development practitioner, and/or charge nurse will continuously monitor for any occurrences of patients experiencing mentation changes and changes in oxygen needs to ensure the nurse is addressing the issues as required. If any non-compliance is observed, the unit director, assistant nurse manager, nursing professional development practitioner, and/or charge nurse will intervene immediately to ensure the safety of the patient. On 11/21/2025 at 4:48 p.m., in the presence of the facility’s Senior Vice President Chief Nursing Executive (SVPCNE), DLAR, RS 1, and RS 2, the facility was informed that the team was unable to validate the IJRP through observation, interview and record review. On 11/21/2025 at 4:58 p.m., the facility was placed on a 23-day termination track (a process that places a hospital or other provider on a termination track if deficiencies are found that pose an immediate jeopardy to patient health and safety). On 11/21/2025 at 5 p.m., the survey team exited the facility without removing the Immediate Jeopardy. On 12/5/2025 at 3:57 p.m., the IJ was removed in the presence of the facility’s DLAR, RS 1 and RS 2. The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. Findings: 1.a. During a review of Patient 1’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 3/8/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Emergency Department (ED) after being involved in a motor vehicle accident. The H&P indicated Patient 1 reported right chest/rib pain that worsens with movement. The H&P further indicated that Patient 1’s past medical history included open heart surgery. H&P indicated that upon assessment Patient 1 was “Alert and oriented to self, place, and time. Able to follow commands and make needs known.” During a concurrent interview and record review on 11/18/2025 at 11:00 a.m. with Registered Nurse (RN) 1, Patient 1’s medical record, the flowsheet section titled, “Neuro Check (Neurological assessment performed by clinical staff to see how well a person’s brain and nervous system are working, including questions and simple physical tests to evaluate memory, alertness, movement, balance, and how the body reacts to touch or sound),” dated from 3/8/2025 (the date of admission to the medical-surgical unit from the Emergency Department) through 3/11/2025, was reviewed. The neurological assessment indicated that from 3/8/2025 until 7:41 a.m. on 3/11/2025, Patient 1 was alert and oriented to self, place, and time. Beginning at 7:41 a.m. on 3/11/2025, the assessment indicated that Patient 1 became disoriented to time (to be confused about the current time, day, month, or year. It is a mental state where a person has lost their sense of time and may not know what to expect at a given hour or even what day it is). RN 1 confirmed that there was no reassessment of Patient 1’s mentation (mental status) or documentation explaining the possible cause of the disorientation. RN 1 stated that when a patient’s mentation changes, the RN should perform a focused assessment and take a full set of vital signs. RN 1 said that Patient 1’s oxygen saturation might be low, requiring increased oxygen supplementation. During an interview on 11/19/2025 at 11:09 a.m. with the Assistant Manager of the Medical-Surgical Unit (NM) 3, NM 3 stated that when a patient experiences a change in mental status, such as being previously oriented to time and then suddenly unable to state the correct time or date, the RN must take a full set of vital signs (measurements of temperature, pulse, respiration, and blood pressure), notify the charge nurse (the nurse responsible for overseeing the unit during a shift), and call the Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration)). The manager stated, “It is never wrong to call the RRT or Code Brain (a hospital protocol for suspected stroke or sudden neurological changes).” The manager further explained that if a patient continued to require increasing oxygen, the RN should complete a focused assessment (a targeted evaluation based on the patient’s symptoms), check the oxygen delivery device (such as a nasal cannula-a small tube placed in the nostrils to deliver oxygen) for proper placement, and notify the physician (the medical doctor responsible for the patient’s care). The manager emphasized that the RN must document the assessment, notify the physician, receive instructions, and carry them out. The charge nurse should also be involved to help coordinate care and support timely decision-making. During a review of the facility’s policy and procedure (P&P) titled, “Unit Scope of Services, 7 North Orthopedics/Trauma,” undated, the P&P indicated, “A complete reassessment is completed every 12 hours or when the status of the patient changes.” During a review of facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessment are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” 1.b. During a review of Patient 1’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 3/8/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Emergency Department (ED) after being involved in a motor vehicle accident. The H&P indicated Patient 1 reported right chest/rib pain that worsens with movement. The H&P further indicated that Patient 1’s past medical history included open heart surgery. H&P indicated that upon assessment Patient 1 was “Alert and oriented to self, place, and time. Able to follow commands and make needs known.” During a concurrent interview and record review on 11/18/2025 at 11:00 a.m. with Registered Nurse (RN) 1, Patient 1’s “Vital Signs,” flowsheet, was reviewed. RN 1 confirmed that on 3/11/2025, the patient’s (Patient 1) oxygen needs increased from 2 liters per minute (L/min) via nasal cannula (a small tube placed in the nostrils to deliver low-flow oxygen) to 3L at 9:26 a.m., then to 5L at 12:24 p.m., followed by the use of BiPAP (Bilevel Positive Airway Pressure-a non-invasive machine that helps a person breathe by pushing air into the lungs), and ultimately a non-rebreather mask at 15L (NRM, a face mask that delivers high-flow oxygen in emergency situations). Despite these escalating oxygen needs, there was no documentation of continuous oxygen saturation monitoring, reassessment, or physician notification during this period. RN 1 also confirmed that no additional monitoring or interventions were performed. During a concurrent interview and record review on 11/20/2025 at 10:39 a.m. with RN 3, the “Orders” section of Patient 1’s medical record, was reviewed. RN 3 confirmed that there was a physician’s order for continuous pulse oximetry monitoring (a non-invasive method used to measure the level of oxygen in the blood on continuous basis) from 3/8/2025 through 3/15/2025. RN 3 also confirmed that Patient 1 was not on continuous pulse oximetry monitoring on 3/11/2025. RN 3 stated that when a patient was on continuous pulse oximetry, the medical record would display a reading every minute, however, this was not in Patient 1’s Medical Record. During the same interview with RN 1, Patient 1’s “Vital Signs” flowsheet, was reviewed. The following oxygen saturation readings were documented on 3/11/2025: -7:41 a.m.: 93% on 3L (liters of supplemental oxygen) oxygen -9:26 a.m.: 94% on 3L oxygen -9:32 a.m.: 92% (no oxygen flow rate documented) -12:24 p.m.: 96% on 5L oxygen -12:24 p.m.: 92% on 5L oxygen (documented by respiratory therapist during breathing treatment) -3:23 p.m.: 91% on BiPAP (Bilevel Positive Airway Pressure, a non-invasive machine that helps a person breathe by pushing air into the lungs) -8:05 p.m.: 91% on non-rebreather mask (NRM, a face mask that delivers high-flow oxygen in emergency situations) at 15L oxygen -RN 3 stated each time a RN had to increase oxygen; there must be a reassessment within 5 to 10 minutes but no later than 15 minutes to see how the patient was doing after increased oxygen. RN3 confirmed that there was no evidence of a reassessment documented. During a review of Patient 1’s “Progress Note - Nursing,” dated 3/11/2025 and documented by RN 4, the following was noted: -At 7:20-7:40 p.m., the patient (Patient 1) was described as having labored breathing (difficulty breathing), using a nasal cannula with humidifier. The patient (Patient 1) was anxious and stated, “My lungs feel like they’re filling up again.” RN 4 documented diminished lung sounds (reduced airflow heard through a stethoscope) in all areas and audible fluid buildup when the patient spoke. The nursing note also indicated that the RN (RN 4) applied a pulse oximeter (a device that measures blood oxygen levels) and recorded a saturation of 80% on oxygen (not documented on Patient 1’s record the amount of oxygen Patient 1 was on) document and a heart rate of 140 beats per minute. RN 4 reported the condition to the crisis nurse, who advised calling the Rapid Response Team (RRT). -At 7:45 p.m., RN 4 called the RRT and placed the patient on a non-rebreather mask. The patient’s (Patient 1) oxygen saturation remained below 90% on 16L oxygen. The RRT assumed care. -At 8:23 p.m., a Code Blue (a hospital emergency code indicating a patient requiring immediate resuscitation) was called. During a concurrent interview and record review on 11/21/2025 at 3:52 p.m. with the Director of Respiratory Services (DIRR), Patient 1’s respiratory assessment flowsheet, dated 3/11/2025, was reviewed. The DIRR stated that switching a patient to BiPAP typically indicated the patient was decompensating (experiencing a worsening of their condition), and BiPAP was used to provide additional breathing support. The DIRR confirmed that at 3:23 p.m. when Patient 1 was switched to BiPAP, RRT should have been activated. The DIRR explained that when a patient showed a change in mentation (mental status) and requires increasing oxygen, the RN should consult the respiratory therapist (RT). The RT would then assess the patient and may recommend calling the RRT and notifying the physician to request an arterial blood gas (ABG-a blood test that measures oxygen and carbon dioxide levels to assess lung function). During the same concurrent interview and record review on 11/21/2025, the DIRR confirmed the change from 3L to 5L on 3/11/2025 at 12:24 p.m., oxygen was initiated by the RN (RN 4) and that there was no documentation indicating the RT was informed of the patient’s (Patient 1) increasing oxygen needs. The flowsheet showed that the RT administered a breathing treatment at 12:35 p.m. on 3/11/2025 while the patient was on 5L oxygen, but there was no documentation that the RN 4 had communicated the oxygen escalation. The DIRR stated that if the RT had been consulted when the oxygen requirement increased from 2L to 5L, the RT would have completed an assessment, recommended an ABG, and advised activation of the RRT. During a review of the facility’s policy and procedure (P&P) titled, “Oxygen Administration Devices and Pulse Oximetry Monitoring Policy: Clinical Manual/General Clinical,” dated 1/22/2019, the P&P indicated, “Continuous Pulse Oximetry: For any patient displaying persistent cardiopulmonary instability...irregular breathing patterns ...Procedure: Monitor V /S, pulse ox values, sensorial status and work of breathing.” During a review of the facility’s policy and procedure (P&P) titled, “Unit Scope of Services, 7 North Orthopedics/Trauma,” undated, the P&P indicated, “A complete reassessment is completed every 12 hours or when the status of the patient changes.” During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command: Duty to intervene Policy: Clinical Administrative,” dated 9/24/2019, the P&P indicated, “(name of the Facility) will support all staff in carrying out their independent duty to intervene in situations where they have knowledge of actions or inaction’s, which may cause harm to patients ... Staff members will utilize the appropriate chain of command when situations arise in which may cause harm to a patient are unresolved ... If impairment is suspected, staff should notify the immediate supervisor who would assure appropriate follow-up. In the event of a suspected impaired physician, the Medical Executive Committee has delineated the specific process for nurse communication of suspected impairment and the process for assuring that the medical needs of the patient are met.” During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessment are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” 1.c. During a review of Patient 1’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 3/8/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Emergency Department (ED) after being involved in a motor vehicle accident. The H&P indicated Patient 1 reported right chest/rib pain that worsens with movement. The H&P further indicated that Patient 1’s past medical history included open heart surgery. H&P indicated that upon assessment Patient 1 was “Alert and oriented to self, place, and time. Able to follow commands and make needs known.” During a concurrent interview and record review on 11/18/2025 at 11:00 a.m. with Registered Nurse (RN) 1, Patient 1’s “Vital Signs” flowsheet, was reviewed. The flowsheet indicated that at 12:35 p.m., Patient 1’s heart rate (HR, the number of heart beats per minute; the normal adult range is 60 to 100 beats per minute) was 102 beats per minute (BPM). RN 1 confirmed that this was above Patient 1’s typical range, which was documented as approximately 60 - 80 BPM. Patient 1’s blood pressure (BP, the force of blood pushing against the walls of the arteries; the normal adult range is approximately 90/60 to 120/80 millimeters of mercury [mmHg, a unit of measurement]) was recorded as 157/96 mmHg. RN 1 confirmed this was elevated compared to Patient 1’s usual BP, which was typically below 145 mmHg. During further review of Patient 1’s Vital Signs flowsheet, the flowsheet also indicated that on 3/11/2025, Patient 1’s oxygen requirements increased from 2 liters per minute (L/min) via nasal cannula (a small tube placed in the nostrils to deliver low-flow oxygen) to 3L at 9:26 a.m., then to 5L at 12:24 p.m., followed by the use of BiPAP (Bilevel Positive Airway Pressure, a non-invasive machine that helps a person breathe by pushing air into the lungs), and ultimately a non-rebreather mask at 15L (a face mask that delivers high-flow oxygen in emergency situations). RN 1 confirmed that during the time the patient (Patient 1) required increased oxygen support and had elevated vital signs, there was no documented evidence that a physician was notified. During a concurrent interview and record review on 11/18/2025 at 11:00 a.m. with Registered Nurse (RN) 1, Patient 1’s medical record, was reviewed. The flowsheet section titled, “Neuro Check,” dated from 3/8/2025 (the date of admission to the medical-surgical unit from the Emergency Department) through 3/11/2025, neurological assessment indicated that from 3/8/2025 until 7:41 a.m. on 3/11/2025, Patient 1 was alert and oriented to self, place, and time. Beginning at 7:41 a.m. on 3/11/2025, the assessment indicated that Patient 1 became disoriented to time (unable to correctly identify the current time or date). RN 1 confirmed that there was no reassessment of Patient 1’s mentation (mental status) or documentation explaining the possible cause of the disorientation within Patient 1’ medical record (MR). RN 1 also stated that there was no documented evidence that the physician was notified regarding Patient 1’s disorientation. During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessment are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command: Duty to Intervene Policy: Clinical Administrative,” dated 9/24/2019, the P&P indicated, “Staff members will utilize the appropriate chain of command when situations arise in which may cause harm to a patient are unresolved... If a physician, registered nurse, paraprofessional, technical or other member of the health care team has any reason to question the care provided to any patient or feels that appropriate consultation is needed and has not been obtained, he/she shall do the following: Problem-solve such questions/concerns with the individual directly involved (i.e. attending physician; nurse; etc.) involving house staff as appropriate. Take every reasonable approach to resolve the questions/concerns at the lowest organizational level possible. Initiate the chain of command appropriate to the designated area if he/she still feels that the question or concern has not been satisfactorily resolved. If a unanimous consensus on the corrective site and side cannot be agreed upon, then immediately proceed up the chain of command. Postpone the procedure until agreement is reached. If one of the physician members identified on the attached chain of command is not part of a specific unit, program, or service line, the next member on the chart who is a part of that unit, program, or service line should be contacted.” 1.d. During a review of Patient 1’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 3/8/2025, the “H&P” indicated, Patient 1 was admitted to the facility’s Emergency Department (ED) after being involved in a motor vehicle accident. The H&P indicated Patient 1 reported right chest/rib pain that worsens with movement. The H&P further indicated that Patient 1’s past medical history included open heart surgery. H&P indicated that upon assessment Patient 1 was “Alert and oriented to self, place, and time. Able to follow commands and make needs known.” During a review of Patient 1’s medical record (MR), the document titled “Rapid Response” report, dated 3/11/2025 at 7:47 p.m., was reviewed. The report indicated, “Reason for RRT: change in respiratory status; change in neurological status.” The report further indicated that Patient 1 was intubated (a procedure in which a tube is inserted into the airway to assist with breathing). During a review of Patient 1’s MR document titled “Surgery Trauma,” dated 3/11/2025, the note stated, “RRT called for desats (desaturation, a drop in the level of oxygen in the blood). 5 L to 15 L NRB (non-rebreather mask, a face mask that delivers high-flow oxygen in emergency situations) with O2 (oxygen) sats (saturation, the percentage of oxygen in the blood) in low 90s.” During a review of Patient 1’s MR document titled, “Code Blue Note,” documented by MD 4 and dated 3/11/2025, the note indicated, “I responded to an overhead code blue call and assumed the role of team ... CPR (cardiopulmonary resuscitation, a life-saving procedure that includes chest compressions and rescue breathing) was initiated ... was intubated (Patient 1).” During an interview on 11/18/2025 at 3:00 p.m. with the Director of the Surgical Intensive Care Unit (DSICU), the DSICU confirmed that staff were expected to perform focused assessments (targeted evaluations based on a patient’s symptoms), notify physicians immediately when a patient’s condition changes, and activate the Rapid Response Team (RRT-a specialized group of clinicians who respond to signs of patient deterioration) when interventions were ineffective or when clinical deterioration was observed. The DSICU stated that failure to take these actions would not align with the facility’s standard protocols. During an interview on 11/19/2025 at 11:09 a.m., with Registered Nurse (RN) 5, RN 5 stated that when a patient’s mentation changes from alert and oriented to being disoriented to time, the RN should immediately perform a focused assessment. This includes checking oxygenation, applying oxygen if needed, and calling a Code Brain and a RRT if the intervention did not improve the patient’s condition. During an interview on 11/19/2025 at 11:10 a.m., with Nursing Manager (NM) 3 of the Medical-Surgical units, NM 3 stated that when a patient required increasing oxygen support, the nurse must notify the physician. NM 3 further stated that physician notification was required because the patient (Patient 1) was experiencing a change in condition, and an order from the physician was necessary to increase oxygen delivery. NM 3 also stated that the criteria for activating a code were outlined in the facility’s education materials, protocol, and policy, and that all nurses received annual education on activating a Code Brain (a hospital protocol for suspected stroke or sudden neurological changes) and a Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration). During a concurrent interview and record review on 11/19/2025 at 12:25 p.m., with the Associate Director of Neurology (ADN 2), the Code Brain protocol titled, “Be Prepared for a Code Brain: Recognize Acute Stroke Symptoms & Call a Code Brain,” was reviewed. ADN 2 confirmed that when a patient exhibits any sudden confusion, a Code Brain may be activated. ADN 2 stated, “It is never wrong to call a Code Brain, because calling a Code Brain will bring resources and expertise to evaluate the patient.” During a review of the facility’s Rapid Response Program, educational materials provided by the Clinical Nursing Educator (CNE 2), undated, the educational materials indicated the following: Criteria for Rapid Response Team Activation (a team of healthcare professionals who respond quickly to a patient whose condition is deteriorating) includes, but is not limited to: a. Staff concern for patient condition b. Acute deterioration in neurological status (sudden worsening of brain function, such as confusion, loss of consciousness, or stroke symptoms) c. Acute deterioration in respiratory status (sudden worsening of breathing, such as shortness of breath or low oxygen levels) d. Acute deterioration in heart rate or blood pressure (sudden changes in pulse or blood pressure that may indicate a medical emergency) During a review of the facility’s policy and procedure (P&P) titled, “Rapid Response Policy,” dated 6/11/2024, the P&P indicated, -“To provide timely and appropriate care for INPATIENT adult and pediatric patients who are showing signs of instability and/ or deterioration. -To provide support to clinical staff in the management of unstable patients and evaluate performance improvement opportunities. -To improve access and outcomes for patients with the potential or actual need for critical care. -To promote collaboration, communication, and education between patient care areas and different services. -To promote and expand interprofessional mentoring and education .... Clinical Surveillance of Adult Inpatients During a review of facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessment are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” 2. During a review of Patient 13’s History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 6/09/2025 at 2:05 6:09 p.m., the H&P indicated the following: Patient 13 had chief complaints of diffuse (widespread, not localized) pain and drenching (soaked) night sweats. Patient 13 with a history of recurrent sepsis (a life-threatening condition where the body’s response to an infection damages its own tissues and organs) ...Psychogenic Non-Epileptic Seizures (mimic seizure [convulsion] but are not caused by abnormal electrical activity, instead they are stress-related and have a psychological origin), osteogenesis imperfecta (a genetic disorder that causes bone to be brittle and break easily) ...Ehlers-Danlos Syndrome (EDS, a group of inherited disorders that cause a defect in connective tissues, primarily affecting skin, joints, and blood vessels, symptoms include stretchy joints, fragile skin, easy bruising and chronic [persistent or recurrent] pain) ...fibromyalgia (a chronic disorder causing widespread pain). During a concurrent interview and record review on 11/19/2025 at 1:57 p.m. with the Nursing Professional Development Practitioner (NPDP 1), Patient 13’s pain assessments and Medication Administration Record (MAR), were reviewed. NPDP 1 stated the following: On 6/10/2025 at 3:51 a.m., Patient 13 had pain rated at 10 (worse pain on a pain scale). Patient 13 was medicated for pain. Patient 13’s pain was not reassessed within one hour, after administering the pain medication. NPDP 1 verified that Patient 13’s next pain assessment was on 6/10/2025 at 6:16 a.m., and Patient 13 was still having pain, rated at 10. NPDP1 said the pain level should be reassessed to determine if the medication was effective, to provide additional pain-relieving interventions to reach accepted pain level goal of zero (0-5), and to notify the provider for additional orders. During a concurrent interview and record review on 11/19/2025 at 2:33 p.m. with the Nursing Professional Development Practitioner (NPDP 2), Patient 13’s pain assessments and Medication Administration Record (MAR), were reviewed. NPDP 2 stated the following: On 6/11/2025 at 6:18 a.m., Patient 13 had a pain level of 8 and medication was given. Patient 13’s pain level was not assessed within one (1) hour after administering the pain medication (Oxycodone [a strong prescription medication]) by mouth. The next pain assessment was done at 8 a.m., and Patient 13’s pain level was still 8. NPDP 2 said that Pain level should be reassessed within 30 minutes after receiving intravenous (IV, in the vein) pain medication and within one (1) hour after receiving an oral pain medication, to check for effectiveness and if pain was not relieved, then other pain-relieving interventions could be implemented or the provider could be notified, for possible additional orders. In addition, at 8 a.m., on 6/11/2025, pain interventions for Patient 13 included applying heat, repositioning, emotional support, relaxation technique and medication. There was no reassessment of pain within an hour to assess for the effectiveness of the interventions. During the same concurrent interview and record review on 11/19/2025 at 2:33 p.m. with the Nursing Professional Development Practitioner (NPDP 2), Patient 13’s pain assessments and Medication Administration Record (MAR), were reviewed. Patient 13’s MAR indicated that on 6/11/2025 at 8:23 p.m., Patient 13 received oxycodone by mouth for pain rated at 9. On 6/11/2025 at 8:53 p.m., Patient 13’s pain level was still 9. The next pain assessment was done next on 6/12/2025 at 2:52 p.m. NPDP 2 verified the pain reassessment should have been done one hour after giving an oral pain medication. During a review of Patient 13’s “Pain Assessments,” the pain assessments indicated the following: -On 6/10/2025 at 3:51 a.m., Patient 13 had a pain rating of 10 (pain scale, measures pain where 1 is mildest and 10 is the worst possible pain, medication given as an intervention). -On 6/10/2025 at 6:16 a.m., Patient 13 had pain rating of 10. No intervention was documented. -On 6/10/2025 at 9 a.m., Patient 13’s stated/functional pain goal was 0. Patient 13’s pain rating was 10 and medication was given. -On 6/11/2025 at 6:18 a.m., Patient 13’s pain rating was 8 and medication was given. -On 6/11/2025 at 8 a.m., Patient 13’s stated/functional pain goal was 5. Patient 13’s pain rating was 8. Interventions included applying heat, repositioning, emotional support, relaxation technique and medication. -On 6/11/2025 at 9:29 a.m., Patient 13’s pain rating was 9 and medication was given. No reassessment of pain level documented. -On 6/11/2025 at 8:23 p.m., Patient 13’s pain rating was 9 and medication was given. -On 6/11/2025 at 8:53 p.m., Patient 13’s pain rating was 9 and medication was given. No reassessment of pain level documented. -On 6/12/2025 at 2:52 a.m., Patient 13’s pain rating was 9 and medication was given. No reassessment of pain level documented. During a review of Patient 13’s “Medication Administration Record (MAR),” the MAR indicated the following: -On 6/09/2025 at 8:48 p.m., to 6/10/2025 at 9:02 p.m., morphine (a potent pain medication used to treat severe pain) 2 milligrams (mg) was ordered to be given every four (4) hours as needed for breakthrough pain (sudden, temporary flare-up of severe pain that “breaks through” the pain relieve provided by a regular, long-acting pain medication regimen for chronic pain): must give oral pain medication first. -Morphine was given on 6/10/2025 at 3:51 a.m. -On 6/10/2025 at 10:53 p.m., oxycodone (a strong prescription pain medication) immediate release (IR) tablet, 15 milligrams (mg) was ordered to be given by mouth, every four (4) hours as needed for severe pain (7-10). -Oxycodone was given 6/11/2025 at 1:45 a.m., 6:18 a.m., 11:10 a.m., 4:02 p.m., and 8:23 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management Adult and Pediatric,” dated 10/14//2025, the P&P indicated the following: 1. Assessment 1. Initial, ongoing and reassessment of pain. a. Initial pain assessment is done upon admission including patient stated/comfort goal and then at least every shift, using the appropriate pain score-rating tool. b. Patients with pain present: On-Going assessment/documentation includes at least every four (4) hours or more frequently as clinically indicated. c. Reassessment of pain level less than 1 hour after intervention or as clinically indicated. Use the same pain scale used for the pre-intervention pain assessment unless otherwise clinically indicated. B. Analgesic Dosing Guidelines: Pain medications should be administered per specific provider orders written in eMAR (electronic Medication Administration Record) and correlating to the ...Patient Stated Functional Pain Goal and Scale. 1. Take the following action post-pain intervention assessment when the pain rating is greater than the patient’s acceptable pain goal: a. Administer pain medication as ordered. b. Notify the provider if medication was ineffective. c. non-pharmacologic (treatment or methods that do not involve medication) therapies should be offered to patients whenever possible (i.e. hot/cold application, music therapy, positioning, etc.) 2. Collaborate with the provider to alter the pain management intervention(s) when the pain scores consistently remain greater than the patient’s acceptable pain/comfort goal or when the patient’s pain consistently returns before the next dose is due. 3. During a review of Patient 4’s “History and Physical (H&P),” dated 11/10/2025, the H&P indicated that Patient 4 had a medical history of hyperlipidemia (excess fats in the blood), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), who was found down (fell to the floor). During a review of Patient 4’s “Flowsheet” titled, “PI (Pressure Injury- localized skin and tissue damage from constant pressure, friction, or shear, often over bony areas) Flowsheet Treatment,” dated 11/12/2025, the flowsheet indicated ... “Pressure Injury Elbow Right ... Pressure Injury Staging: Possible Stage III, Stage IV ... Pressure Injury Elbow Left ... Pressure Injury Staging: Possible Stage II (Clear blister, open) ...” There were no measurements documented for the pressure injuries to the right and left elbow. During a review of Patient 4’s “Flowsheet” titled, “Head to Toe,” dated 11/13/2025, the flowsheet indicated that Patient 4 had a Braden Scale (used to evaluate a patient’s risk for developing pressure injuries; A lower score indicates a higher risk of pressure ulcers, with a total score of 18 or less suggesting a patient is at risk and needs preventative measures) Score of 19 (a patient has no risk or very low risk for developing pressure injuries). During a review of Patient 4’s “Wound photos” titled, Media Information, dated 11/11/2025, the document indicated that there were photos taken of Patient 4’s pressure injuries on the right and left elbows but there were no measurements of the pressure injuries documented. During an interview on 11/18/2025 at 2:00 a.m. with the Nursing Professional Development Practitioner (NPDP 1), the NPDP 1 stated that assessments should be accurately documented as ordered and that per policy, only abnormal findings should be documented. During an interview on 11/18/2025 at 3:00 p.m. with Registered Nurse 6 (RN 6), RN 6 stated that when a patient was admitted to the facility with pressure injuries, skin assessments and photos with measurements should be done. RN 6 stated that measurements of the wounds measure the progression to determine if the wound was healing. During an interview on 11/19/2025 at 10:30 a.m. with the Wound Ostomy Continence Nurse (WOCN), the WOCN stated that it was recommended to measure a wound when photos were taken, and measurements of wounds were important to look at the progression or deterioration of the wound. During a review of the facility’s policy and procedure (P&P) titled, “Wound and Pressure Injury Photographic Documentation Clinical Guideline,” undated, the P&P indicated ... “The accuracy and detail of a picture can assist in appropriate wound staging and in properly assessing the extent of healing ... II. Procedure ... B. Using a Scale 1. The inclusion of a scale/ruler provides visual reference for the size of the wound. 2. It should be visible within the photo. 3. It should be small enough to not obscure anatomical landmarks. 4. It should be long enough to measure the wound. 5. All wounds are measured in centimeters. C. Frequency ... 1. Within 24 hours of admission ... 4. Any significant change in wound/injury appearance.” During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity Assessment and Interventions Clinical Guidelines: General Clinical/Clinical Guidelines, dated 5/17/2022, the P&P indicated ... “Documentation ...Wound assessment to include size, shape, orientation and anatomical location of the lesion, drainage or any other pertinent information.”

“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: 48212 Based on observation, interview and record review, the facility failed to: 1. Ensure its nursing staff assessed/re-assessed one (1) of 39 sampled patient’s (Patient 25) change of condition (any significant change, declining, or otherwise altering, from their usual health and functional status, requiring observation, documentation, and often a revised care plan) and provide interventions in a timely manner, in accordance with facility’s policies and procedures regarding hypoglycemia (low blood sugar, a condition where the blood glucose levels drop below the normal range, typically below 70 mg/dL [unit of measurement]) protocol and assessment/re-assessment, when: 1.a. Patient 25 had a blood glucose (sugar) of 49 mg/dL (milligram per deciliter, a unit of measurement) on 10/27/2025 at 8:50 a.m. (blood sugar was not re-checked, hypoglycemia protocol [a standardized set of steps for treating low blood sugar], not followed, and Dextrose [a sterile solution used to provide the body with extra water and sugar] not administered until 3 p.m.) 1.b. Patient 25 had a change of respiratory status on 10/27/2025 at 8 p.m. (Respiratory rate [breaths per minute] was in 30’s from 8 p.m. to 9:43 p.m.). This deficient practice resulted in Patient 25’s condition declining without immediate intervention. A Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration) was eventually called on 10/27/2025 at 9:43 p.m. Patient 25 was intubated (a procedure in which a tube is inserted into the airway to assist with breathing). As of 11/20/2025, Patient 25 was in the facility’s Intensive Care Unit (ICU, a special hospital department for patients with life-threatening illnesses or injuries that require constant, intensive medical care) and remained intubated. 2. Ensure one of 39 sampled patient’s (Patient 32) complete head-to-toe (an evaluation of the body system to establish a baseline, identify current health status and detect potential or existing problems) assessment, was accurately documented, in accordance with facility’s policy and procedure titled, “Documentation: Patient Care Process Policy Clinical Administrative.” This deficient practice had the potential to result in a delay of necessary care and treatment for patient 32, when critical assessment information is not properly documented to properly guide treatment decisions. 3. Ensure nursing staff notified the physician and document one of 39 sampled patient’s (Patient 29) physician notification of heart rhythm (the pattern of the heart’s electrical activity, which controls its beating) changes, when Patient 29 had premature ventricular contractions (PVCs, extra heartbeat) and ventricular tachycardia (V-tach, fast heart rhythm that does not allow the heart to fill with blood and pump well throughout the body), in accordance with the accepted standards of nursing practice regarding documentation and the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative.” This deficient practice had the potential for crucial patient information not to be communicated, which could cause a delay in implementing necessary medical interventions for Patient 29 and for the care team to not know what had occurred for Patient 29. 4. Ensure one of 39 sampled patient’s (Patient 4) pressure injury treatments were consistently implemented and documented by the nurses, including a timely evaluation by the Wound Ostomy Care Nurse (WOCN) after a consultation was ordered, in accordance with the facility’s policy regarding wound care treatment. This deficient practice placed Patient 4 at increased risk for worsening of pressure injury which may result in possible prolonged hospitalization, delayed recovery and/or infection. On 11/20/2025 at 4:32 p.m. the survey team called the first Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Director of Licensure, Accreditation & Regulation (DLAR), Regulatory Specialist (RS) 1, Regulatory Specialist (RS) 2. The IJ was called due to the facility’s failure to ensure that nursing staff assessed and reassessed a patient’s (Patient 25) change in condition (any significant or sudden alteration in a patient’s physical, mental, or behavioral state that deviates from their baseline, indicating a need for medical attention and potentially a change in the care plan) and provided timely interventions, in accordance with facility policies and procedures. On 10/27/2025 at 8:50 a.m., Patient 25 experienced a critically low blood glucose (sugar) level of 49 mg/dL (milligrams per deciliter, a unit of measurement); but did not receive treatment or a recheck within the required 15-minute window. Dextrose (is a sterile solution used to provide the body with extra water and carbohydrates [calories from sugar]) was not administered in accordance with the facility’s protocol until 3:02 p.m., over six hours later. Additionally, Patient 25 exhibited signs of respiratory deterioration (the worsening of a person’s breathing, which can lead to a medical emergency known as respiratory failure) beginning at 8:00 p.m. the same day (10/27/2025), with a respiratory rate (the number of breaths they take in one minute) in the 30s (a regular respiratory rate for a healthy adult at rest is between 12 and 20 breaths per minute), but no reassessment or physician notification occurred until a Rapid Response Team (RRT, a specialized group of clinicians who respond to signs of patient deterioration) was called at 9:43 p.m. Patient 25 was subsequently intubated (a procedure in which a tube is inserted into the airway to assist with breathing) and transferred to the Intensive Care Unit (ICU, a special hospital department for patients with life-threatening illnesses or injuries that require constant, intensive medical care), where they remained intubated as of 11/20/2025. These failures resulted in delayed recognition and treatment of hypoglycemia (low blood sugar, a condition where the blood glucose levels drop below the normal range, typically below 70 mg/dL [unit of measurement]) and respiratory distress (difficulty breathing, indicated by signs like rapid or shallow breathing, chest retractions, and a bluish skin tone), placing the patient at risk for serious harm and contributing to the patient’s clinical deterioration (when a patient’s condition gets worse, moving from a stable state to an unstable one that puts them at risk for serious problems like organ damage or even death). On 11/21/2025 at 2:45 p.m., the facility submitted an Immediate Jeopardy Removal Plan (IJRP, interventions to correct the deficient practice) for review and approval. The IJRP included the following: The expectation of the nurse to perform required assessments/reassessments and to notify providers of changes in patient’s condition in a timely manner, was immediately reviewed and reinforced with nursing staff (medical-surgical, ICU, emergency department, women & children, and peri-op [peri-operative, provides comprehensive care for patients before, during, and after a surgical procedure]) from night shift (11/20/25) and day shift (11/21/2025), in person through staff huddles and 1:1. The Hypoglycemia Protocol was also immediately reviewed and reinforced with the nursing staff (medical-surgical, ICU, emergency department, women & children, and peri-op) from night shift (11/20/25) and day shift (11/21/2025), in person through staff huddles and 1:1. The Education Tip Sheet that addresses the nursing expectation to assess/re-assess patients, notify physicians in a timely manner of changes in condition, and Hypoglycemia protocol was also sent via email to nursing staff who are scheduled to work (medical-surgical, ICU, emergency department, women & children, and peri-op) to provide the opportunity to review before they present to their scheduled shift. All nurses will receive this review and reinforcement in person during staff huddles and 1:1 until every nurse working in these departments have received this review and reinforcement. Sign in sheets are signed by the nurses to validate the nurse received the review and reinforcement of nurse’s expectation to assess/re-assess patients, notify physicians in a timely manner of changes in condition, and Hypoglycemia protocol. The unit director, assistant nurse manager, nursing professional development practitioner, and/or charge nurse will continuously monitor for any occurrence of abnormal labs, vital signs, changes in condition, notification of provider, documentation of required assessment/reassessment and interventions, and need for/actual activation of rapid response team, to validate the nurse is following policy and procedure as it pertains to the situation. If any non-compliance is observed, the unit director, assistant nurse manager, nursing professional development practitioner, and/or charge nurse will intervene immediately to ensure the safety of the patient. On 11/21/2025 at 4:48 p.m., in the presence of the facility’s Senior Vice President Chief Nursing Executive (SVPCNE), DLAR, RS 1, and RS 2 the facility was informed that the team was unable to validate the IJRP through observation, interview and record review. On 11/21/2025 at 4:58 p.m., the facility was placed on a 23-day termination track (a process that places a hospital or other provider on a termination track if deficiencies are found that pose an immediate jeopardy to patient health and safety). On 11/21/2025 at 5 p.m., the survey team exited the facility without removing the Immediate Jeopardy. On 12/5/2025 at 3:56 p.m., the IJ was removed in the presence of the facility’s DLAR, RS 1 and RS 2. The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. Findings: 1.a. During a review of Patient 25’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 10/25/2025, the H&P indicated, Patient 25 was admitted to the facility on 10/25/2025 with diagnosis of toxic hepatic encephalopathy (a condition where a buildup of toxins, normally cleared by the liver, harms the brain’s function). During a review of Patient 25’s “Progress Note Nursing,” dated 10/27/2025, documented by Registered Nurse (RN) 10, the note indicated, on 10/27/2025 at 9 a.m. Patient 25’s blood sugar was 49 mg/dL. MD (medical doctor) aware and new fluid order created. New ultrasound (a non-invasive imaging that uses high-frequency sound waves to create real-time images of internal body structures) PIV (peripheral intravenous, a flexible tube inserted into a vein to administer fluids, medications, and other treatments) being inserted.” During a review of Patient 25’s “Hypoglycemia flowsheet (document integrated in the used to document and track all key data related to a patient’s low blood glucose events),” dated 10/27/2025, indicated, on 10/27/2025, Patient 25’s last glucose (POCT [point of care test, finger stick]) was 49 mg/dL at 8:50 a.m., and 90 mg/dL at 5 p.m. (blood sugar not re-checked within 15 minutes after 8:50 a.m.). During an interview on 11/19/2025 at 2:52 p.m. with Registered Nurse (RN 14), RN 14 stated the following: when a patient’s blood glucose level was less than 70 mg/dL, nurse will follow hypoglycemia protocol (a standardized set of steps for treating low blood sugar) to provide treatment, recheck blood glucose (sugar) in 15 mins and call the physician. During a concurrent interview and record review on 11/19/2025 at 3:32 p.m. with Assistant Nurse Manager (ANM) 1, Patient 25’s MAR (Medication Administration Record), was reviewed. The MAR indicated RN 10 administered IV fluid with D5WLR (a type of intravenous fluid that contains both dextrose [a form of glucose] and electrolytes found in Lactated Ringer’s solution [a balanced solution]) with folic acid (man-made [synthetic] form of a vital B vitamin [B9], used as a medicine to help the body make healthy new cells and red blood cells) 1mg at 200ml/hr on 10/27/2025 at 3:02 p.m. ANM 1 confirmed there was no D50 (a high-concentration intravenous solution that is 50% simple sugar, and 50% water) or Glucagon (substance given to a patient as a medication to quickly raise their very low blood sugar [severe hypoglycemia] to a safe level) given to Patient 25 to treat the low blood sugar. During a concurrent interview and record review on 11/19/2025 at 3:55 p.m. with the Assistant Nurse Manager (ANM 1), Patient 25’s “Hypoglycemia flowsheet,” dated 10/27/2025, was reviewed. The “Hypoglycemia flowsheet” indicated, on 10/27/2025, Patient 25’s last glucose (POCT [point of care test, finger stick]) was 49 mg/dL at 8:50 a.m. and 90 mg/dL at 5 p.m. ANM 1 stated there was no rechecking of blood sugar in 15 mins after the initial blood glucose of 49 mg/dL. ANM 1 said the Nurse should follow hypoglycemia protocol, perform assessment, check for patient’s mentation (the mental processing, thinking, and mood of a patient) and notify physician. ANM 1 also stated there was a delay in reassessing the blood sugar and providing intervention. During an interview on 11/20/2025 at 10:31 a.m. with RN 10, RN 10 stated the following: RN 10 took care of Patient 25 during day shift on 10/27/2025. Patient 25 was NPO (nothing by mouth, a medical instruction for patients to avoid eating or drinking anything for a specific period), A/O x O (is an informal way of describing a patient who is unconscious or completely unresponsive) and confused. Patient 25 did not receive any tube feeding (liquid nutrition, fluids, and medicine through a soft, flexible tube placed directly into the stomach). Patient 25’s blood glucose was 49 mg/dL in the morning, and RN 10 informed the physician. The physician had ordered IV fluids (D5W LR with 1 mg folic acid at 200 mL/hr) for Patient 25, but RN 10 did not administer the IV fluids until the afternoon, stating they were waiting for the Pharmacy to mix and deliver them (the D5WLR) to the unit. RN 10 was aware of the hypoglycemia protocol, which required an IV (Intravenous, through the vein) push when blood glucose was below 70 mg/dL; however, Patient 25 did not have IV access at that time. During the same interview on 11/20/2025 at 10:31 a.m. with RN 10, RN 10 confirmed not following the hypoglycemia protocol to give treatment and did not re-check Patient 25’s blood glucose in 15 minutes per protocol. RN 10 stated without intervention, Patient 25’s blood glucose could continue to drop and could result in cardiac arrest (when the heart suddenly and unexpectedly stops beating). RN 10 stated she (RN 10) could have called RRT (Rapid Response Team) to get assistance, given Patient 25’s low blood glucose and lack of IV access, but she did not call for RRT. During an interview on 11/20/2025 at 11:15 a.m. with Charge Nurse (CN 1), CN 1 stated the following: blood glucose of 49 mg/dL was low and required immediate attention. Nurse should activate the hypoglycemia protocol and provide treatment for patient. If patient was NPO, nurse could give D50 IV push. Without intervention, the patient could die. During a review of facility’s policy and procedure (P&P) titled, “Hypoglycemia Protocol: Adult/Pediatric/Newborn Treatment,” dated 4/2025, The P&P indicated, “Procedure: A. Assess the patient for signs and symptoms of hypoglycemia and/or when there is a resulted serum blood glucose lab value <70 mg/dl ... B. perform a STAT blood glucose test. C. Nurse will place Hypoglycemia Protocol order with “Protocols/Standardized Procedure” order mode. D. Treatment Protocol: Adults and Children >= 50kg (Attachment 1) ... Attachment 1: when blood glucose was below 70mg/dL and Patient was NPO, give D50 25 grams (50 ml) IVP over 4 minutes then retest POCT BG (blood glucose) every 15 minutes after treatment until BG >= 70mg/dL. NOTIFY healthcare provider of the event after BG >=70 mg/dL. During a review of facility’s unit scope of service for Medical-Surgical Neurology, the document indicated, “Assessment and reassessment time frames and parameters ... reassessment occur every four hours ... or as patient condition warrants. A complete reassessment is performed every 12 hours or when the status of the patient changes.” During a review of facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessment are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” 1.b. During a review of Patient 25’s “History and Physical (H&P),” dated 10/25/2025, the H&P indicated, Patient 25 was admitted to the facility on 10/25/2025 with diagnosis of toxic hepatic encephalopathy. During a review of Patient 25’s Physician order, dated 10/26/2025 at 2:31 a.m., the order indicated, Notify physicians for temperature greater than 101 F degrees (Fahrenheit, a unit of measurement) ...Heart rate less than 50 or greater than 120, Respiratory rate less than 8 or greater than 30, Oxygen saturation less than 92. During a review of Patient 25’s Vital Signs flowsheet, dated 10/27/2025, the flowsheet indicated: -At 12 a.m.: temp (temperature) 97.2 F - Heart rate (HR) 114 - Respiratory Rate (RR) 24 - Blood pressure (BP) 95/52 - O2 Sat (oxygen saturation, level of oxygen in the blood) 98% on room air -At 4:39 a.m.: temp 97.7 F - HR 88 - RR 23 - BP 102/58 - no O2 Sat recorded -At 7:54 a.m.: temp 98.3 F - HR 86 - no RR recorded - BP 111/55 - O2 Sat 97% -At 11:43 a.m.: temp 98.4F - HR 85 - no RR recorded - BP 91/56 - O2 Sat 98% -At 3:55 p.m.: temp 99.3F - HR 121 - RR 24 - BP 118/60 - O2 Sat 98% -At 8 p.m.: temp 99F - HR 122 - RR 32 - BP 124/61 - O2 Sat 95% on room air -At 9:43 p.m.: temp 101.2F - HR 125 - RR 30 - BP 139/69 - O2 Sat 89% on 6 L (6 liters of oxygen supplement) via Nasal Cannula (a simple device that delivers extra oxygen through a small tube with two prongs that fit just inside the nostrils). During a concurrent interview and record review on 11/19/2025 at 4:01 p.m. with Assistant Nurse Manager (ANM) 1, Patient 25’s vital signs on 10/27/2025 from 12 a.m. to 9:43 p.m., was reviewed. ANM 1 stated nurse should recheck Patient 25’s vital signs within an hour and perform assessment on Patient 25 to get an overall picture of Patient 25’s clinical presentation. Nurse should notify physician if patient had a change of condition. ANM 1 confirmed that RN 11 did not recheck Patient 25’s vital signs until 9:43 p.m. (1 hour and 43 mins later). ANM 1 stated Patient 25 could be more unstable and result in respiratory distress (when a person has difficulty breathing; their lungs can’t get enough oxygen into the blood to meet the body’s needs) without proper intervention. During a concurrent interview and record review on 11/20/2025 at 11:03 a.m. with CN 1, Patient 25’s vital signs on 10/27/2025 from 12 a.m. to 9:43 p.m., was reviewed. CN 1 stated Patient 25 was having a change of condition because Patient 25’s temperature was trending up. There was also concern of Patient 25’s respiratory status because the RR changed from 24 to 32 (from 4 p.m. to 8 p.m.). Patient 25 was becoming tachypneic (having fast, shallow breathing. Instead of taking deep, full breaths). CN 1 said the RN needed to check and assess the patient if there were any symptoms, and reach out to the physician. CN 1 further stated there was a gap between 8 p.m. and 9:43 p.m. A lot could happen between that time. There was patient safety concern. Patient 25’s condition could deteriorate and result in respiratory distress. During a concurrent interview and record review on 11/20/2025 at 11:21 a.m. with CN 1, Patient 25’s Nursing assessment flowsheet, dated 10/27/2025 and 10/28/2025, was reviewed. The Nursing assessment flowsheet indicated, a head-to-toe assessment (a systematic and comprehensive physical examination of a patient from the top of the head to the bottom of the feet. This evaluation includes checking vital signs, a patient’s general appearance, and the functionality of all body systems, such as neurological, cardiovascular, and respiratory. It is used to gather baseline information about a patient’s health status and to identify any potential or existing health problems.) was performed on 10/27/2025 at 10 a.m. and on 10/28/2025 at 12 a.m. CN 1 confirmed there was no nursing assessment when Patient 25 had the change of condition. During an interview on 11/20/2025 at 11:22 a.m. with CN 1, CN 1 confirmed there was no notification of physician regarding Patient 25’s Vital Signs change on 10/27/2025 at 8 p.m. During an interview on 11/20/2025 at 11:29 a.m. with ANM 2, ANM 2 stated nurses should notify physician as soon as possible within an hour if patient’s vital signs were out of range of what physician had ordered. During a review of Patient 25’s Code Blue (a hospital emergency code indicating a patient requiring immediate resuscitation [the process of restoring a person’s heart and lungs to working order after they have stopped]) /RRT Summary (RRT note), dated 10/27/2025, the RRT note indicated RRT was called on 10/27/2025 at 9:59 p.m. The RRT note also indicated, “RRT for desaturation (a drop in a person’s blood oxygen saturation level to below normal levels) while on room air, placed on NRB (non-rebreather mask) - due to altered mental status and increased work of breathing, medical team decided to intubate patient (Patient 25) for impending respiratory failure. Patient (Patient 25) was intubated and transferred to ICU.” During a review of Patient 25’s “Brief Clinical Note Addendum,” dated 10/28/2025, the clinical note indicated, “(on 10/27/2025) at 2143 (9:43 p.m.), I was called emergently to assess the patient (Patient 25) for acute deterioration. Upon arrival along with RRT team, the patient (Patient 25) was found to be in respiratory failure. RR of 40 + per minute with accessory muscles use and moaning ... lung auscultation (the medical process of listening to the sounds of breathing in the lungs, typically using a stethoscope, to check for normal or abnormal sounds that can indicate health problems) was significant for diffused coarse rhonchi (low-pitched, rattling, or snoring-like sounds heard in the lungs, caused by obstructions from mucus or fluid in the larger airways) ... repeat chest X ray (an imaging test that uses a small amount of radiation to create pictures of the structures inside the chest, including the heart, lungs, and bones) revealed new left sided infiltrate (an abnormal substance, like pus, blood, or fluid, that has collected in the lung’s airspaces, appearing as a hazy area on a chest X-ray) ... given concern for acute respiratory failure secondary to pneumonia (lung infection) and possible aspiration (when something other than air gets into a patient’s airways) with unprotected airway. Patient (Patient 25) was emergently intubated and transferred to MICU (medical ICU).” During a review of facility’s policy and procedure (P&P) titled, “Hypoglycemia Protocol: Adult/Pediatric/Newborn Treatment,” dated 4/2025, the P&P indicated, “Procedure: A. Assess the patient for signs and symptoms of hypoglycemia and/or when there is a resulted serum blood glucose lab value <70 mg/dl ... B. perform a STAT blood glucose test. C. Nurse will place Hypoglycemia Protocol order with “Protocols/Standardized Procedure” order mode. D. Treatment Protocol: Adults and Children >= 50kg (Attachment 1) ... Attachment 1: when blood glucose was below 70mg/dL and Patient was NPO, give D50 25 grams (50 ml) IVP over 4 minutes then retest POCT BG (blood glucose) every 15 minutes after treatment until BG >= 70mg/dL. NOTIFY healthcare provider of the event after BG >=70 mg/dL. During a review of the facility’s unit scope of service for Medical-Surgical Neurology, the document indicated, “Assessment and reassessment time frames and parameters ... reassessment occur every four hours ... or as patient condition warrants. A complete reassessment is performed every 12 hours or when the status of the patient changes.” During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessment are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” 2. During a review of Patient 32’s History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/9/2022, the H&P indicated Patient 32 was admitted to the facility with chief complaint of right foot pain and swelling. During a concurrent interview and record review on 11/18/2025 at 11:59 a.m. with Nursing Professional Development Practitioner (NPDP) 3, Patient 32’s “Crisis Head-to-Toe Assessment flow sheet (a document that indicates a thorough, systematic nursing evaluation of a patient’s entire body, from head to feet, to establish a baseline health status, identify potential problems, and monitor for changes, using techniques like inspection, palpation, percussion, and auscultation to check each body system, including neurological, respiratory, cardiovascular, gastrointestinal, and integumentary. It ensures comprehensive patient care by catching early warning signs, guiding interventions, and focusing on safety and individual needs),” dated 3/21/2022, was reviewed. NPDP 3 verified Patient 32’s head to toe assessment on 3/21/2022 at 7:37 p.m. was incomplete in which only pain and respiration (the physical act of breathing) were assessed by the nurse. During the same interview on 11/18/2025 at 11:59 a.m. with NPDP 3, NPDP 3 stated that the expectation for nursing would be to perform a complete head-to-toe assessment, and the head-to-toe assessment should be completed within each shift (a designated period a nurse works to provide patient care). NPDP 3 further stated that a head-to-toe assessment provided the baseline of a patient and a way to know of any early warning signs of serious issues. During a concurrent interview and record review on 11/20/2025 at 10:49 a.m. with Registered Nurse (RN) 6, the policy and procedure titled, “Patient Care Process Policy Clinical Administrative,” was reviewed. NPDP 4 stated nurses were to document the assessment performed and if not documented, then the assessment was not done. During a review of facility’s policy and procedures (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” effective date 6/7/2024, the P&P indicated, “Purpose Provide a system of documentation that reflects screening, assessment and interventions ...Initial screenings, assessment and shift/ other assessments are to be documented when performed ...” 3. During a review of Patient 29’s “Brief Pre-Cath (catheterization, a procedure to look inside the blood vessels) H&P (History and Physical) and Pre-Moderate Sedation (medicine used to put someone asleep) Notes,” dated 10/29/2025, the records indicated Patient 29 had chest pain after a thyroidectomy (removal of a part or whole thyroid gland [makes hormones for energy and growing]) procedure. Patient 29 had a medical history of Coronary Artery Disease (CAD, a condition where fats build up in the coronary arteries [major blood vessels supplying oxygen and nutrients to the heart muscle] narrowing and restricting blood flow in the heart) and Non-ST-Elevation Myocardial Infarction (NSTEMI, type of heart attack due to blocked blood vessels in the heart). During a concurrent interview and record review on 11/19/2025 at 10:15 a.m. with Nursing Professional Development Practitioner (NPDP) 5, Patient 29’s “Flowsheet History,” dated 11/17/2025 to 11/18/2025, was reviewed. The record indicated the following: -On 11/17/2025 at 8:25 p.m. Patient 29’s heart rhythm was Normal Sinus Rhythm (NSR, regular heartbeat) and the cardiac strip (recording of the heart’s electrical activity) was reviewed by the nurse. -On 11/17/2025 at 11:04 p.m., Patient 29’s heart rhythm was NSR with multifocal (comes from different areas of the heart) PVCs and the cardiac strip was reviewed by the nurse. -On 11/18/2025 at 1:46 a.m., Patient 29’s heart rhythm was NSR with PVCs and the cardiac strip was reviewed by the nurse. -On 11/18/2025 at 4:00 a.m., Patient 29’s heart rhythm was NSR with PVCs and had a run of Ventricular tachycardia (v-tach) and the cardiac strip was reviewed by the nurse. -NPDP 5 stated the nurses review and validate the cardiac strips every four hours. NPDP 5 verified that the last provider notification documented was on 11/11/2025. NPDP 5 confirmed there were no documented physician notification when Patient 9 was having multifocal PVCs and a run of ventricular tachycardia. During an interview on 11/19/2025 at 2:35 p.m. with Registered Nurse (RN) 14 and RN 15, RN 15 stated it was important to document which doctor was notified regarding changes in a patient’s condition or cardiac rhythm change and document as well the doctor’s response. RN 14 stated “it was important to document what the physician said to make sure we (the staff) did everything we could,” what interventions were ordered and carried out, who was the physician involved, and “to escalate if needed.” RN 14 also stated if there were multiple premature ventricular contractions (PVCs) in a row or a patient had any other accompanying issues or symptoms during a cardiac rhythm change (such as a patient complaining of chest pain during a change in cardiac rhythm), the (RNs) would call the doctor. Likewise, RN 15 stated it was important to notify the physician of rhythm changes, document if a physician was notified, and the nurses should also document how many beats of ventricular tachycardia was observed because of a concern for patient decline. During an interview on 11/19/2025 at 3:50 p.m. with the Nursing Professional Development Practitioner (NPDP) 6, NPDP 6 stated nurses should notify the physician of cardiac rhythm changes because the patient could go into a lethal arrythmia. NPDP 6 stated if there was no documentation it would be difficult to trace what happened to the patient. During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/7/2024, the P&P indicated, “Purpose: Provide a system of documentation that reflects screenings, assessment and interventions ...The Electronic Medical Record (EMR) is a document that requires screenings/assessments to be performed at certain intervals, admission, transfer, and then by exception (PRN) ...In addition, abnormal findings need to be reported to a provider within a reasonable period. Emergent abnormal findings need to be reported immediately to a provider ...Data entered is a permanent part of the electronic record ...Clinical documentation undergoes periodic review/audits to maintain conformity to regulations of the State of California (Title 22), standards of accreditation (TJC, CMS Conditions of Participation, etc), (name of the facility) policies and procedures, and professional practice standards in the care of patients. 4. During a review of Patient 4’s “History and Physical (H&P),” dated 11/10/2025, the H&P indicated that Patient 4 had a medical history of hyperlipidemia (excess fats in the blood), diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). The H&P also indicated that Patient 4 was brought to the Emergency department by paramedics on 11/10/2025 after Patient 4 passed out after going to the bathroom at home and sustaining a fall. Patient 4 was admitted to the hospital on 11/11/2025. During a review of Patient 4’s “Flowsheet,” titled, “Head to Toe,” dated 11/10/2025, the flowsheet indicated that Patient 4 had a Braden Scale (used to evaluate a patient’s risk for developing pressure injuries; A lower score indicates a higher risk of pressure ulcers, with a total score of 18 or less suggesting a patient is at risk and needs preventative measures) Score of 19 (a patient has no risk or very low risk for developing pressure injuries). During a concurrent observation and interview on 11/17/2025 at 3:15 p.m. with RN 19, Patient 4 was observed sitting in bed. RN 19 stated that Patient 4 was able to reposition himself and requires one person to help with assistance when transferring in and out of bed. During a review of Patient 4’s “Flowsheet” titled, “PI (Pressure Injury, localized damage to the skin and/or underlying tissue) Flowsheet Treatment,” dated 11/12/2025, the flowsheet indicated ... “Pressure Injury Elbow Right ... Pressure Injury Staging: Possible Stage III, Stage IV ... Pressure Injury Elbow Left ... Pressure Injury Staging: Possible Stage II (Clear blister, open) ...” During a review of Patient 4’s “Pressure Injury Prevention Protocol,” dated 11/12/2025 the protocol indicated ... “Stage III, IV, Unstageable Pressure Injury Treatment UNTIL DISCONTINUED Comments: 1. Cleanse all pressure injuries with NS (normal saline)/Wound Cleaner and protect peri wound with skin barrier prep. 2. If pressure injury is Intact: Cover with silicon foam dressing 3. If pressure injury is Non-Intact (without depth): A.) Apply Honey Based Gel Sheet and cover with silicone foam dressing B.) Date and Change every 3 days or as needed if dislodged ... 10. Consult to WOCN/Wound Care Nurse for wound deteriorations.” During a concurrent interview and record review on 11/18/2025 at 3:15 p.m. with Registered Nurse 6 (RN 6), Patient 4’s “Flowsheet” titled, “PI Flowsheet Treatment,” dated 11/12/2025 through 11/16/2025, was reviewed. RN 6 said the following: -RN 6 stated that based on the documentation on Patient 4’s flowsheet, there were no treatments to Patient 4’s left and right elbow pressure injuries until 11/16/2025. -RN 6 said that according to the “Pressure Injury Prevention Protocol,” treatments should have been done to Patient 4’s pressure injuries. -RN 6 further stated that wound care treatments should be done to ensure that the wound bed was properly healed. During a concurrent interview and record review on 11/18/2025 at 2:30 p.m. with the Nursing Professional Development Practitioner (NPDP 1), Patient 4’s “Pressure Injury Prevention Protocol,” was reviewed. NPDP 1 stated that Patient 4’s wound care consult request was placed on 11/12/2025, as part of the pressure injury prevention protocol. During a review of Patient 4’s “Flowsheet,” titled, “Head to Toe,” dated 11/15/2025, the flowsheet indicated that Patient 4 had a Braden Scale (used to evaluate a patient’s risk for developing pressure injuries; A lower score indicates a higher risk of pressure ulcers, with a total score of 18 or less suggesting a patient is at risk and needs preventative measures) Score of 17. During an interview on 11/19/2025 at 10:30 a.m. with the Wound Ostomy Continence Nurse (WOCN), the WOCN stated that a protocol (Pressure Injury Prevention Protocol) was triggered due to the nurse’s assessment of Patient 4’s pressure injuries. WOCN stated that the protocol was a set of standards that the nurses should follow. During an interview on 11/19/2025 at 10:40 a.m. with the WOCN, the WOCN stated that based on Patient 4’s flowsheet, treatments were not consistently completed by the nurses. WOCN stated that treatments should have been initiated as recommended so that there were no delays in care. The wound care protocol should have been in place so that there was no delay in Patient 4’s care. During an interview on 11/19/2025 at 10:45 a.m. with the WOCN, the WOCN stated the following: -The WOCN stated that the facility’s policy and procedure (P&P) did not specify a timeframe for when a wound care nurse should evaluate a patient after a consultation was placed. -The WOCN stated that the facility was short staffed of wound care nurses. The WOCN also added that it was recommended that the patient be seen by the wound care nurse as soon as possible to assess the patient’s pressure injuries. -The WOCN verified that a wound care consult was placed on 11/12/2025, however Patient 4 was not seen by the WOCN until 11/17/2025. During a review of Patient 4’s “wound care consult” titled, “WOCN Progress Note,” dated 11/17/2025, the WOCN note indicated ... “Pressure Injury Elbow Right Pressure Injury Staging: Possible stage III, stage IV, Unstageable (WOCN to Stage) ...WOCN pressure injury staging: Unstageable (wound covered in yellow/black tissue with no visible depth) Pressure Injury Elbow Left Pressure Injury Staging: Possible Stage III, Stage IV, SDTI, Unstageable (WOCN to Stage) ...WOCN Pressure Injury Staging: Unstageable (wound covered in yellow/black tissue with no visible depth).” During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity Assessment and Interventions Clinical Guidelines: General Clinical/Clinical Guidelines,” dated 5/17/2022, the P&P indicated ... “The condition of the patient’s skin will be assessed, and findings documented in the electronic medical record upon admission, each shift, and discharge. Preventive measures to provide relief from prolonged pressure, friction, shearing, moisture, or sensitizing products will be emphasized in the patient’s plan of care ...Intervention ...Notify Wound Ostomy Nurses for Community Acquired Pressure Tissue Injuries ... Activate Pressure Injury Treatment Protocol ... Cleanse skin tears with normal saline (or wound cleanser) and apply a non-adherent dressing obtain additional wound care orders from MD or CWOCN when necessary ... Documentation: Treatment ...” During a review of the facility’s policy and procedure (P&P) titled “Pressure Injuries: Assessment and Intervention Policy: Clinical Manual/ General Clinical,” dated 4/15/2024, the P&P indicated ... “If pressure injury is present (skin, mucosal membrane, medical device related), clinical RN notifies physician/member of clinical team. Clinical RN obtains wound care orders by appropriate documentation and accepting protocols and/ or best practice alerts ... Community Acquired Pressure Injury ... RN to inform MD/member of clinical team, RN leadership and place WOCN consult for stage 3, 4, unstageable, deep tissue pressure injury/DTPI and/ or change in pressure injury status/deterioration.””

“STANDING ORDERS FOR DRUGS CFR(s): 482.23(c)(1)(ii ),(c)(3) & (c)(3)(iii) (ii) Drugs and biologicals may be prepared and administered on the orders contained within pre-printed and electronic standing orders, order sets, and protocols for patient orders only if such orders meet the requirements of §482.24(c)(3). (3) With the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders in accordance with State law and hospital policy, and who is responsible for the care of the patient as specified under §482.12(c) ... This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure nursing service staff’s compliance with the facility’s established standing orders (a pre-written, physician-approved directive allowing nurses or other qualified staff to provide specific treatments, assessments, or medications [like pain relief] without needing an individual doctor’s order for every patient, improving efficiency and immediate care, especially for common situations or emergencies) policy for pain management when a staff registered nurse ordered 1000 milligrams (mg, measuring unit) of Tylenol (an over-the-counter medication commonly used to relieve pain and reduce fever ) for one of 39 sampled patients (Patient 7), which was outside the Emergency Department’s standing orders protocol for pain management. The standing order protocol only permits 650 mg for pain. This deficient practice had the potential to result in either an overdose (too much medication) resulting in complications such as organ damage or underdose (too little medication) leading to uncontrolled pain and/or emotional distress for Patient 7. Findings: During a review of Patient 7’s History of Present Illness (HPI, a detailed account of the patient’s current health issue, including the onset, characteristics, and progression of symptoms), dated 9/14/2025, the HPI indicated that Patient 7 visited the Emergency Department (ED) due to generalized body aches, headache, and runny nose after receiving the COVID-19 vaccine (a biological preparation designed to protect individuals from the SARS-CoV-2 virus, which causes COVID-19). During a concurrent interview and record review on 11/18/2025 at 11:06 a.m. with Assistant Nurse Manager (NM 2), Patient 7’s pain assessment flowsheet which records pain levels and treatments, dated 9/14/2025, was reviewed. The record indicated that Patient 7 had no documented complaints of pain from the time Patient 7 arrived at the emergency department (ED, a hospital area for urgent care) on 9/14/2025 at 6:01 p.m. through 11:48 p.m. the same day. NM 2 confirmed that Patient 7 had a documented pain level of 8 (a high level of pain) at 11:49 p.m. and received 30 milligrams (mg, a unit of measure) of Toradol intramuscularly (injected into a muscle). NM 2 also verified that on 9/14/2025 at 11:01 p.m. (40 minutes earlier), Patient 7 received 1000 mg of Tylenol (an over-the-counter medication commonly used to relieve pain and reduce fever), but the pain level assessment was not documented for this administration. During an interview on 11/18/2025 at 11:06 a.m. with the Assistant Nurse Manager (NM 2), NM 2 confirmed that on 9/14/2025, a registered nurse (RN) ordered 1000 mg of Tylenol for Patient 7 prior to the patient being evaluated by an attending physician. NM 2 said that the order was placed under the Pain Management Protocol; however, that protocol only authorized a maximum of 650 mg of Tylenol for pain. Furthermore, there was no documented pain assessment in Patient 7’s medical record prior to the administration of the Tylenol 1000 mg. NM 2 said that the higher dose may have been intended for fever management, which would be permissible under a different protocol, but there was no documentation of fever at any point during Patient 7’s stay in the Emergency Department from 9/14/2025 to 9/15/2025. NM 2 also said that they (NM 2) were unable to determine the indication for 1000 mg of Tylenol based on the reviewed documentation. During an interview on 11/19/2025 at 2:35 p.m. with the Associate Director of the Emergency Department (NM 9), NM 9 reviewed Patient 7’s pain assessment flowsheet and Medication Administration Record (MAR), both dated 9/14/2025. NM 9 said that at 10:45 p.m. (on 9/14/2025), no pain reassessment was documented. NM 9 then said that at 11:01 p.m., 1000 mg of Tylenol was given to Patient 7 and NM 9 questioned the appropriateness of the dosage, stating that it (Tylenol) was ordered under a standardized procedure (a written protocol that authorizes qualified healthcare professionals such as registered nurses to perform specific medical tasks or functions that would otherwise require a physician’s order) without a documented pain scale and/or indication for administration. NM 9 further stated that had the nurse followed the appropriate pain management protocol, the option to order 1000 mg would not have been available, as the protocol only permits 650 mg for pain. NM 9 said that ED nurses added must adhere to specific protocol requirements when ordering medications and that additional education was needed to ensure compliance. During the same interview on 11/19/2025 at 2:35 p.m. with the Associate Director of the Emergency Department (NM 9), NM 9 did not state the potential implications for the patient when medications were ordered without following standardized protocols and only said that further education was needed for the nurse who ordered 1000 mg of Tylenol to ensure compliance. During an interview on 11/20/2025 at 11:55 a.m. with the Executive Director of Licensure, Accreditation and Regulation (DLAR), the DLAR said that ordering medication outside of the standardized protocol can negatively affect the patient. The DLAR said, “It may interfere with the provider’s plan of care, their disposition goals, and the initial workup. Additionally, administering medication without a prescribing license is beyond the scope of nursing practice and can complicate the diagnostic process.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy,” dated May 2025, the P&P indicated the following: “Patients have the right to: appropriate assessment and management of your (Patient’s) pain, information about pain, pain relief measures, and participation in pain management decisions...” During a review of the facility’s protocol titled, “Adult and Pediatric Pain Management Protocol Standardized Procedure Policy,” dated 10/2024, the protocol indicated that registered nurses performing standardized procedures are required to immediately communicate with the patient’s physician prior to initiating the procedure and to document this communication in the patient’s medical record. The protocol further requires documentation of special circumstances, such as patient complaints, as well as the administration of pain management interventions and medications. -The procedure section outlines that nurses must assess patients presenting with a complaint of pain, determine the type of pain, and document the pain scale. For adults experiencing moderate to severe pain, the protocol authorizes ordering 650 mg of Tylenol (1 tablet). Additionally, the protocol mandates that nurses document medications as administered, record vital signs, and complete both the initial pain assessment and a reassessment after medication administration.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 50516 Based on observation, interview and record review, the facility failed to: 1. Ensure that a pain medication, documented as administered on 6/11/2025 at 8:53 p.m., in the pain assessment record was accurately documented in the MAR for one of 39 sampled patients (Patient 13), in accordance with the facility’s policies regarding pain management and documentation. There was no documented medication being administered at 8:53 p.m. on 6/11/2025 in Patient 13’s MAR. This deficient practice had the potential to result in delayed or inappropriate treatment including poor care coordination for Patient 13 due to lack of documentation. 2. Ensure nursing documentation was accurate for one of 39 sampled patients (Patient 27), in accordance with Federal regulatory requirement regarding medical records that must be accurately written, when Patient 27’s nursing note indicated Patient 27 threw themselves onto the floor contrary to what was observed from a security camera footage in which Patient 27 was observed being assisted onto the floor within the Emergency Department (ED) triage waiting room. This deficient practice resulted in an inaccurate description of Patient 27’s visit to the ED which could have affected Patient 27’s care and emotional wellbeing. Findings: 1. During a concurrent interview and record review on 11/19/2025 at 2:33 p.m. with the Nursing Professional Development Practitioner (NPDP 2), Patient 13’s pain assessments record and the Medication Administration Record (MAR), were reviewed. NPDP 2 stated the following: NPDP 2 verified that the pain assessment documentation record on 6/11/2025 at 8:53 p.m., indicated Patient 13 had a pain level of 9 (On a scale of 0-10; 0=no pain, 10=worst possible pain) and was given a medication for pain. However, NPDP 2 verified that Patient 13’s pain medication administration was not reflected in the MAR on 6/11/2025 at 8:53 p.m. to indicate what pain medication was administered to Patient 13. NPDP 2 stated it may have been an error (referring to the missing pain medicine documentation), however, NPDP 2 stated the documentation (as to what pain medication was administered to Patient 13 on 6/11/2025 at 8:53 p.m.) should be accurate for continuity of care. During a review of Patient 13’s “Pain Assessments” record, the pain assessments record indicated that on 6/11/2025 at 8:53 p.m., Patient 13’s pain rating was 9 and a pain medication was given. During a review of Patient 13’s “Medication Administration Record (MAR)” with the NPDP2, the MAR indicated the following: -On 6/10/2025 at 10:53 p.m., oxycodone (a strong prescription pain medication) immediate release (IR) tablet, 15 milligrams (mg, a unit of measure) was ordered to be given by mouth, every four (4) hours as needed for severe pain (7-10). Oxycodone was given on 6/11/2025 at 1:45 a.m., 6:18 a.m., 11:10 a.m., 4:02 p.m., and 8:23 p.m. -On 6/10/2025 at 10:54 p.m., until 6/11/2025 at 1:57 p.m., hydromorphone (a very strong prescription pain killer) injection 0.5 mg was ordered to be given via intravenous push (IVP, administered in the vein) every four (4) hours for breakthrough pain (sudden, temporary flare-up of severe pain that “breaks through” the pain relief provided by a regular, long-acting pain medication regimen for chronic pain). PRN (as needed) comment: “Must give oral pain med first, if after 1-hour pain is not controlled may give breakthrough dose of IV.” Hydromorphone was given on 6/11/2025 at 4:03 a.m. and 10:06 a.m. -On 6/11/2025 at 4:30 a.m., hydromorphone injection 0.2 mg was ordered to be given Once via IVP. Hydromorphone was administered on 6/11/2025 at 5:20 a.m. -NPDP 2 verified that there was no documented pain medication either IVP or oral pain medication having been administered on 6/11/2025 at 8:53 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management Adult and Pediatric,” dated 10/14//2025, the P&P indicated the following: Documentation of Medication Administration: The eMAR (Medication Administration Record) serves as a reference document used by licensed personnel in administering medications. The authorized personnel will document each dose given on the eMAR appropriate drug line and in the appropriate column for the day. 1. Medications administered to patients are to be immediately documented on the patients’ eMAR right after they have been administered. If a patient does not take the prescribed medication, the time that the medication should have been administered is noted on the MAR and the reason for omitting the dose is documented ...Areas using ...electronic health record charting should document in the eMAR ... 3. Documentation on other appropriate forms may also include ...Patient’s response/reaction to PRN (as needed) medications in the electronic health record progress notes. During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/07/2024, the P&P indicated the following: The Electronic Medical Record (EMR) is a document that requires screenings/assessments to be performed at certain intervals, admission, transfer, and then by exception ...Data entered is a permanent part of the electronic record. Incorrect documentation entered into the record by the staff member/clinician may be marked as “invalid” and/or overwritten with corrected data if the record is in the active status (within 72 hours) ...Initial screenings, assessments and shift/other reassessments are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided. 2. During a review of Patient 27’s “Patient Care Timeline,” dated 8/21/2025, the record indicated Patient 27 arrived at the Emergency Department (ED) for chest pain and shortness of breath. During an interview on 11/19/2025 at 3:50 p.m. with the Nursing Professional Development Practitioner (NPDP) 6, NPDP 6 stated it was important for documentation to be accurate to ensure proper understanding of the patient status and for managing care. During a concurrent observation, interview and record review on 11/20/2025 at 3:41 p.m. with the Director of Licensing, Accreditation and Regulation (DLAR), the security camera footage on 8/21/2025 of Patient 27 in the ED (Emergency Department) Triage (the process of sorting patients in an emergency department to determine the severity of their condition and prioritize who needs to be seen first) waiting room, was observed and reviewed. DLAR stated that based on the security camera footage reviewed, Patient 27 “Lowered herself down” to the ground. During a concurrent observation, interview, and record review on 11/21/2025 at 11:52 a.m. with the Assistant Director (AD) 2 of ED, the security camera footage, captured on 8/21/2025 which showed Patient 27 in the ED Triage waiting room, was observed and reviewed. AD 2 stated that based on the security camera footage, Patient 27 was swaying at the nurses’ station with a visitor holding onto Patient 27. AD 2 also stated Patient 27 “Sinks down to the floor” and then security personnel and a clinical partner approached Patient 27, who was lying on the floor. After about a minute and half, the clinical partner and visitor assisted Patient 27 into the wheelchair. During the same observation and interview on 11/21/2025 at 11:52 a.m. with AD 2, AD 2 stated, “This did not look like a fall. It happened slowly and she (Patient 27) was being supported.” AD 2 defined a fall as an unintentional descent to the ground or floor, considering factors like speed and whether it was controlled or uncontrolled. AD 2 also stated it could have been a fall, but it’s unclear if it was intentional or accidental. During a concurrent interview and record review on 11/21/2025 at 11:52 a.m. with AD 2, Patient 27’s “Patient Care Timeline,” dated 8/21/2025, was reviewed. The record indicated in the “ED Notes” section, “Pt (Patient 27) threw herself onto floor and started crying out/hyperventilating (to breathe rapidly and deeply).” AD 2 stated she (AD 2) believed the documentation (regarding Patient 27 which was documented as ‘threw herself on the floor’) in the ED Notes section, matched the video observation of how Patient 27 got on the floor despite having viewed the video footage herself (AD 2) and stating previously that “This did not look like a fall. It happened slowly and she (Patient 27) was being supported.” During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/7/2024, the P&P indicated, “Purpose: Provide a system of documentation that reflects screenings, assessment and interventions. The Electronic Medical Record (EMR) is a document that requires screenings/assessments to be performed at certain intervals, admission, transfer, and then by exception (PRN) ...Data entered is a permanent part of the electronic record. Incorrect documentation entered into the record by the staff member/clinician may be marked as “invalid” and/or overwritten with corrected data if the record is in the active status (within 72 hours of discharge).””

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to: 1. Ensure the nursing staff documented the evaluation and reassessment for one of 39 sampled patients (Patient 25), in response to Patient 25’s sudden increase in respiration rate (number of breaths per minute) on 10/27/2025 at 8 p.m., in accordance with the facility’s policy and procedure pertaining to reassessment and documentation. This deficient practice resulted in Patient 25’s medical record not reflecting Patient 25’s clinical presentation when Patient 25 had an increased respiration rate. This deficient practice also had the potential to result in leading to other healthcare team members not being able to evaluate the cause of Patient 25’s change of condition (change from baseline status, usually refer to worsening from baseline status and required medical attention) which may potentially lead to delay of treatment and care. 2.Ensure the Emergency Department (ED) physician completed one of 39 sampled patient’s (Patient 8) ED physician notes (a medical note written by a physician that includes important details about the patient’s condition, treatment decisions, and care provided during the visit) regarding Patient 8’s ED visit on 11/17/2025, in accordance with the facility’s Medical Staff Rules and Regulations. This deficient practice had the potential to negatively impact Patient 8’s safety and continuity of care as it may have limited other providers’ access to critical medical information that are vital for accurate diagnosis and treatment planning and safe discharge. Findings: 1. During a review of Patient 25’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 10/25/2025, the H&P indicated, Patient 25 was admitted to the facility on 10/25/2025 with diagnosis of toxic hepatic encephalopathy (a condition where a buildup of toxins, normally cleared by the liver, harms the brain’s function). During a review of Patient 25’s Code Blue (a hospital emergency code indicating a patient requiring immediate resuscitation [the process of restoring a person’s heart and lungs to working order after they have stopped]) /RRT (Rapid Response Team, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) Summary (RRT note), dated 10/27/2025, the RRT note indicated RRT (Rapid Response Team) was called on 10/27/2025 at 9:59 p.m. The RRT note also indicated, “RRT for desaturation (a drop in a person’s blood oxygen saturation level to below normal levels) while on room air, placed on NRM (non-rebreather mask [delivers a high concentration of oxygen up to 100 %, to patient with severe respiratory distress [difficulty breathing] or hypoxia [deficiency in the amount of oxygen reaching the tissues]) - due to altered mental status (a sudden or significant change in a person’s usual awareness, thinking, attention, or behavior, like confusion, disorientation, memory problems, or unusual emotional responses, indicating the brain isn’t working normally due to an underlying issue, not just a mood change) and increased work of breathing, medical team decided to intubate patient (Patient 25) for impending respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). Patient (Patient 25) was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and transferred to ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill).” During an interview on 11/19/2025 at 11:55 a.m. with the Assistant Nurse Manager (ANM 3), ANM 3 emphasized the importance of documenting patient condition changes. ANM 3 said this ensures clinicians understand the care plan, reasons for interventions, and the patient’s responses or outcomes. During a concurrent interview and record review on 11/19/2025 at 4:02 p.m. with the Assistant Nurse Manager (AMN 1), Patient 25’s nursing assessment and nursing progress notes, dated 10/27/2025, was reviewed. ANM 1 confirmed there was no assessment and no documentation regarding Patient 25’s clinical presentation on 10/27/2025 when Patient 25 experienced respiratory distress which resulted in RRT. NM 1 stated it was unknown what happened to Patient 25 due to lack of documentation. During a concurrent interview and record review on 11/20/2025 at 11:03 a.m. with Charge Nurse (CN) 1, Patient 25’s “vital signs flowsheet (record of vital signs [measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level]),” dated 10/27/2025 from 12 a.m. to 9:43 p.m., was reviewed. The vital signs flowsheet indicated: -At 12 a.m.: temp (temperature) 97.2 degrees Fahrenheit (F, unit of measure 100.4 degrees Fahrenheit equivalent to 38.0 degrees Celsius)- Heart rate (HR) 114 (beats per minute) - Respiratory Rate (RR, a regular respiratory rate for a healthy adult at rest is between 12 and 20 breaths per minute) 24 (breaths per minute) - Blood pressure (BP) 95/52 millimeters of mercury (mmHg, unit of measure) - O2 Sat (oxygen saturation, level of oxygen in the blood) 98 % on room air -At 4:39 a.m.: temp 97.7 F - HR 88 (beats per minute)- RR 23 (breaths per minute) - BP 102/58 mmHg- no O2 Sat recorded -At 7:54 a.m.: temp 98.3 F - HR 86 (beats per minute)- no RR recorded - BP 111/55 mmHg - O2 Sat 97% -At 11:43 a.m.: temp 98.4F - HR 85 (beats per minute)- no RR recorded - BP 91/56 mmHg- O2 Sat 98% -At 3:55 p.m.: temp 99.3F - HR 121 (beats per minute)- RR 24 (breaths per minute) - BP 118/60 mmHg - O2 Sat 98% -At 8 p.m.: temp 99F - HR 122 (beats per minute) - RR 32 (breaths per minute) - BP 124/61 mmHg - O2 Sat 95% on room air -At 9:43 p.m.: temp 101.2F - HR 125 (beats per minute) - RR 30 (breaths per minute) - BP 139/69 mmHg - O2 Sat 89% on 6 L (6 liters of oxygen supplement) via Nasal Cannula (a simple device that delivers extra oxygen through a small tube with two prongs that fit just inside the nostrils). During the same concurrent interview and record review on 11/20/2025 at 11:03 a.m. with Charge Nurse (CN) 1, CN 1 stated Patient 25 was having a change of condition because Patient 25’s temperature was trending up. There was also concern regarding Patient 25’s respiratory status because the RR changed from 24 to 32 (from 4 p.m. to 8 p.m.). Patient 25 was becoming tachypneic (having fast, shallow breathing. Instead of taking deep, full breaths). CN 1 said the RN needed to check and assess the patient if there were any symptoms and reach out to the physician. CN 1 further stated there was a gap between 8 p.m. and 9:43 p.m. A lot could happen between that time. There was concern for patient safety. Patient 25’s condition could deteriorate (getting worse) and result in respiratory distress (a condition that occurs when the body needs more oxygen, and can be caused by a number of factors, including infections, chronic illness, or a blocked airway). During a concurrent interview and record review on 11/20/2025 at 11:21 a.m. with CN 1, Patient 25’s Nursing assessment flowsheet, dated 10/27/2025 and 10/28/2025, was reviewed. The Nursing assessment flowsheet indicated, a head-to-toe assessment (a systematic and comprehensive physical examination of a patient from the top of the head to the bottom of the feet to gather baseline information about a patient’s health status and to identify any potential or existing health problems) was performed on 10/27/2025 at 10 a.m. and on 10/28/2025 at 12 a.m. CN 1 confirmed there was no nursing head-to-toe assessment documented when Patient 25 had change of condition on 10/27/2025 at 8 p.m. During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... Policy: A. The Electronic Medical Record (EMR) is a document that requires screenings/ assessment to be performed at certain intervals, admission, transfer and then by exception ... other reassessments are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.” 2. During a review of Patient 8’s treatment care timeline (a chronological record of key clinical events, decisions, and care provided during a patient’s episode of treatment), dated 11/17/2025, the record indicated that Patient 8 returned to the Emergency Department (ED) 20 minutes after being discharged from the main hospital due to a fall sustained while walking out of the facility. Patient 8 was admitted to the ED for the second time at 3:53 p.m. on 11/17/2025 and discharged again at 4:42 p.m. on the same day. During an interview on 11/19/2025 at 1:24 p.m. with the Associate Director of the Emergency Department (NM 9), NM 9 confirmed that Patient 8’s medical record did not contain a completed emergency physician’s note for the ED visit on 11/17/2025. NM 9 stated that the physician began a note at 4:08 p.m. on 11/17/2025 but did not complete it. NM 9 said that physician documentation must be completed within 24 hours but noted that this would need to be verified against the facility’s medical staff rules and regulations. NM 9 acknowledged that the absence of a physician’s note could have implications for patient care but did not elaborate on what those implications might be. During an interview on 11/20/2025 at 2:37 p.m. with the Director of Medical Records (Dir 1), Dir 1 said that physicians had 24 hours to complete their progress notes after patient visits in accordance with the facility’s medical rules and regulations. DIR 1 also stated that progress notes entries must be documented and readily available before discharge. Dir 1 further said that the completion of this documentation is essential to ensure that records were available for other health care providers during the patient’s stay. During a review of the facility’s Section 4.4.1.2 of the Medical Staff Rules and Regulations, dated 5/2025, the Medical Staff Rules and Regulations document indicated that an Emergency Department (ED) medical record must be documented within twenty-four (24) hours of discharge from the Emergency Room and authenticated within fourteen (14) calendar days of discharge. The regulation further indicated that the ED medical record must contain evidence of the patient’s clinical course appropriate to the complexity of the patient’s condition.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its nursing staff documented rechecking of blood sugar every fifteen (15) minutes for one of 39 sampled patients (Patient 25), in accordance with the facility’s hypoglycemia (low blood sugar) protocol (a standardized set of steps for treating low blood sugar), when Patient 25’s blood sugar was 49 milligrams per deciliter (mg/dL, unit of measure) on 10/27/2025 at 8:50 a.m. This deficient practice could lead to Patient 25’s hypoglycemia being unassessed, delaying recognition of worsening condition and increasing risk of adverse events (unfavorable medical events), including death. Findings: During a review of Patient 25’s “History and Physical (H&P, a comprehensive assessment of a patient’s health status in their medical record),” dated 10/25/2025, the H&P indicated, Patient 25 was admitted to the facility on 10/25/2025 with diagnosis of toxic hepatic encephalopathy (a condition where a buildup of toxins, normally cleared by the liver, harms the brain’s function). During a review of Patient 25’s “Progress Note Nursing,” dated 10/27/2025, documented by Registered Nurse (RN) 10, the “Progress Note Nursing” indicated, on 10/27/2025 at 9 a.m., Patient 25’s blood sugar was 49 mg/dL. “MD (medical doctor) aware and new fluid order created. New ultrasound (a non-invasive imaging that uses high-frequency sound waves to create real-time images of internal body structures) PIV (peripheral intravenous, a flexible tube inserted into a vein to administer fluids, medications, and other treatments) being inserted.” During a review of Patient 25’s “Hypoglycemia flowsheet (document integrated in the used to document and track all key data related to a patient’s low blood sugar events),” dated 10/27/2025, the “Hypoglycemia flowsheet” indicated, on 10/27/2025, Patient 25’s last blood sugar (POCT [point of care test, finger stick]) was 49 mg/dL at 8:50 a.m., and 90 mg/dL at 5 p.m. (blood sugar not re-checked within 15 minutes after 8:50 a.m.). During an interview on 11/19/2025 at 2:52 p.m. with Registered Nurse (RN 14), RN 14 stated the following: when a patient’s blood sugar level was less than 70 mg/dL, nurse should follow the hypoglycemia protocol (a standardized set of steps for treating low blood sugar) to provide treatment, recheck the blood sugar in fifteen (15) minutes and call the physician. RN 14 also stated nurses must document the rechecked blood sugar in the patient’s medical record. During a concurrent interview and record review on 11/19/2025 at 3:55 p.m. with the Assistant Nurse Manager (ANM 1), Patient 25’s “Hypoglycemia flowsheet,” dated 10/27/2025, was reviewed. The “Hypoglycemia flowsheet” indicated, on 10/27/2025, Patient 25’s last blood sugar (POCT [point of care test, finger stick]) was 49 mg/dL at 8:50 a.m. and 90 mg/dL at 5 p.m. ANM 1 stated there was no rechecking of blood sugar in fifteen (15) minutes after the initial blood sugar of 49 mg/dL at 8:50 a.m. ANM 1 said the nurse should follow the hypoglycemia protocol, perform assessment, check for patient’s mentation (the mental processing, thinking, and mood of a patient) and notify physician. ANM 1 also stated there was a delay in reassessing the blood sugar and providing intervention. During an interview on 11/20/2025 at 11:15 a.m. with the Charge Nurse (CN 1), CN 1 stated the following: blood sugar of 49 mg/dL was low and required immediate attention. Nurse should activate the hypoglycemia protocol and provide treatment for patient. If patient was NPO (latin term ‘nil por os’ which means nothing by mouth instructing patients not to eat or drink anything before a procedure, test, or for other medical reasons, to prevent complications), nurse could give D50 (a concentrated intravenous [IV] solution of 50% Dextrose in Water, used as an emergency treatment for severe low blood sugar) IV push. Without intervention, the patient could die. During a review of the facility’s policy and procedure (P&P) titled, “Hypoglycemia Protocol: Adult/Pediatric/Newborn Treatment,” dated 4/2025, The P&P indicated, “Procedure: A. Assess the patient for signs and symptoms of hypoglycemia and/or when there is a resulted serum blood glucose lab value <70 mg/dL ... B. perform a STAT blood glucose (blood sugar) test. C. Nurse will place Hypoglycemia Protocol order with “Protocols/Standardized Procedure” order mode. D. Treatment Protocol: Adults and Children >= 50 kilograms (Attachment 1) ... Attachment 1: when blood glucose was below 70mg/dL and Patient was NPO, give D50 25 grams (50 ml [milliliters, a unit of measure]) IVP (Intravenous Push, administered into a vein) over 4 minutes then retest POCT BG (blood glucose) every 15 minutes after treatment until BG >= 70mg/dL. NOTIFY healthcare provider of the event after BG >=70 mg/dL. During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Patient Care Process Policy Clinical Administrative,” dated 6/2024, the P&P indicated, “Purpose: provide a system of documentation that reflects screening, assessment and interventions ... other reassessments are to be documented when performed. Interventions, patient education are to be documented during or immediately after performed/provided.””

“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: 42937 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 27) informed consent (a process where a patient gives their permission to undergo a procedure after being informed of the risks, benefits, and alternatives) was obtained in patient’s (Patient 27) preferred language (language the patient choose to communicate in) in Spanish, in accordance with the facility’s policy and procedure regarding consents and Patient Rights (a subset of human rights. Example: the right to considerate and respectful care). This deficient practice had the potential for Patient 27 not to fully understand the treatment plan and associated risks and benefits of the surgery before giving the consent to the providers, which may result in poor patient outcomes. Findings: During a review of Patient 27’s history and physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/19/2024, the H&P indicated that Patient 27 was a 70 year old female who came from an assisted living facility (a type of housing designed for older adults who need some help with daily activities like bathing, dressing, or medication management) with complaints of headache, nausea (the urge to vomit)/vomiting, and altered mental status (a change in cognitive function, level of consciousness, or behavior, often presenting as confusion). Patient 27 also had right eyebrow abrasion (a superficial rub or wearing off of the skin, usually caused by a scrape). The H&P also indicated Patient 27 did not remember if she fell or hit her head. Computed tomography (CT, a medical imaging procedure that uses X-rays to create detailed images of the inside of the body) of the head revealed subarachnoid hemorrhage (or SAH, is when there’s bleeding in the space between the brain and the membranes that cover it). During a concurrent interview and record review on 1/8/2025 at 11:40 a.m. with the Nurse Educator 1 (NE1), Patient 27’s electronic medical record (EMR, a digital version of paper charting), was reviewed. The EMR indicated that Patient 27 preferred language was Spanish. On 12/20/2024, Patient 27 underwent right frontal (front part of brain) external ventricular drainage (or EVD, is a temporary method surgically draining fluid from the ventricles [fluid-filled cavity] in the brain). An electronic informed consent (a legal document that a patient signs after a doctor thoroughly explains the details of a proposed surgery, including its risks, benefits, potential complications, and alternative treatments) for right external ventricular drain placement (surgical insertion of a catheter into the brain to drain fluid) in English language format, was signed by patient on 12/19/2024 at 4:44 p.m. NE1 stated that Patient 27’s preferred language was Spanish and that the facility do provide the option of having the informed consent in Spanish language format. There was no documentation that an interpreter was utilized. During an interview on 1/8/2025 at 11:49 a.m. with the Director of Office of Licensing, Accreditation and Regulatory (DOLAR), DOLAR stated that Patient 27’s preferred language was Spanish, unless an interpreter was utilized, then her informed consent should have been in Spanish language format, not English. During a review of the facility’s policy and procedure (P&P) titled, “Consent: Informed Policy Clinical/ Administrative,” with effective date of 12/04/2024, the P&P indicated the following: “Self-determination Right The patient’s right to informed consent to hospital services is recognized by California law. -An adult patient with capacity has a fundamental right of self-determination over his/her body with respect to medical care. “Securing Consent When Communication Barriers Exist -If a patient or his/her legal representative cannot communicate with the physician, or prefers to have the information communicated in a preferred language other than English, a competent interpreter in that language must be provided. -The interpreter’s responsibilities will include translating the information regarding the recommended medical treatment that the patient or patient’s legal representative needs to receive before deciding whether to give consent, as well as instructions regarding medical care. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities Policy: Clinical Manual/Administrative,” with effective date of 12/01/2024, the P&P indicated the following: “Receive information about his/her health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms he/she can understand. The patient has the right to effective communication and to participate in the development and implementation of his/her plan of care. The patient has the right to participate in ethical questions that arise in the course of his/her care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life¿ sustaining treatment.””

“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: 42976 Based on observation, interview, and record review, the facility failed to provide privacy for two of 30 sampled patients (Patient 9 and Patient 12) in accordance with the facility’s policy and procedure regarding patient’s rights, when the facility did not provide a privacy curtain during patient treatment in Patient 9’s and Patient 12 ‘s room. This deficient practice resulted in Patient 9’s and Patient 12’s privacy rights not being respected as random people on the unit could see Patient 9 and Patient ‘s 12’s activities such as dressing changes, medical and nursing treatments. Findings: 1.a. During a review of Patient 12’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated Patient 12 was admitted on 4/26/2024 for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). Patient was admitted to the Intensive Care Unit (ICU, provides critical care and life support for patients who are very sick or injured) due to respiratory failure (a serious condition that makes it difficult to breath on your own) and was intubated (a medical procedure that involves inserting a tube into the windpipe [trachea]). During a concurrent observation and interview on 1/07/2025 at 2:37 p.m. with Associate Director (AD) 2 outside of Patient 12’s room, Registered Nurse (RN) 9 was observed in the room lifting Patient 12’s gown and providing care to abdomen of Patient 12. No curtains were provided for privacy. AD 2 stated the following: Confirmed that RN 9 was changing the G-tube (Gastrostomy tube, a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dressing of Patient 12 and did not provide privacy for Patient 12. It is important staff provide privacy for Patient 12 when doing G-tube dressing change, so that patient (Patient 12) is not exposed to other people on the unit. AD will provide education to staff about providing privacy to patients. During an interview on 1/07/2025 at 2:45 p.m. with Registered Nurse (RN) 9, RN 9 stated the following: Confirmed RN 9 was doing dressing change for G-tube of Patient 12 and did not provide privacy. Forgot to pull the curtain for privacy. Will make sure to provide privacy and not expose Patient 12 to others. Patient 12 is confused and cannot voice concerns for himself if someone is looking at him (Patient 12). During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibility Policy,” dated 12/1/2024, the P&P indicated, “Patients’ Rights: Considerate and respectful care and to be made comfortable patient has the right to respect for his/her personal values and beliefs. Have personal privacy respected. Privacy curtains will be used.” 1.b. During a review of Patient 9’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/02/2025, the H&P indicated Patient 9 was admitted on 1/02/2025 for bilateral (both) foot wounds with reports of blisters to both feet and treatment plan of antibiotics. During a concurrent observation and interview on 1/07/2025 at 2:42 p.m. with Associate Director (AD) 2 outside of Patient 9’s room, two medical doctors entered Patient 9’s room and removed the foot dressing of Patient 9. No curtains were provided for privacy. AD 2 stated the following: Confirmed the two individuals entering Patient 9’s room were staff medical doctors. The two staff should have provided privacy to the patient before removing the foot dressing of Patient 9. AD 2 will let leadership know to educate the two medical doctors to provide privacy to the patients. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibility Policy,” dated 12/1/2024, the P&P indicated, “Patients’ Rights: Considerate and respectful care and to be made comfortable patient has the right to respect for his/her personal values and beliefs. Have personal privacy respected. Privacy curtains will be used.””

“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: 42976 Based on observation, interview, and record review, the facility failed to: 1. Ensure the call light (a device that serves as a means of communication for patients to their care providers that are outside the patients’ rooms) was within reach for one of 30 sampled patients (Patient 13), in accordance with the facility’s policies and procedures regarding Fall (when someone unintentionally ends up on the ground or a lower level) Prevention (the practice of reducing the risk of falling and injuries from falling). This deficient practice had the potential to result in a delay in attending to Patient 13’s immediate needs as well as may result in a fall with or without injuries. 2. Ensure that a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking [uncontrolled movement], blank stares, and loss of consciousness [a state where a person is completely unaware of their surroundings and unable to respond to stimuli such as voice or touch]) precaution padding (device to prevent the patient from injuring themselves against the hard frame or side rails of the hospital bed during a seizure episode) was applied to the side rails (safety devices used to prevent patients from falling out of their beds) for one of 30 sampled patients (Patient 12), in accordance with the facility’s policy and procedure regarding seizure management. This deficient practice had the potential for Patient 12 to suffer injuries such as bruising, lacerations (cuts), or broken bones when without padded side rails for protection while having a seizure episode. 3. Ensure one of 30 sampled patient’s (Patient 25) pre procedure checklist (a tool that helps ensure patient safety and prepare the patient for surgery. It includes confirming the patient’s identity, procedure, and consent, and checking for any allergies or risk factors) was completed prior to surgery, in accordance with the facility’s policy and procedure regarding “Admission Protocol for Patients Admitted in the pre-Operative Holding Area...” This deficient practice had a potential to result in delays in the procedure, increased risk of medical errors, including potential for adverse patient outcomes such as severe reaction to medication due to unidentified allergies. 4. Ensure one of 30 sampled patient’s (Patient 19) admission assessment (a process that involves collecting and analyzing a patient’s health information to identify their current and future care needs) was completed within 24 hours of inpatient admission, in accordance with the facility’s admission process. This deficient practice had the potential for Patient 19’s care needs to not be identified, and appropriate treatment plan not developed which may result in prolonged hospitalization and delayed recovery. Findings: 1. During a review of Patient 13’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/12/2024, the H&P indicated Patient 13 was admitted on 12/12/2024 for falls (when someone unintentionally ends up on the ground or a lower level) and shortness of breath (difficulty breathing). Patient 13 reported multiple falls at home prior to hospital admission. During a concurrent observation and interview on 1/07/2025 at 2:54 p.m. with Associate Director (AD) 2, in Patient 13’s room, the call light cord was observed hanging above the right bottom raised side rail bed of Patient 13 with the call light device on the floor, and not within reach of Patient 13. AD 2 stated the following: Confirmed call light device found on the floor in Patient 13’s room. Call light should be within reach for Patient 13 to use in case Patient 13 needs to call the nurse for help. Patient 13 can fall out of bed reaching for the call light. Patient 13 is unable to reach call light on the floor. Will educate staff on making sure call light is within reach and not on the floor. During a review of the facility’s policy and procedure (P&P) titled, “Fall Prevention,” dated 2/20/2024, the P&P indicated, “Check the patient for potential dangers hourly during the daytime and evening and every two hours overnight to compile a universal fall precaution, correct potential dangers in the patient’s room. Position the call light within the patient’s reach out at all times.” 2. During a review of Patient 12’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated Patient 12 was admitted on 4/26/2024 for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking [uncontrolled movement], blank stares, and loss of consciousness [a state where a person is completely unaware of their surroundings and unable to respond to stimuli such as voice or touch]). Patient 12 was admitted to the Intensive Care Unit (ICU, provides critical care and life support for patients who are very sick or injured) due to respiratory failure (a serious condition that makes it difficult to breath on your own) and was intubated (a medical procedure that involves inserting a tube into the windpipe [trachea]). During a concurrent interview and record review on 1/09/2025 at 3:47 p.m. with the Associate Director (AD) 2, Patient 12’s “Order Review,” was reviewed. The Order Review indicated active Seizure Precaution (safety measures to help prevent injuries and ensure the well-being of people experiencing seizures) order starting on 4/26/2024 for Patient 12. AD 2 stated the following: Confirmed seizure precaution for Patient 12 is still active and Patient 12 should have padding on the side rails to protect patient (Patient 12). During a concurrent observation and interview on 1/09/2025 at 3:58 p.m. with Associate Director (AD) 2, in Patient 12’s room, side rails for Patient 12 were observed not padded. AD 2 stated the following: AD 2 confirmed the side rails were not padded for Patient 12. AD 2 will educate staff to pad side rails for Patient 12. It is important to provide seizure precaution for Patient 12 which includes padded side rails in case patient (Patient 12) has a seizure and will not injure self. During a review of the facility’s policy and procedure (P&P) titled, “Seizure Management Policy,” dated 11/18/2024, the P&P indicated “Patients at risk for seizures need precautionary measures to help prevent injury if a seizure occurs. Equipment: Padding for side rails.” 3. During a review of Patient 25’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/2/2025, the H&P indicated Patient 25 was a 79 year old male with history of Type 2 diabetes (or DM2, a chronic disease that occurs when the body doesn’t produce enough insulin [a hormone that helps regulate blood sugar levels] or doesn’t use it properly), hypertension (high blood pressure), and Hyperlipidemia (high levels of fats or lipids in the blood), and was being admitted to the emergency room (Emergency Department, an area of the hospital designed to provide immediate medical care to patients with serious or life-threatening illnesses or injuries) for weakness. During a concurrent interview and record review on 1/7/2025 at 3:10 p.m. with the Assistant Nurse Manager 6 (ANM 6), Patient 25’s electronic medical record (EMR), was reviewed. The EMR indicated that on 1/6/2025, Patient 25 had a bilateral (both) lower extremity wound debridement (a surgical procedure that removes infected or dead tissue from both lower extremities). There was no record that a pre procedure checklist (a tool that helps ensure patient safety and prepare the patient for surgery. It includes confirming the patient’s identity, procedure, and consent, and checking for any allergies or risk factors) was completed prior to Patient 25’s debridement surgery. ANM 6 stated that a pre procedure checklist was not completed prior to Patient 25’s debridement surgery. ANM 6 said that it was important that a pre procedure checklist be completed because the pre-procedure list ensured that all necessary steps and information before a surgical procedure were carried out and completed, thus minimizing the risk of errors. During a review of the facility’s policy and procedure (P&P) titled, “Admission Protocol for Patients Admitted in the pre-Operative Holding Area: OR/ Anesthesia,” with effective date of 12/04/2024, the P&P indicated the following: “Documentation Requirements The following shall be on the patient’s medical record prior to the patient being moved into the OR. The nurse shall verify that the documentation is complete prior to patient transfer to the OR, including but not limited to: 1. A history and physical examination that is completed by a Medical Staff Member with appropriate privileges.: “Prior to starting the procedure, but no more than thirty days prior to the procedure. 2. Pre-op tests, documentation of waivers, based on the [Name of Facility] pre-op testing guidelines, and on the needs of the patient. 3. MD Documentation of informed consent, specifically stating that the risks, benefits and alternatives of the procedure have been discussed with the patient or their legal representative. 4. Additional special consents required for the procedure (i.e., Hysterectomy consent, Sterilization consent, etc.) 5. Ensure that consent for blood transfusion is signed when there is an order for type and cross/ type and screen for blood transfusion. 6. MD documentation of Interval H&P: to attest that the patient has been re-evaluated immediately prior to the procedure. For AM admits and outpatients, an Interval H&P needs to be done After admission, right before surgery/procedure. For inpatients, an Interval H&P needs to be done within 24 hours.” 4. During a review of Patient 19’s electronic medical record (EMR), the EMR indicated that Patient 19 was a 40 years old female with history of seizure (a sudden change in behavior, movement or consciousness due to abnormal electrical activity in the brain) and substance abuse (the harmful or hazardous use of psychoactive substances [drugs that affect the mood, awareness, thoughts, feelings, etc.], including alcohol and illicit [illegal] drugs). Patient 19 was originally at a different facility (General Acute Care Hospital 1) for seizure and was intubated (patient inserted with a breathing tube through the mouth and down the throat into the lungs). Patient was transferred and admitted to the current facility (General Acute Care Hospital 2) on 1/5/2025 for higher level of care (a more intensive or specialized level of medical treatment or support, usually provided when a patient’s condition requires greater monitoring, intervention, or specialized expertise compared to standard care). During a concurrent interview and record review on 1/9/2025 at 10:45 a.m. with the Nurse Educator (NE) 1, Patient 19’s medical record titled, “Admission Navigator,” was reviewed. The record indicated that the nursing admission assessment was not completed. NE1 stated that there was no admitting assessment completed on admission for Patient 19 and that it was the admitting nurse’s responsibility to complete the admission assessment. NE1 added that the importance of completing an admission assessment was for the nurse to gather comprehensive information about a patient upon arrival at the facility, allowing the nurse to create a care plan (a process through which nurse identifies, documents, and keeps track of a parent’s state or condition, needs, and risks) that will enable the delivery of appropriate and safe care. During a review of the facility’s policy and procedure (P&P) titled, “Admission,” with last revised date of 5/20/2024, the P&P indicated the following: “The Joint Commission and DNV GL-Healthcare (accreditation bodies that evaluate the quality of patient care services provided) require that each patient undergo an admission assessment by a registered nurse within 24 hours of inpatient admission. The Healthcare Facilities Accreditation Program requires that a registered nurse perform an initial assessment within the time frame established by the individual facility. During this assessment, the nurse should prioritize the patient’s needs, always be conscious of the patient’s levels of fatigue and comfort and maintain the patient’s privacy while obtaining the health history. According to the American Hospital Association’s Patient Care Partnership (which replaced the Patient’s Bill of Rights), patients have the right to expect that all examinations, consultations, and treatments will be conducted in a manner that protects their privacy. -Obtain a complete patient history. Include all previous hospitalizations, illnesses, surgeries, and food and medication allergies. -Screen the patient for influenza immunization and for tobacco and unhealthy alcohol use. -Ensure that a complete list of the medications that the patient was taking at home (including over-the-counter medications, supplements, and herbal preparations) is documented in the patient’s medical record. Include doses, routes of administration, and frequencies for all medications. Compare this list with the patient’s current medications. Reconcile and document any discrepancies (omissions, duplications, adjustments, deletions, and additions) in the patient’s medical record to reduce the risk of transition-related adverse drug events. -Determine whether the patient has an advance directive and, if so, ask for a copy to place in the patient’s medical record. If the patient doesn’t have one, provide the necessary advance directive information to the patient. -Review patient rights with the patient and family (if appropriate). -Perform an admission assessment. Ask the patient to explain the reason for coming to the facility. Record the answer (in the patient’s own words) as the chief complaint. Follow up with a physical assessment, focusing on the patient’s complaints. Record any noted marks, bruises, or discolorations on the nursing assessment form. -Screen the patient for suicide ideation (thoughts of killing one’s self) using a brief, standardized, evidence-based screening too. If the patient is at risk for suicide, address immediate safety needs and collaborate with the multidisciplinary health care team to determine the most appropriate setting for 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: 42976 Based on interview, and record review, the facility failed to: 1. Initiate and implement a Peripheral Inserted Central Catheter (PICC, a long, flexible tube that’s inserted into a vein in the arm and threaded into a vein near the heart) line care plan (a written document that details the specific nursing care a patient needs, outlining their individual health needs, goals, and the interventions required to achieve them) for one of 30 sampled patients (Patient 14), who was diagnosed with Mediastinal Mass (a growth in the chest that can be benign [noncancerous] or malignant [cancerous]) and had a PICC line to receive medication, in accordance with the facility’s policy and procedure regarding care plan preparation. This deficient practice had the potential for Patient 14’s needs and risks to remain unidentified which may result in complications such as infection, bleeding, blood clots, etc. 2. Ensure one of 30 sampled patient’s (Patient 24) care plan for infection (the invasion and growth of germs in the body) was initiated on admission, in accordance with the facility’s policy and procedure regarding care plan preparation. Patient 24 was placed on contact isolation (a medical practice used to prevent the spread of infectious diseases by isolating a patient who has germs that can be transmitted through direct or indirect contact with their body or contaminated surfaces in their room) upon being admitted to the hospital on 1/1/2025 for previously testing positive for Extended-Spectrum Beta-Lactamase (ESBL, is an enzyme that makes some bacteria resistant to antibiotics) in the urine on 12/8/2024. This deficient practice had the potential for Patient 24’s needs and risks to remain unidentified and may also result to the spread of infection to other patients, staff, and visitors. Findings: 1. During a review of Patient 14’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/22/2024, the H&P indicated Patient 14 was transferred from outside facility for further work up due to a mediastinal mass (a growth in the chest that can be benign [noncancerous] or malignant [cancerous]). During a review of Patient 14’s PICC (Peripheral Inserted Central Catheter, a long, flexible tube that’s inserted into a vein in the arm and threaded into a vein near the heart) Insertion Note, dated 1/04/2025, the PICC Insertion Note indicated Patient 14 had a PICC line placed on 1/04/2025 to the right arm. During a concurrent interview and record review on 1/09/2025 at 3:47 p.m. with the Nurse Professional Development Practitioner (NPDP) 6, Patient 14’s Care Plan (a written document that details the specific nursing care a patient needs, outlining their individual health needs, goals, and the interventions required to achieve them), was reviewed. There was no care plan initiated or implemented regarding Patient 14’s PICC line. NPDP 6 stated the following: Confirmed no care plan for PICC line was initiated or implemented for Patient 14. The assigned nurse for Patient 14 should and need to select the care plan Risk for central line associated blood stream infection. During an interview on 1/09/2025 at 2:40 p.m. with the Assistant Nurse Manager (ANM) 6, ANM stated the following: Assigned nurse is responsible for selecting the right care plan for Patient 14. Confirmed the care plan, Risk for central line associated blood stream infection should be selected for patient with a PICC line. Patients with PICC line are at risk for infection whenever they have PICC line placed, and therefore, should have right care plan selected. “I will follow up to educate staff and remind staff to select care plan risk of central lines associated blood stream infection.” During a review of the facility’s policy and procedure (P&P) titled, “Care Plan Preparation,” with last revised date of 5/20/2024, the P&P indicated the following: “A care plan directs a patient’s nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. A care plan consists of three parts: goals or expected outcomes (which describe behaviors or results to be achieved within a specified time), appropriate nursing actions or interventions necessary to achieve these goals, and evaluations of the established goals.” “A nursing care plan should be written for each patient, preferably within 24 hours of admission. It’s usually started by the patient’s primary nurse or the nurse who admits the patient. If the care plan contains more than one nursing diagnosis, the nurse must assign priorities to each one and implement those with the highest priority first. The nurse must update and revise the plan throughout the patient’s stay based on the patient’s response.” “A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the practitioner and other members of the health care team, planning patient discharge, and documenting patient care. In addition, the care plan can be a management tool for use in determining staffing needs and assignments.” 2. During a concurrent interview and record review on 1/7/2025 at 2:37 p.m. with the Assistant Director 5 (AD5), Patient 24’s medical record titled, “History and Physical,” dated 1/1/2025, was reviewed. The H&P indicated that Patient 24 was a 67 year old male with Human immunodeficiency virus (HIV, is a virus that attacks the body’s immune system [A complex network of cells, tissues, organs, and the substances they make that helps the body fight infections and other diseases]), hypertension (high blood pressure) and anxiety (a feeling of fear, dread, and uneasiness), and presented on 1/1/2025 with agitation (a feeling of intense distress, irritability, or restlessness that can make it hard to relax). The H&P also indicated that Patient 24 was previously admitted for pneumonia (a lung infection that causes inflammation and fluid buildup in the air sacs of the lungs), altered mental status (a change in mental function), as well as ESBL (Extended-Spectrum Beta-Lactamase, an enzyme that makes some bacteria resistant to antibiotics) bacteremia (a serious bacterial infection in the blood caused by ESBL-producing bacteria). AD5 stated that Patient 24 was on contact isolation (a set of precautions that healthcare workers take to prevent the spread of germs from a patient to others) for previously testing positive of ESBL urine last 12/8/2024. During a concurrent interview and record review on 1/7/2025 at 2:54 p.m. with the Assistant Nurse Manager 6 (ANM6), Patient 24’s electronic medical record titled, “Care Plans Report,” was reviewed. The report indicated that there was no nursing care plan for infection. ANM6 said that nursing staff should have initiated a care plan for infection because Patient 24 was placed on isolation for contact precaution (a medical practice used to prevent the spread of infectious diseases by isolating a patient who has germs that can be transmitted through direct or indirect contact with their body or contaminated surfaces in their room) and was previously identified ESBL positive of urine. ANM 6 also stated that it was important that nursing staff identify the infection problem in the care plan because it will outline the patient’s care needs, goals, and interventions. ANM 6 further said, it also ensured that all healthcare providers involved were on the same page and consistent in providing care for Patient 24. During a review of the facility’s policy and procedure titled, “Care Plan Preparation,” with last revised date of 5/20/2024, the P&P indicated the following: “A care plan directs a patient’s nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. A care plan consists of three parts: goals or expected outcomes (which describe behaviors or results to be achieved within a specified time), appropriate nursing actions or interventions necessary to achieve these goals, and evaluations of the established goals.” “A nursing care plan should be written for each patient, preferably within 24 hours of admission. It’s usually started by the patient’s primary nurse or the nurse who admits the patient. If the care plan contains more than one nursing diagnosis, the nurse must assign priorities to each one and implement those with the highest priority first. The nurse must update and revise the plan throughout the patient’s stay based on the patient’s response.” “A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the practitioner and other members of the health care team, planning patient discharge, and documenting patient care. In addition, the care plan can be a management tool for use in determining staffing needs and assignments.””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 42937 Based on interview and record review, the facility failed to ensure one of six (6) sampled nursing personnel (Registered Nurse 9), completed an annual health screening (a screening process for identifying potential health issues that could compromise nursing staff ability to practice safe infection control measures, protecting both staff and patients by ensuring they are up-to-date on necessary vaccinations) in accordance with the facility’s policy and procedure regarding health screening. Registered Nurse (RN) 9’s last annual health screening was on 12/7/2023. The deficient practice had the potential of failing to monitor for staff exposure to infectious diseases and identifying any health concerns that might increase the risk of transmitting infections to patients, visitors, or other staff. Findings: During a concurrent interview and record review on 1/9/2025 at 3:38 p.m. with the Manager of Clinical Operation (MCO), Registered Nurse 9’s (RN9) personnel health records titled, “Annual Health Evaluation,” was reviewed. The record indicated that RN9’s last annual health evaluation was completed on 12/7/2023. MCO stated that all staff were expected to complete a health evaluation annually. RN 9 failed to complete her annual health evaluation last 12/7/2024. The MCO said RN9 had been previously out for medical leave but had been back working since November 2024. RN9 failed to schedule an appointment with employee health. MCO further stated Staff were expected to complete an annual health evaluation because it ensured nurses were physically and mentally capable of providing safe patient care, it ensured that nurses were up-to-date on necessary vaccinations, monitoring for potential exposure to infectious diseases, and identifying any personal health concerns that might increase their risk of transmitting infections to patients, visitors, or other staff. During a review of the facility’s policy and procedure (P&P) titled, “Health Screening Procedures for Employees and Non-Employee Groups”, with effective fate of 2/28/2024, indicates the following: Employee Annual Clearance -All employees must receive annual clearance to continue working. -When all laboratory and data have been reviewed and the individual is determined safe to work, EHS will “clear” the employee to work. If the employee is not cleared, he or she will receive a form indicating that he or she is not cleared. The employee’s department and/or Human Resources representative will be notified by the EHS provider that the person has not been cleared to work. -Individuals will be notified of any borderline abnormal laboratory test by letter requesting that they return to EHS to discuss the results of their evaluation. Individuals with abnormal labs may be contacted by phone by an EHS RN, NP, or MD in addition to receiving a letter. -For those individuals that work in areas that require Respiratory Fit Testing, the process will be incorporated into their annual clearance timeframes.”

“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: 36206 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 provide an assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient’s health) for one of 30 sampled patients (Patient 1), when Patient 1’s blood pressure was not taken with vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) check in one of one sampled unit (Unit 1, pre-operative unit [a floor within a hospital where nursing care is provided prior to operative and invasive procedures]). This deficient practice had the potential for medical care and interventions to be delayed resulting in patient harm for Patient 1. (Refer to A-0395) 2. The facility failed to ensure Registered Nurse (CN) 4 was competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one of 30 sampled patients (Patient 22) This deficient practice had the potential to result in inadequate return of blood from the machine to the patient (Patient 22) causing harm or even death during hemodialysis treatment. (Refer to A-0397) 3. The facility failed to notify the physician regarding an increased respiratory rate of one of 30 sampled patients (Patient 1). The physician was not notified of abnormal vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) exhibited by Patient 1 in accordance with physician order (written instructions a physician has for a patient’s treatment) and the facility’s policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities. This deficient practice had the potential for a delay in the provision of medical care and treatments provided to the patient (Patient 1) which may result in complications such as acute respiratory distress (a type of lung failure due to fluid build-up in the lungs and low blood oxygen levels). (Refer to A-0398) 4. The facility failed to notify the physician when one of 30 sampled patient’s (Patient 1) heart rate was 50 beats per minute (bpm, Normal is 60 to 100 bpm) in accordance with the physician order and the facility’s policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities. This deficient practice had the potential for cardiac (heart) complications such as further decreased heart rate leading to cardiac arrest (when the heart stops beating), thus requiring additional medical interventions, treatment and/or care for Patient 1. (Refer to A-0398) 5. The facility failed to administer one of 30 sampled patient’s (Patient 1) medication (Bumex, a diuretic [causing increased urination] medication) in a timely manner per Physician order and in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice had the potential for Patient 1 to have a worsening of health condition which may result in lengthened patient recovery time and prolonged hospitalization. (Refer to A-0398) 6. The facility failed to ensure one of one sampled registered nurse (RN 4) 4 followed the facility’s policy and procedure (P&P) for putting on (donning) personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield.) while taking care of one of 30 sampled patients (Patient 17), who was on contact precaution (interventions taken to prevent transmission of infectious agents). This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 4 not wearing proper personal protective equipment (PPE) and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. (Refer to A-0398) 7. The facility failed to ensure that an assessment, reassessment of pain level including documentation of vital signs monitoring was completed for one of 30 sampled patients (Patient 21) in accordance with the facility’s policy and procedure regarding assessment, reassessment, and vital signs monitoring. This deficient practice had the potential to result in the delay of appropriate treatment or medical intervention for Patient 21 which may lead to serious complications or death. (Refer to A-0398) 8. The facility failed to ensure its Contract Dialysis Company (CDC or Company) followed county masking guidelines of wearing a face mask, over the nose and mouth, in patient care areas for one of 30 sampled patients (Patient 12). This deficient practice had the potential for the spread of infections such as Covid-19 (coronavirus, a highly contagious respiratory disease that spreads through droplets released when an infected person coughs, sneezes, or talks) and creating an unsafe environment for Patient 12. (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: 36206 Based on observation, interview, and record review, the facility failed to post a Notice of Patient Rights in an inpatient unit that included the current telephone number and address of the State Agency for patients to file a complaint. This deficient practice had the potential for patients not to be provided with the contact information of the State Agency in the event a patient needed to file a complaint. Findings: During concurrent observation and interview on 4/2/2024 at 10:55 a.m. with the Assistant Director (AD 2) for Nursing Services, the following was observed: In the Cardiac Surgical Intensive Care Unit (a unit that provides the highest level of care for critical patients with heart surgery), there was a notice posted on the wall of the hallway regarding patient rights. The notice did not contain the current contact information of the State Agency for patients to contact to a file a complaint. The AD 2 dialed the phone number posted on the notice and stated number was no longer in service. AD 2 stated Patients and their representatives had the right to file a complaint and patients would not be able to contact the State Agency to file a complaint due to the incorrect contact information. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 11/05/2020, the P&P indicated the following: Patient Rights ... File a complaint with the State Department of Public Health Services regardless of whether the patient use the hospital’s grievance process ... 48186”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36206 Based on observation, interview and record review, the facility failed to obtain a physician’s order (written instructions a physician has for a patient’s treatment) for restraints (purposely limiting or obstructing the freedom of a person’s bodily movement) in accordance with the facility’s policy and procedure regarding restraints use, for one of 30 sampled patients (Patient 5), when Patient 5 had 4 bedrails up while in bed. This deficient practice had the potential for the patient (Patient 5) to be unable to readily get out of bed or to have an accident while attempting to get out of bed. Findings: During a review of Patient 5’s History and Physical (H&P, a physician’s formal and complete assessment of the patient and the problem), the H&P indicated Patient 5 was admitted to the facility 3/18/2024 at 1:44 a.m. with a diagnosis of weakness. During a concurrent observation and interview on 4/2/2024 at 2:38 p.m. with Registered Nurse 3 (RN 3), Patient 5 was observed in bed, laying on his (Patient 5’s) back with 4 bedrails up. RN 3 stated that Patient 5 was restrained using bilateral soft wrist restraints (purposely limiting or obstructing the freedom of a person’s bodily movement), but this was discontinued, and the patient (Patient 5) no longer requires the use of restraints. RN 3 said that the patient (Patient 5) should not have had all 4 bedrails up as this was considered a restraint. During a record review on 4/2/2024 at 2:38 p.m., Patient 5’s medical record was reviewed and indicated that Patient 5 did not have a physician’s order (written instructions a physician has for a patient’s treatment) for the use of restraints during the time of observation (4/2/2024). RN 3 stated that the use of restraints required a physician’s order. RN 3 acknowledged that if the patient (Patient 5) had 4 bedrails up without an order, the patient could have an accident, while attempting to get out of bed. During an interview on 4/2/2024 at 12:23 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that the use of 4 bedrails is considered a restraint and that all restraints require a physician’s order per policy. During a review of the facility’s policy and procedure (P&P) titled, “Restraints and Seclusion Use Policy: Clinical Manual/General Clinical,” dated 4/3/2023, the P&P indicated the following: “Purpose: To provide a policy for the use of violent and non-violent restraints, and death in restraints. Policy: All patients have the right to be free from unnecessary restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. When the use of restraint is necessary, the least restrictive method must be used to ensure a patient’s safety. The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner (LP) who is responsible for the care of the patient and authorized to order restraint or seclusion Ill. Definitions: A. Restraint: any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition ...” During a review of the facility’s policy and procedure (P&P) titled, “Falls Prevention Protocol and Interventions Policy: Clinical Manual/General Clinical,” dated 12/30/2022, the P&P indicated the following: “Policy: Nurses will assess all patients for potential fall risk. This includes the initial admission and ongoing assessment ... III. Procedure: ... C. ...Three bed rails up at all times, Note: If four bed rails are required the Restraint and Seclusion policy will be implemented ...” 48186”

“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: 48186 Based on observation, interview and record review, the facility failed to provide an assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient’s health) for one of 30 sampled patients (Patient 1), when Patient 1’s blood pressure was not taken with vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) check in one of one sampled unit (Unit 1, pre-operative unit [a floor within a hospital where nursing care is provided prior to operative and invasive procedures]). This deficient practice had the potential for medical care and interventions to be delayed resulting in patient harm for Patient 1. Findings: During a concurrent observation and interview on 4/3/2024 at 10:40 a.m. with Charge Nurse 1 (CN 1), 7 bays (beds located in a room of a hospital) were observed in Unit 1 (pre-operative unit [a floor within a hospital where nursing care is provided prior to operative and invasive procedures]). CN 1 stated that when patients arrived on the unit (Unit 1), they (referring to patients) received an initial assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient’s health) that included vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body). CN 1 further stated that vital signs should be completed in Unit 1 prior to a scheduled surgical procedure. During a concurrent interview and record review on 4/3/2024 at 2:00 p.m. with the Accreditation Specialist 2 (AS 2), Patient 1’s medical record was reviewed and AS 2 verified the following information: Patient 1 arrived to the pre-operative unit on 4/21/2022 at 5:20 a.m. and was admitted at 6:18 a.m. Patient 1 was in Unit 1 pre-operatively to receive a Mitral Valve replacement (a type of heart surgery to replace a part of the heart that allows blood to flow through the heart in the right direction). Patient 1’s pre-operative vital signs on 4/21/2022 at 6:15 a.m. indicated a temperature (T) of 97 degrees Fahrenheit (F, a unit of measurement), and at 7:04 a.m. a respiratory rate (RR) of 18. The medical record titled, “strip report,” dated 4/21/2022 at 7:05 a.m., indicated additional vital signs taken were a heart rate (HR) of 56 and an oxygen saturation (spO2, measures the amount of oxygen in the blood) 97%. During a concurrent interview and record review on 4/3/2024 at 2:39 p.m. with the Accreditation Specialist 2 (AS 2) and the Executive Director, Office of Licensure, Accreditation & Regulation (EDOLAR), AS 2 and EDOLAR verified Patient 1’s blood pressure was not included in the pre-operative vital signs. AS 2 said that a complete set of vital signs should have included a temperature, respiratory rate, heart rate, oxygen saturations and blood pressure. AS 2 stated that per policy, it was the responsibility of the Registered Nurse (RN) to ensure one complete set of vital signs was obtained while Patient 1 was in the pre-operative unit. AS 2 further stated that it was important to obtain vital signs to have a full assessment of the patient status to provide the appropriate care and interventions for the patient. During a review of the facility’s policy and procedure (P&P) titled, “Admission Protocol for Patients Admitted in the Pre-Operative Holding Area: OR (Operating Room, where surgical procedures are performed)/Anesthesia (a medical intervention that prevents patients from feeling pain during procedures such as surgery),” dated 10/25/2021, the P&P indicated the following: “Policy Statement: The role of the Perianesthesia Nurse (works with patient that are undergoing or recovering from anesthesia or sedation) in the preoperative holding area is to provide safe nursing care in accordance with the American Society of Anesthesiologist (ASA), American Society of PeriAnesthesia Nursing (AS PAN) Standards of Practice and Institutional and regulatory requirements ... Purpose: To promote a safe perianesthesia setting by providing guidelines for best practice for the care of the pre-operative patient ... Procedure: ...D. ... Assess and document vital signs on admission and as needed ...””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 31993 Based on observation, interview and record review, the facility failed to ensure Registered Nurse (CN) 4 was competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one of 30 sampled patients (Patient 22) This deficient practice had the potential to result in inadequate return of blood from the machine to the patient (Patient 22) causing harm or even death during hemodialysis treatment. Findings: A review of Patient 22’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/18/2024, indicated Patient 22 was admitted for Respiratory Failure (a serious condition that makes it difficult to breathe on your own). Patient 22 also received Hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) on 4/1/2024. During an interview with Registered Nurse (CN) 4 on 4/2/2024 at 2 p.m., CN 4 stated that in the event that the Dialysis nurse become incapacitated, CN 4 will call for a rapid response team (RRT, a team of healthcare providers summoned to the patient’s bedside when a patient demonstrates signs of imminent clinical deterioration) and call the dialysis center located in the facility’s 6th floor. CN 4 was not able to verbalize how to turn off the dialysis machine in the event the dialysis nurse was incapacitated. During a concurrent observation and interview on 4/2/2024 at 2:40 p.m. with the Manager of Dialysis for Contract Company (MDS) and the Facility Dialysis Director (Dir DS), both the MDS and the Dir DS confirmed there was a sign posted in each of the dialysis machines regarding instructions on how to shut off the Hemodialysis machine in case of an emergency. However, both the MDS and the Dir DS were not able to verbalize and confirm if non-dialysis nurses were provided with an in-service on how to safely disconnect a patient from the dialysis machine in case of an emergency. During a concurrent interview and record review on 4/5/2024 at 9:15 a.m. with the MDs and the Dir DS, a copy of the facility’s documentation of in-service regarding how to turn off the hemodialysis machine in case of an emergency provided for non-dialysis nurses, was requested. However, the facility was not able to provide evidence of any in-service provided to non-dialysis nurses regarding emergencies during hemodialysis. In addition, the Facility did not have a Policy and Procedure (P&P) regarding emergency termination of dialysis by a non-dialysis staff.”

“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: 48186 Based on observation, interview and record review, the facility failed to: 1.a. Notify the physician regarding an increased respiratory rate for one of 30 sampled patients (Patient 1). The physician was not notified of abnormal vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) exhibited by Patient 1 in accordance with physician order (written instructions a physician has for a patient’s treatment) and the facility’s policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities. This deficient practice had the potential for a delay in the provision of medical care and treatments provided to the patient (Patient 1) which may result in complications such as acute respiratory distress (a type of lung failure due to fluid build-up in the lungs and low blood oxygen levels). 1.b. Notify the physician when one of 30 sampled patient’s (Patient 1) heart rate was 50 beats per minute (bpm, Normal is 60 to 100 bpm), in accordance with the physician order and the facility’s policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities. This deficient practice had the potential for cardiac (heart) complications such as further decreased heart rate leading to cardiac arrest (when the heart stops beating), thus requiring additional medical interventions, treatment and/or care for Patient 1. 2. Administer one of 30 sampled patient’s (Patient 1) medication (Bumex, a diuretic [causing increased urination] medication) in a timely manner per Physician order and in accordance with the facility’s policy and procedure regarding medication administration. This deficient practice had the potential for Patient 1 to have a worsening of health condition which may result in lengthened patient recovery time and prolonged hospitalization. 3. Ensure one of one sampled registered nurse (RN 4) 4 followed the facility’s policy and procedure (P&P) for putting on (donning) personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield.) while taking care of one of 30 sampled patients (Patient 17), who was on contact precaution (interventions taken to prevent transmission of infectious agents). This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 4 not wearing proper personal protective equipment (PPE) and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. 4. Ensure that an assessment, reassessment of pain level including documentation of vital signs monitoring was completed for one of 30 sampled patients (Patient 21) in accordance with the facility’s policy and procedure regarding assessment, reassessment, and vital signs monitoring. This deficient practice had the potential to result in the delay of appropriate treatment or medical intervention for Patient 21 which may lead to serious complications or death. 5. Ensure its Contract Dialysis Company (CDC or Company) followed county masking guidelines of wearing a face mask, over the nose and mouth, in patient care areas for one of 30 sampled patients (Patient 12). This deficient practice had the potential for the spread of infections such as Covid-19 (coronavirus, a highly contagious respiratory disease that spreads through droplets released when an infected person coughs, sneezes, or talks) and creating an unsafe environment for Patient 12. Findings: 1.a. During a review of Patient 1’s medical record titled “Face Sheet (a document that gives a patient’s information at a quick glance),” the Face Sheet indicated Patient 1 was admitted to the facility on 5/8/2022 at 12:57 a.m. with diagnoses of shortness of breath (unable to breath normally) and hyperkalemia (too much potassium in the blood). During a concurrent interview and record review on 4/4/2024 at 2:19 p.m. with Nurse Professional Development Practitioner 1 (NPD 1), Patient 1’s medical record titled “Vital Signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body),” dated 5/18/2022, was reviewed. The vital signs indicated the following: at 7:51 a.m., the respiratory rate was 31; at 11:00 a.m. the respiratory rate was 38; and at 11:09 a.m., the respiratory rate was 39. NPD 1 verified there was a physician order, dated 5/8/2022 at 5:18am, for nursing staff to notify the physician if the respiratory rate was greater than 30. NPD 1 confirmed there was no notification to the physician by nursing staff per the physician order (written instructions a physician has for a patient’s treatment). NPD 1 further confirmed per the nursing progress note that the physician was not notified until 5/18/2022 at 11:25 a.m. The nursing progress note indicated: “[Physician] rounding. Discussed plan of care. Pending BiPap delivery to room for patients work of breathing.” NPD 1 verified, there was no documentation in the medical record to notify the physician of Patient 1’s increased respiratory rate on 5/18/2022 at 7:51 a.m. until 5/18/2022 at 11:25 a.m. During an interview on 4/4/2024 at 11:15a.m. with the Assistant Nurse Manager 1 (ANM 1) and Assistant Nurse Manager 2 (ANM 2), ANM 2 stated the following: The physician should be notified per the parameters indicated in the physician order. Per policy, the physician orders are what Registered Nursing (RN) staff follow when determining when to notify the physician. ANM 1 said the following: when to notify the physician is based off the assessment of the nurse. If there are out of range vital signs, the Registered Nurse should notify the physician immediately, per the physician order. ANM 1 stated that when the physician is notified of vital signs, per the physician order, this should be documented in the patient’s medical record. ANM 1 and ANM 2 acknowledged that if the physician is not notified of vital signs timely, the patient can decompensate (functional deterioration of a structure or system that had been previously working). During a review of the facility’s policy and procedure (P&P) titled, “Nursing Service Department Scope of Service,” dated 3/13/2024, the P&P indicated the following: “Nursing Mission: ...committed to leadership and excellence in the delivery of quality, compassionate, value-added, person-centered health care services ... Scope of Service Provided: ... Service is provided within the scope as defined by the California Nurse Practice Act (Section 2723 of the Business and Professions Code): “The practice of nursing means those functions, including basic health care, which help people cope with difficulties in daily living which are associated with their actual or potential health or illness problems or the treatment thereof which require a substantial amount of scientific knowledge or technical skill” and includes: ... Direct and indirect patient care services, including, but not limited to, the administrations of medication and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist as defined by Section 1316.5 of the California Health and Safety Code ...” A review of the California Nurse Practice Act (The body of California law that mandates the Board to set out the scope of practice and responsibilities for RNs) (Section 2723 of the Business and Professions Code) indicated the following: “ ... (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures ...” 1.b. During a review of Patient 1’s medical record titled, “Face Sheet (a document that gives a patient’s information at a quick glance),” the Face Sheet indicated Patient 1 was admitted to the facility on 4/21/2022 at 5:27 a.m. with a diagnosis of mitral valve insufficiency (a heart condition where the heart valve flaps don’t close tightly, causing blood to move backward when the valve is closed). During a concurrent interview and record review on 4/4/2024 at 2:19 p.m. with Nurse Professional Development Practitioner 1 (NPD 1), Patient 1’s medical record titled “vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body),” dated 4/29/2024, indicated: At 4:00 p.m. Patient 1’s heart rate was 50. NPD 1 confirmed there was no notification to the physician by nursing staff per the physician order. NPD verified the physician order, dated 4/21/2022 at 11:25 a.m., indicated to notify the physician for heart rate less than 55. Patient 1’s physician order, dated 4/29/2022 at 6:47 p.m., indicated an order to discharge to home. Patient 1 was discharged from the facility on 4/29/2022 at 6:47 p.m. During an interview on 4/4/2024 at 11:15 a.m. with Assistant Nurse Manager 1 (ANM 1) and Assistant Nurse Manager 2 (ANM 2), ANM 2 stated the following: The physician should be notified per the parameters indicated in the physician order. Per policy, the physician orders are what Registered Nursing (RN) staff follow when determining when to notify the physician. ANM 1 said the following: when to notify the physician is based off the assessment of the RN. If there are out of range vital signs, the Registered Nurse should notify the physician immediately, per the physician order. ANM 1 stated that when the physician is notified of vital signs, per the physician order, this should be documented in the patient’s medical record. ANM 1 and ANM 2 acknowledged that if the physician is not notified of vital signs timely, the patient can decompensate (functional deterioration of a structure or system that had been previously working). During a review of the facility’s policy and procedure (P&P) titled, “Nursing Service Department Scope of Service,” dated 3/13/2024, the P&P indicated the following: “Nursing Mission: ...committed to leadership and excellence in the delivery of quality, compassionate, value-added, person-centered health care services ... Scope of Service Provided: ... Service is provided within the scope as defined by the California Nurse Practice Act (Section 2723 of the Business and Professions Code): “The practice of nursing means those functions, including basic health care, which help people cope with difficulties in daily living which are associated with their actual or potential health or illness problems or the treatment thereof which require a substantial amount of scientific knowledge or technical skill” and includes: ... Direct and indirect patient care services, including, but not limited to, the administrations of medication and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist as defined by Section 1316.5 of the California Health and Safety Code ...” A review of the California Nurse Practice Act (The body of California law that mandates the Board to set out the scope of practice and responsibilities for RNs) (Section 2723 of the Business and Professions Code) indicated the following: “ ... (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures ...” 2. During a review of Patient 1’s medical record titled “Face Sheet (a document that gives a patient’s information at a quick glance),” the Face Sheet indicated Patient 1 was admitted to the facility on 5/8/2022 at 12:57 a.m. with diagnoses of shortness of breath (unable to breath normally) and hyperkalemia (too much potassium in the blood). During a concurrent interview and record review on 4/4/2024 at 2:19 p.m. with Nurse Professional Development Practitioner 1 (NPD 1), Patient 1’s medical record was reviewed and indicated a physician order (written instructions a physician has for a patient’s treatment) for bumetanide (Bumex, a diuretic [causing increased urination] medication) 2 milligrams (mg, a unit of measurement) injection, intravenous (IV) push (a medication or fluid substance delivered directly into the bloodstream quickly) to start 5/18/2022 at 10:00 a.m. NPD verified the medication was given on 5/19/2022 at 1:19 p.m. During an interview on 4/4/2024 at 11:15 a.m. with Assistant Nurse Manager 1 (ANM 1) and Assistant Nurse Manager 2 (ANM 2), ANM 1 and ANM 2, stated the following: Per policy, Registered Nurses (RNs) have one hour before and one hour after a medication is due, to administer the medication to the patient. It is important to give medications timely to ensure patients get the care required for their diagnosis. If a medication is not given on time, there is a delay in patient care and treatment provided and this can negatively affect the patient. During a review of the facility’s policy and procedure (P&P) titled, “ Medication Administration and Documentation, Procedure: Medication Management,” dated 2/8/2024, the P&P indicated the following: “Policy: ...medications are safely administered ... E. Prior to medication ... 2. Prior to the medication administration, the individual administering the medication does the following: a. verifies: ... Medication is being administered at the proper time ...” 3. During a review of Patient 17’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), the H&P indicated that Patient 17 was admitted on 3/19/2024 due to a mechanical trip (an external force or object caused the fall) and fall (an unplanned descent to the floor with or without injury) at home. The H&P also indicated that Patient 17 tested positive for Extended-spectrum beta-lactamases (ESBL, a bacteria that cannot be killed by many of the antibiotics that doctors use to treat infections) therefore Patient 17 required contact isolation (interventions that are implemented before going into a patient’s room and after leaving a patient’s room to stop germs from spreading to others). During a concurrent observation and interview on 4/4/2024 at 11:15 a.m. in 8 North East (medical surgical unit, a unit that serves the general population hospitalized for various causes such as surgery, testing observation, etc.) with Registered Nurse (RN) 4, RN 4 stated all Personal Protective Equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield.) must be worn and removed when entering and/or leaving a contact isolation room. RN 4 stated that she (RN 4) was in a hurry when entering the room to check if the patient (Patient 17) had four side rails up while lying in bed. RN 4 did not wear appropriate PPE when she (RN 4) entered Patient 17’s room. During an interview with the accreditation specialist (AS 2), who was present and witnessed the time RN 4 entered the room without PPE, AS 2 stated that RN 4 should have never entered that contact isolation room (Patient 17’s room) without proper protective gear. AS 2 said the expectation is for the staff to remember to wear their PPE prior to entering an isolation room regardless of whether this person is in a rush or not. During a review of the facility’s policy and procedure (P&P) titled, “ Isolation, Standard Precautions Policy: Epidemiology/Infection Prevention,” dated 1/17/2024, the P&P indicated, “ Standard Precautions are used for all patient care activities to protect healthcare personnel (HCP) from infection and to prevent the spread of infection from patient to patient. All healthcare personnel, including medical staff, will routinely use personal protective equipment (PPE).” The P&P also indicated to wear a gown, apron, or other PPE attire, that is appropriate to the task, to protect skin and prevent soiling of clothing during procedures and other patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. 4. During a review of Patient 21’s facility document titled “patient care timeline,” dated 3/31/2024, the document indicated the following: On 3/31/2024 at 8:40 p.m., Patient 21 arrived at the emergency department (ED, responsible for the provision of medical care to patients arriving at the hospital in need of immediate care) with complaints of chest pain and shortness of breath. At 8:46 p.m., Patient 21’s Vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) were: temperature 98.3 degrees Fahrenheit (F), heart rate 71 (Normal), respiratory rate 18 (Normal), blood pressure 135/62, Oxygen saturation (measures the amount of oxygen in the blood) 98% on room air; No documentation if Patient 21 was having chest pain or if assessed to be having chest pain At 8:50 p.m., Patient 21 was determined to have an emergency severity index 2 (ESI 2, a prioritization tool used in the Emergency Department to classify patients from most urgent to least urgent. ESI 2 indicates high risk situation). At 9:10 p.m., Patient 21 was placed on cardiac monitoring (device used to record the electrical activity of the heart) At 9:27 p.m., Patient 21 was administered Toradol (Ketorolac, used for short-term treatment of moderate to severe pain in adults) 15 milligrams (mg, a unit of measurement)Intravenous (through the vein). No baseline pain scale was documented prior to Toradol administration. At 9:30 p.m., Patient 21 had a documented pain level of 7 (Pain scale is 0- 10 with 10 as severe). No documented pain re-assessment after 1 hour of Toradol administration. No vital signs documented as well. At 10:38 p.m., Patient 21 was given Morphine (medication prescribed for severe pain) 4 mg IVP (intravenous push, administered through the vein) At 11:16 p.m., Patient 21’s Pain Assessment included: Sedation Level: slightly drowsy easily arousable Pain location: Chest Pain interventions: Medication; Rest Pain rating: 3 (Pain Scale 1 to 10). Pain quality: discomfort. Pain onset: Gradual Pain Duration: Continuous Another pain site: No At 11:28 p.m., Patient 21 was admitted as inpatient During a concurrent interview and record review on 4/4/2024 at 4:30 p.m. with the Accreditation Specialist(AS2) and the Associate Director of the Emergency Department (AD3), Patient 21’s medical record was reviewed. Both AS2 and AD3 confirmed that there were no succeeding vital signs recorded for patient 21 after the initial vital signs taken on 3/31/2024 at 8:40 p.m. until 4/1/2024 at 12:50 a.m. AD3 stated that since Patient 21 had an ESI level of 2, vital signs should have been reassessed every 2 hours and documented. AD3 also said that there was no medical screening examination documented by the physician. In addition, AD3 confirmed there was no pain assessment documented prior to and after pain medication administration. AD3 stated that pain assessment should have been done and documented within an hour after Toradol administration. AD3 said that vital signs should have been checked along with pain assessment. A review of Patient 21’s facility document titled, “Patient Care Timeline,” dated 4/1/2024, indicated the following: On 4/1/2024, a transthoracic echocardiogram (a test that uses ultrasound [sound waves] to create images of the heart) was ordered at 7:19 a.m. and was completed at 10:45 a.m. At 10:52 a.m., the transthoracic echocardiogram preliminary result was communicated to MD in ED At 11:00 a.m., Patient 21 complained of chest pain of 8 (out of the pain scale of 0-10); Nitroglycerin (medication used to treat Chest pain) Infusion was started At 11:11 a.m., Patient 21 was evaluated by the Cardiothoracic surgery team (a team that specializes in surgery of the heart) A review of Patient 21’s facility document titled, “transthoracic echocardiogram report” study, dated 4/1/2024 indicated Patient 21 had Aortic dissection from the Aorta root to the abdominal Aorta and very severe aortic valve regurgitation (blood flowing back into the aorta). A review of Patient 21’s Medical Record titled, “Operating report,” dated 4/1/2024 indicated, Patient 21 was emergently transferred to the OR (Operating Room, where surgical procedures are performed) for Emergency repair of Aortic Dissection (a serious condition in which a tear occurs in the inner layer of the body’s main artery [a blood vessels that carries oxygenated blood to other parts of the body]) at 12:40 p.m. on 4/1/2024. A review of a Facility Document titled “Documentation patient care process in the emergency department” dated 10/12/2023 indicated Patient “reassessment is done based on prioritization of the change in condition, interventions, and treatment provided and pain management, the patient reports pain, and response to intervention will be documented using the one to ten scale” and “assessment after pain interventions will be documented within 60 minutes of the intervention... insufficient pain relief and or adverse effects are documented and reported to the physician immediately... vital signs are monitored ...” 5. During a review of Patient 12’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/23/2024 at 11:47 p.m., the H&P indicated the following: Patient 1 was admitted from an outside hospital for alcoholic cirrhosis of liver (alcohol-related scarring of the liver) with ascites (buildup of fluid in the abdomen) and acute kidney failure (a rapid decline in kidney function). During an observation on 4/2/2024 at 2:41 p.m., in the Dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) Unit, the following was observed: Patient 12 was undergoing hemodialysis (a treatment to filter waste and water from the blood) in the Unit. The Biomedical Technician (BMT) was observed near Patient 12 in the patient care area. The BMT wore a facemask that was positioned under BMT’s nose. BMT repositioned the face mask to cover the nose and mouth. Then, BMT sat down in the nurse’s station in the Dialysis Unit and started talking on the cellular phone with the face mask under his nose. During an interview on 4/2/2024 at 2:41 p.m., with the Clinical Nurse Manager for the Contracted Dialysis Service (CNMCDS), CNMCDS stated hemodialysis was provided to hospitalized patients by a Contracted Dialysis Service (CDS) in the Dialysis Unit or at the bedside. During an interview on 4/2/2024 at 2:55 p.m., the BMT stated he (BMT) placed the mask under his nose because he was talking on the phone and declined to answer any further questions. During an interview on 4/2/2024 at 2:56 p.m., the CNMCDS stated that all staff in patient care areas were required to wear a facemask, covering the bridge of the nose and mouth, to protect oneself and patients from the potential spread of Covid-19. During an interview, on 4/2/2024 at 3:22 p.m., the Executive Director of the Office for Licensing, Accreditation, and Regulatory (EDOLAR) stated the facility followed current county guidelines, and face masks were required in patient care areas to prevent the potential spread of infections. During a review of the facility’s policy and procedure titled, “Isolation, Standard Precautions Policy: Epidemiology / Infection Prevention,” dated 1/17/2024, the P&P indicated the following: Standard precautions is a system of infection control which assumes all blood, body fluids, secretions and excretions from all patients are a potentially infectious. Standard precautions are applied to prevent health care personnel occupational exposures from all patients and from contaminated medical equipment ...Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during delivery of health care ...Universal Pandemic Precautions (UPP) ...Because COVID-19 can be transmitted from patients who do not have symptoms ...Face mask must be worn at all times ... During a review of a document titled, “Masking Guidelines Relaxed,” dated 3/12/2024, the document indicated the following: With Covid-19 cases continuing to decline ...the Hospital is relaxing some of its masking requirements. These new standards ...follow recent county guidance while ensuring we continue to protect our most vulnerable patients from healthcare workers who may potentially be infected with COVID-19, flu, or RSV (Respiratory Syncytial Virus, a respiratory virus that affects the lungs and breathing passages). The following guidelines are now in effect ... All Hospital team members ... well-fitted mask will be required in all areas where patients are provided care. During a review of a service agreement between the Hospital and the Contracted Dialysis Company (CDC or Company) titled, “Hospital Services Agreement,” dated 3/1/2022, the service agreement indicated “All Company Staff shall comply with the policies and procedures of the Hospital in effect of the date hereof that relate to the provision of the Services, to the extent not inconsistent with applicable laws or regulations, the express terms of this Agreement, and/or Company’s own policies and procedures ...””