Kaiser Foundation Hospital - Fresno

“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: 49884 Based on interview and record review Licensed Nurses (LNs) failed to develop individualized care plans for three of 31 patients (Patients 5, 27, and 14) when: 1. LNs did not develop an individualized care plan for Patient (Pt) 5’s chief complaint (CC- the primary reason why a patient seeks medical attention) of “fatigue (extreme tiredness resulting from mental or physical effort or illness)” in accordance with hospital policy and procedure (P&P) titled “Plan of Care and Patient Education- Interdisciplinary” dated 1/15/25. 2. LNs did not develop an individualized care plan for Pt 27’s airway despite the chief complaint of “shortness of breath” and the presence of a stoma (surgically created opening) in his neck due to a laryngectomy (voice box removal). 3. LNs did not develop an individualized care plan for Pt 14’s plan of birth, a vaginal birth after cesarean (VBAC). These failures had the potential for inconsistent delivery of care for Pt 5, 27, and 14, and had the potential for not receiving nursing care to reflect their individual needs and goals which could negatively affect patient well-being. Findings: 1. During a review of Pt 5’s electronic medical record (EMR- digital versions of patients’ paper charts, storing demographics, medical history, medications, diagnoses, immunizations, and test results in one secure system for a single practice or hospital) on 12/4/25 at 11:23 a.m., of Pt 5s “History and Physical (H&P- a comprehensive patient assessment by a healthcare provider)” the document indicated Pt 5 is a 68-year-old admitted to the hospital as an inpatient on 12/2/25 after coming to the Emergency Department (ED) for “fatigue.” During a review of Pt 5’s EMR on 12/2/25 at 11:30 a.m., of Pt 5’s “H&P” the document indicated Pt 5 presented to the Emergency Department (ED- a hospital facility providing immediate, 24/7 care for severe injuries and acute illnesses) “history of obesity, adrenal insufficiency (the glands, located above the kidneys, don’t produce enough vital hormones, mainly cortisol, and sometimes aldosterone, leading to fatigue), chronic orthostatic hypotension (when your blood pressure drops significantly and suddenly when you stand up from sitting or lying down, causing dizziness, lightheadedness, blurred vision, or fainting) and cirrhosis (severe scarring of the liver due to long-term damage from various conditions) decompensated by esophageal varices (swollen, fragile blood vessels in the esophagus (food pipe)) and recurrent episodes of hepatic encephalopathy (the damaged liver can’t filter toxins [harmful or dangerous to health or life] (mainly ammonia) from the blood) who presents with abdominal pain and nausea. Patient reports that she was in her usual state of health until today. In the morning, she started to have left lower quadrant [stomach] pain, constant and burning in nature. Throughout the rest of the day patient became very tired, sleeping through most of the day. Family was concerned her ammonia (too much ammonia in the blood, which is toxic to the brain) was high and brought her in for evaluation. In ED, patient was found to have colitis (inflammation of the large intestine (colon) that causes symptoms like abdominal pain, cramping, diarrhea (often bloody), and urgency to have a bowel movement) with shock (a life-threatening medical condition where the body’s tissues and organs don’t get enough oxygen-rich blood, leading to cellular dysfunction and potential organ failure) requiring norepi[nephrine-medication to raise blood pressure], HBS (undefined acronym) was consulted for admission...” During a review of Pt 5’s EMR the “Plan of Care” dated 12/2/25 indicated, the “Problem: Adult Inpatient Care Plan” and “Fall/Injury Risk...” being the only identified and documented patient problems for nursing intervention and monitoring. During a concurrent interview and record review on 12/2/25 at 11:34 a.m., with the Quality Nurse Consultant (QNC), Pt 5’s EMR indicated, a care plan (CP- a comprehensive document that outlines the individualized care and treatment a patient will receive from a healthcare team. It serves as a roadmap for nurses and other healthcare providers to ensure consistent, coordinated, and evidence-based care) for Pt 5’s admission diagnosis had not been initiated. QNC stated it is expected that nurses will initiate a patient specific CP, update it once per shift, and complete CPs in accordance with hospital policy. QNC stated CPs should be patient-specific and that Pt 5’s CP did not include a focus or plan for the management of Pt 5’s chief complaint of fatigue. 2. During a concurrent interview and record review on 12/3/25 at 1:30 p.m. with Clinical Nurse Specialist (CNS) 1, ANM 5, Pt 27’s “H&P”, dated 11/30/25, and “Care Plan”, dated 12/1/25 were reviewed. The “H&P” indicated Pt 27 arrived at the hospital on 11/30/25 with complaint of shortness of breath. Pt 27 had a past medical history (PMH) of stage four (cancer has spread from original site to distant parts of body making it advanced) voice box cancer with lung metastasis (secondary growth), after laryngectomy (voice box removal). Pt 27 was admitted to the hospital as an inpatient on 11/30/25 for kidney failure. The “Care Plan” indicated, Pt 27 had a care plan to address issues for confusion, falls, infection, comfort, and restraints. ANM 5 stated, LNs should have addressed Pt 27’s airway in the care plan, since he had problems with his airway. ANM 5 stated care plans were supposed to be patient specific and individualized. ANM 5 stated the purpose of the care plan was to progress the patient towards their goals to discharge the patient safely. 3. During a concurrent interview and record review with the Assistant Nurse Manager of OB (ANM 1) (Obstetrics - pertaining to pregnant women) on 12/3/25 at 9:30 a.m., the Electronic Medical Record (EMR) for Pt 14 was opened and reviewed. The document titled, “OB Admission History and Physical” dated 12/2/25 at 7:04 a.m. indicated Pt 14 was a 30 year old woman who had a cesarean section delivery (infant delivered surgically through the abdomen) and wished to attempt to deliver her second child vaginally. The Patient assessment indicated, “Active Hospital Problems: Supervision of High Risk Pregnancy, hx (history) of cesarean section ...” The ANM 1, who stated she is also the Clinical Educator for the OB department, stated Pt 14 came in already in labor with a plan to do a VBAC (Vaginal birth after Cesarean) and stated VBACs are considered high risk deliveries. The document titled, “Plan of Care,” which the ANM 1 stated was the Care Plan (CP-a document that outlines a patient’s health conditions, treatments and other information to guide their care and ensure continuity) was initiated on 12/2/25 at 3:45 p.m. The CP included goals and plans for caring for Pt 14 after the baby was born, but did not include a plan for managing the high risk pregnancy prior to delivery. The ANM 1 stated the nurses should have created a Care Plan right after she was admitted to provide guidance and awareness of the high risk delivery. During an interview on 12/5/25 at 2:50 p.m. with the Chief Nursing Executive (CNE), CNE stated it is her expectation that all patient CPs include the chief complaint. CNE stated fatigue (admitting diagnosis) should have been addressed in [Pt 5’s] CP. The CNE stated Pt 27 should have had a care plan that addressed his difficulty breathing, and Pt 14 should have had an individualized care plan started soon after admission for her planned VBAC. During a review of the hospital’s P&P titled “Plan of Care and Patient Education- Interdisciplinary” dated 1/15/25, the P&P indicated, “... 1.0 Policy Statement 1.2 .1 Care is planned and provided in an interdisciplinary manner. The Patient Plan is developed by using a multi-dimensional approach to address the plans and goals for care, interventions and treatment, and services based on the patient’s needs. 1.2 The Patient Plan is initiated within eight hours of admission to the hospital. 1.3 The Patient Plan is individualized and based on the specific patient needs identified during the initial admission assessment and ongoing assessments and reassessments throughout hospitalization. 1.4 Progress toward identified patient goals and appropriate interventions is reviewed each shift and communicated during each shift report and upon transfer to another unit or level of care. 1.5 Each discipline may add new problems to the Patient Plan, edit and resolve existing problems, and document the patient’s progress towards goals... 2.0 Purpose 2.1 This policy provides guidelines for use of the Patient Plan and Patient Education activities within “hospital name” by members of the interdisciplinary team and describes the process for documenting the plan of care... 5.0 Procedure 5.2 Develop an individualized Patient Plan after collaborating with the patient and/or their representative, interdisciplinary team members, and review of pertinent patient information (e.g. PER, Notes, Doc Flowsheets, Patient Plan Progress Notes, and Event Log in Patient Plan). Review and update the Patient Plan every shift and as needed...” During a review of a professional article from the American College of Obstetrics and Gynecology (ACOG) titled ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery retrieved from https://pubmed.ncbi.nlm.nih.gov/30681543/ the article indicated, “...Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level. However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery . Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC...””

“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: 49884 Based on observation, interview and record review, the facility failed to ensure licensed nurses (LNs) followed the hospital’s policies and procedures (P&P) for five of 31 sampled patients (Pts) (Pt 1, Pt 2, Pt 27, Pt 28, and Pt 31), when : 1. Staff failed to ensure the brakes of the patient hospital bed for one (1) of 31 sampled patients, (Pt 1), were locked in accordance with hospital policy and procedures (P&P) “Fall Prevention (Adult) [Area] Regional Policy” dated 10/15/25 and “Safe Patient Handling for Hospitals” dated 9/18/24. This failure resulted in a fall with injury; suspicious for fracture (broken bone) of Pt 1’s left hip/thigh, with the potential to contribute to a decline in medical condition up to and including death. 2. Licensed Nurses (LNs) did not follow the hospital’s P&P titled, “Fall Prevention (Adult) [Area] Regional Policy”, and the “[Brand Name and model] MedSurg [Medical Surgical] Bed Operations Manual”, for one of two sampled high fall risk patients (Pt 2) when the bed alarm (a safety device with sensors that alerts nurses when a high-risk patient tries to get out of bed unassisted) an intervention instituted by LNs to prevent falls and injury was inaudible outside of Pt 2’s room. This failure allowed Pt 2 to get out of bed unassisted and fall to the floor without staff being alerted until someone in the hall heard him call for help. 3. LNs did not follow the hospital’s P&P titled, “Pain Assessment and Management”, for two of 31 (Pts 28 and 31) patients. LNs failed to reassess Pt 31 timely after pain medication and did not follow physician orders for Pt 28, who reported severe pain but received medication ordered for mild pain. These failures placed Pt 28 and Pt 31 at risk for inadequate pain management and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of the patients. 4.The cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) Crash Cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) on 3 East Medical Surgical (MS) Unit was not checked daily according the hospital’s P&P titled, “Adult/Pediatric Crash Cart Stocking and Pediatric Emergency Jump Bag [portable medical kit]”, and the hospital document titled, “Adult Crash Cart Daily Checklist”, when it was not checked on 12/1/25. This failure placed patients at risk of not having their needs met during emergencies if the crash cart malfunctioned. 5. The hospital failed to ensure LNs documented accurately and completely for one of 21 sampled patients (Pt 27) by not using unapproved abbreviations, according to the hospital’s P&P titled, “HIM [Health Information Management] Medical Record Documentation Requirements [Area] Regional Policy” This failure had the potential to cause poor patient outcomes due to a lack of communication, medical errors, and delayed care. Findings: 1. During a review of Pt 1’s “Face Sheet (FS)”, dated 1/17/25, the “FS” indicated, Pt 1’s “...DOB (Date of Birth) 5/2/1950....Admit Date: 1/17/25... Admit Diagnosis: colon obstruction [when food, liquid, gas, or stool can’t move through the large intestine, either partially or completely], htn [high blood pressure], hx [history of] colon cancer...” During a review of Pt 1’s History and Physical (H&P- an assessment from physician including medical history and exam) dated 1/18/25, the H&P indicated “... Chief Complaint: Abdominal [stomach] pain and constipation [unable to pass feces] in the setting of partial colectomy [a surgery to remove a diseased or damaged section of the colon] History of Present Illness: The patient is a 74-year-old with a history of hypertension, iron deficiency anemia [not enough healthy red blood cells to carry adequate oxygen to your body’s tissue], hypothyroidism [a small butterfly-shaped gland in your neck, doesn’t produce enough essential hormones that control your body’s energy use], colon cancer status post partial colon resection [surgery to remove a diseased section of the colon] and presents to the emergency room with constipation for 5 days and bloating. CT [Computed Tomography, a sophisticated imaging test that uses X-rays and a computer to create detailed cross-sectional “slices” or 3D pictures of your bones, organs, soft tissues, and blood vessels] of the abdomen shows findings concerning for colonic obstruction... The ascending [first segment of large intestine] and transverse colon [middle section of large intestine] are significantly distended [swollen from the inside] and fluid-filled. The small bowel [area between stomach and large intestine] loops are distended and fluid-filled as well. There is [concern] for ileitis [inflammation of the ileum, the final section of the small intestine]. Trace [a very small quantity] ascites [the abnormal buildup of fluid in the peritoneal cavity, the space between the lining of the abdomen (peritoneum) and the abdominal organs, causing swelling and pressure in the belly] in the upper abdomen. Other findings as described. The patient will be admitted for care...” During a review of Pt 1’s “Fall” note dated 1/20/25 at 11:01 a.m., the note indicated “...Fall ...Location: Room. Description of event: Transporter, [name] Patient Care Aide [PCA], and writer entered room to help pull pt over to bed with “brand name” mat [transfer aide] from gurney. Pt slid halfway onto bed and then bed rolled out from underneath Pt 1 and Pt 1 slipped between bed and gurney. RN 4 stated the “Brand name” mattress was fully inflated and went with pt during fall. Pt slowly slid to floor with “brand name” mattress under her body, no injuries. Fall code called... Injury sustained: no apparent injury Level of Consciousness: gcs [Glasgow Coma Scale- a neurological scale used to assess a patient’s level of consciousness after a brain injury or in cases of impaired consciousness 3 [deep coma], 15 [fully alert]) 15 (intact mentation] Pain: no...” During a review of Pt 1’s “Physician Note” dated 1/20/25, the note indicated “...Patient had a witnessed fall during transfer from bed to gurney. No obvious injuries, pain in the left hip with movement of left leg/hip. Will check X-ray to rule out any occult [not easily seen] fractures...” During a review of Pt 1’s “Radiology Order” dated 1/20/25, the “Radiology Order” indicated, “...Order: XR LEFT HIP...Frequency: One Time...Reason for Exam: fall rule out fracture...” During a concurrent interview and record review on 12/3/25 at 1:49 p.m. with the Quality and Safety Improvement Consultant (QSIC), the QSIC stated Pt 1’s fall was reported to Risk Management on 1/20/25. The QSIC stated the hospital conducted a “Comprehensive System Analysis (CSA-an in depth investigation after an event to determine cause)” on 2/11/25 which resulted in staff education and training sessions in person, daily safety huddles at shift change, and completion of computer-based modules focused on safe patient handling, communication and clarification of staff roles and responsibilities. The QSIC stated education was “rolled out” to staff 3/5/25 with a complete by date of 6/5/25. During an interview on 12/4/25 at 2:00 p.m., with Registered Nurse (RN) 4, RN 4 stated she recalled the event and explained she assumed care of Pt 1 while Pt 1’s primary RN went on a lunch break. RN 4 stated in report she learned Pt 1 was away from the unit expected return from CT was soon. RN 4 stated she responded to Pt 1’s room upon her return from CT and found Patient Transport Aide (PTA) 1 had positioned the beds to help Pt 1’s transfer and was positioned at Pt 1’s left. RN 4 stated Pt 1, a bariatric (relates to the medical field of treating obesity) patient required at least 3 persons to transfer Pt 1 safely. RN 4 stated Patient Care Aide (PCA) 1 brought in a “brand name” inflatable transfer mattress pump into the room and started inflating the mattress. RN 4 stated she was positioned at the foot of the gurney and bed. RN 4 stated PCA was positioned at the right of Pt 1’s hospital bed side. RN 4 stated upon transferring Pt 1 was halfway onto the hospital bed from the gurney when she observed the beds moving away from one another creating a “crack” at the center of the two beds and Pt 1 slid down to the floor. RN 4 stated Pt 1 landed once on the inflated mat hitting her left arm, bounced hitting her head on the second impact. RN 4 stated Pt 1 denied pain on assessment. RN 6 stated she called a “Code F” which is an overhead page alerting others that a patient has fallen and staff may need extra help. RN 4 stated she later learned that the wheels on the hospital bed had not been locked prior to transfer. RN 4 stated it is the team’s responsibility to ensure all wheels are locked to ensure safe patient transfer and this was not the case with this event. RN 4 stated, “We should have made sure the wheels were locked before moving the patient.” During an interview on 12/5/25 at 9:30 a.m., with PTA 1, PTA 1 stated she was transporting Pt 1 by gurney from CT to her in patient room on 1/20/25. PTA 1 stated she positioned the gurney next to the hospital bed. PTA 1 stated she recalled locking the gurney but leaving the hospital bed unlocked. PTA 1 stated due to the room configuration, the third staffer would have to move the bed to make room to position themselves between the hospital bed and the restroom door. PTA stated Pt 1 slid between the beds while the hospital bed moved away from the gurney falling to the floor. PTA 1 stated the team should have made sure to lock all wheels before moving Pt 1. PTA 1 stated “closed looped” communication could have been better and now makes sure to pause and ask if all wheels are locked when transferring patients. During an interview on 12/5/25 at 2:50 p.m., with the Chief Nursing Executive (CNE), the CNE stated it is her expectation that staff follow hospital P&P and manufacturer instructions for use (IFUs) [inflatable mattress and pump]. CNE stated patient locking the wheels and proper patient positioning may have prevented the event. During a review of the hospital’s P&P titled, “Safe Patient Handling for Hospitals”, dated 9/18/24, the P&P indicated “... Policy Statement: “hospital system” supports a culture of safety that protects members, patients, visitors, and staff in “hospital system” Hospitals’ general acute care hospitals. Purpose: The purpose of this policy is to provide guidance to ensure consistent safe patient handling and mobilization practices in “hospital system” general acute care hospitals in compliance with federal, state, and local regulations. Scope/Coverage: This policy applies to all employees who are employed by the following entities (collectively referred to as “hospital system”)... 5.2.6 Employees are responsible for: Complying with the requirements stated herein, also including: 5.2.6.1 Working safely and following established safe patient handling policy and procedures...” These findings represent past noncompliance with regulatory requirements. There was sufficient evidence the facility corrected the noncompliance as of 3/28/25 and there were no other occurrences of the same deficient practice at the time of the survey the facility was in substantial compliance with this regulatory requirement and therefore does not require a plan of correction. 2. During a concurrent interview and record review on 12/4/25 at 9:20 a.m. with Nurse Manager (NM) 1, NM 1 opened Pt 2’s Electronic Medical Record (EMR- a digital version of a patient’s medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans) for review. Pt 2’s document titled, “H&P”, dated, 8/29/25, indicated, Pt 2 arrived in the emergency department (ED) with complaint of right hip pain after a fall when getting out of bed reaching for his walker. The “H&P” indicated Pt 2 had a past medical history (PMH) of atrial fibrillation (irregular heartbeat) on diabigatran (medicine to prevent blood clots), severe obesity (excessive body fat), and multiple myeloma (rare blood cancer affecting cells in the spongy tissue inside bones, weakens bones). The document titled, “XRAY [a picture of the bones and other parts inside of the body] RIGHT FEMUR (bone of the upper thigh)”, dated 8/29/25, indicated, Pt 2 had a severely displaced (separates) comminuted (shatters) intertrochanteric (bumpy parts of the top of the thigh bone) fracture (broken or cracked bone) of the right femur. NM 1 stated Pt 2 was admitted as an inpatient on 8/29/25 at 10:48 a.m. for right hip surgery. NM 1 stated Pt 2 was moved to the MS unit on 8/29/25 at 12:51 p.m. During a concurrent interview and record review on 12/4/25 at 9:40 a.m. with NM 1, NM 1 opened Pt 2’s EMR for review. The document titled, “Assessments”, dated 8/31/25 indicated RN 1 assigned a Schmid Fall Risk Scale score (a clinical tool in healthcare for evaluating a patient’s risk of falling, higher score is a greater risk) of three. NM 1 stated a three indicated a high risk of falling. The document titled, “Safety Interventions”, dated 8/31/25, were reviewed. The document included, headers titled, “patient safety”, “patient rounds”, and “precautions” The documents titled “Precautions, and Patient Safety” indicated, LNs had placed Pt 2 under fall precautions, and a bed alarm was on and set. NM 1 stated fall precautions meant Pt 2 had nonskid shoes or slippers when out of bed, nurses completed safety rounds, and he had supervised activity when out of bed. The document titled “Assessments”, dated 8/31/25 indicated RN 1 completed a nursing assessment at 4 p.m. and 8 p.m. RN 2 documented Pt 2’s GCS score 15 out of 15. NM 1 stated Pt 2 had no change in mental status from previous LN assessments. The document titled, “Nursing Note,” dated 8/31/25 at 10:44 p.m., (late entry) indicated, at approximately 8:38 p.m. RN 1 found Pt 2 on the floor in a sitting position, with the bed alarm going off. RN 1 noted Pt 2 was awake and alert and able to answer questions. NM 1 stated Pt 2 did not have injuries related to the fall. NM 1 stated, she investigated the fall. NM 1 stated, prior to the fall Pt 2 was alert and oriented, and was behaving normally. NM 1stated Assistant Nurse Manager (ANM) 2 was moving another patient through the hall, heard the alarm by Pt 2’s door, and found Pt 2 sitting on the floor. NM 1 stated through the results of their investigation discovered the bed alarm could be heard in the room but could not be heard at the nurse’s station and overhead. NM 1 stated the bed was taken out of service, to ensure the bed was not malfunctioning, and discovered the bed was not connected to the call system. During a review of the hospital document titled, “[Brand Name and model] MedSurg Bed Operations Manual”, “undated”, indicated, “ ...The [Brand Name and model] MedSurg bed is equipped with a hospital grade plug for protection against electric shock hazard. It must be plugged directly into a properly grounded three prong receptacle [outlet]. Plug the optional interface cable into the 37-pin connector under the litter frame at the head end of the bed, into the “Patient Station”, “Head Wall”, “Docker Station” or equivalent (whichever applies). Test the interface cable to verify it is functioning properly. Additional Alarm Conditions ...If the operator would like to set the Awareness alarm to the Nurse Call Station, the “Status To N/C” must be turned “On” through the Advanced Options Menu in the Main Menu.” ...The advanced menu items include: ...3. Awareness Alarm 4. Status To N/C ... Advanced options: the operator can choose between 10 exit alarms ...The operator can enable or disable an audible alarm for [bed type] Awareness alert states. ... If an audible alarm is required, the operator can set the Awareness alarm to “On” through the Advanced Options Menu in the Main Menu. ... If the operator would like to set the Awareness alarm to the Nurse Call Station, the “Status To N/C” must be turned “On” through the Advanced Options Menu in the Main Menu ...” During an interview on 12/4/25 at 11:26 a.m. with ANM 2, ANM 2 stated she recalled Pt 2’s fall on 8/31/25. ANM 2 stated she worked on the MS Unit as the Assistant Nurse Manager. ANM 2 stated that on 8/31/25 at approximately 8:30 p.m. she was moving another patient from one unit to another. ANM 2 was with three other individuals, moving the patient in the hallway outside Pt 2’s hospital room and the door was partially open. ANM 2 stated she heard a bed alarm going off but didn’t know which room but then realized the bed was going off in Pt 2’s room. ANM 2 stated the pt said either help or help me, and she and Patient Care Technician (PCT) 1 went into the room while the third staff member took the other pt where they should go. ANM 2 stated Pt 2 appeared alert and oriented. ANM 2 stated the light was off in the room, but the patient’s tablet screen was illuminating the room from the bed. ANM 2 stated Pt 2 was sitting on the floor but leaning on his left arm as though attempting to get up. ANM 2 reported that Pt 2 did not recall how he ended up on the floor. ANM 2 stated Pt 2 had not tried to get out of bed unassisted before. ANM 2 stated she did not hear the bed alarm until very close to the room, and the alarms were normally heard in the nurse’s station and overhead. During a telephone interview on 12/4/25 at 2:13 p.m. with PCT 1 with the Clinical Nursing Director (CND) in attendance, (Patient Care Technician (PCT) 1 stated she remembered Pt 2’s fall on 8/31/25. PCT 1 stated she was assigned Pt 2 for her 3 p.m. to 11:30 p.m. shift on 8/31/25. PCT 1 stated she cleaned up Pt 2, picked up his dinner tray, and gave him his tablet when asked. PCT 1 stated nothing seemed abnormal, and he was not ambulatory (able to walk without assistance). PCT 1 stated that after her lunch around 8:30 p.m. she assisted ANM 2 in moving a patient, and when she was several doors from Pt 2’s room she heard someone say, “help, or I need help”. PCT 1 stated she let go of the other bed, went into Pt 2’s room and turned on the light. PCT 1 saw Pt 2 sitting on the floor leaning to the left trying to get himself up. PCT 1 reported that Pt 2 indicated he was not injured. PCT 1 stated Pt 2’s door was only opened a crack. PCT 1 stated she could not hear the bed alarm until she opened the door to Pt 2’s room. When asked if the bed alarms were usually difficult to hear outside the rooms, PCT 1 stated sometimes they could be depending on how loud the unit was, but the bed alarms were supposed to be hooked up to the nursing station to get an alert. PCT 1 stated Pt 2’s alarm was more difficult to hear since the door was almost fully closed. During an interview on 12/4/25 at 2:42 p.m. with the QSIC, the QSIC stated the fall investigation determined Pt 2’s bed was not hooked up to the call light system and should have been. During an interview on 12/4/25 at 3 p.m. with RN 1, RN 1 stated she recalled Pt 2’s fall on 8/31/25. RN 1 stated she was Pt 2’s primary nurse on 8/31/25 and Pt 2 fell during her shift, she worked from 3 p.m. to 11:30 p.m. RN 1 stated when she started her shift she got report from the morning nurse the Pt 2 had a fall at home, and he had a hip fracture with surgical repair one day before. RN 1 stated during her assessment at 8 p.m. Pt 2 had GCS of 15 and was alert and oriented to person, place, time, and event. RN 1 stated Pt 2 asked for all his needs and had no side effects to the medications he was administered. RN 1 stated Pt 2 was a high fall risk but had not tried to get out of bed before his fall. RN 1 stated she could not hear the bed alarm before entering the room, but once in the room the bed alarm was audible. RN1 stated Pt 2 was sitting on the floor with legs outstretched, close to the bed, and no physical injuries were noted during the focused assessment. RN 1 stated Pt 2 did not hit his head. RN 1 stated Pt 2 told her he needed help and told her he did not know how he fell when asked. During an interview on 12/5/25 at 3:20 p.m. with the CNE the CNE stated the bed alarms worked in two ways, audible and an alert in the nursing station. The CNE stated staff could hear the alarm but even at the highest volume it may not carry. The CNE stated during Pt 2’s fall investigation the hospital discovered the hospital bed’s alarm notifications system was not plugged into the wall to notify the nursing station, leaving only the audible alarm. The CNE stated staff should go through the room during their safety checks before patients arrive, and during handoff reports, to ensure all the equipment in the room was in working order. The CNE stated that the bed alarm had not properly alerted the nurses’ station of a possible patient fall, which resulted from staff error. The CNE stated her expectation was for staff to check equipment to ensure patient safety. During a review of the hospital’s P&P titled, “Fall Prevention (Adult) [Area] Regional Policy”, dated 10/15/25, was reviewed. The P&P indicated, “ ...committed to maintaining patient safety by identifying patients at risk for falls and at high risk of injury from falls and implementing evidence-based interventions to prevent falls and injury. ...To provide evidence-based interventions [indicating an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research] to protect the patient from injury related to falling ...a fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor ...” 3. During a concurrent interview and record review on 12/3/25 at 3:31 p.m. with NM 5 and ANM 6, ANM 6 opened Pt 28’s “EMR” for review. The document titled, “H&P” dated 11/28/25, indicated, Pt 28 arrived at the ED on 11/28/25 with complaint of headache and ears ringing for three days. The “H&P” indicated Pt 28 had a Computed Tomography (CT - medical imaging procedure using X-Rays and a computer to create detailed pictures inside the body) of the head with results indicating a large subdural hematoma with midline shift (SDH-a life-threatening condition where a collection of blood on the surface of the brain is large enough to push the brain past its natural center line). Pt 28 was admitted to the hospital as an inpatient on 11/28/25 for nontraumatic brain compression. During a concurrent interview and record review on 12/3/25 at 3:40 p.m. with NM 5 and ANM 6, Pt 28’s, “Pain Assessment Flowsheet (PAF-where LNs document pain assessments)”, and “Medication Administration Record (MAR- a record of drugs administered to a patient)”, dated 12/1/25 were reviewed. The “PAF”, indicated Pt 28 reported a pain score of nine (severe) out of 10 (worst) at 11:49 p.m., and LNs administered 650 milligrams (mg- a unit of measure) tablet of acetaminophen (a mild pain medication). ANM 6 stated the physician order for acetaminophen was written to be given as needed for mild pain (1-3). ANM 6 stated her expectation was for LNs to follow MD orders. ANM 6 stated LNs should document in the EMR when a patient preferred a milder pain medication than ordered. During a concurrent interview and record review on 12/3/25 at 2:10 p.m. with the CND, ANM 5, and CNS 1, CNS 1 opened Pt 31’s “EMR” for review. The document titled, “H&P”, dated 12/1/25, indicated, Pt 31 arrived at the ED on 12/1/25 after a ground level fall and worsening right hip pain. The “H&P” indicated Pt 31 was admitted to the hospital as an inpatient on 12/1/25 for a surgical repair of an intertrochanteric fracture of a right femur with minimal lateral displacement of the distal fragment (lower part of the thigh bone shifted slightly outwards). The documents titled, “PAF”, and “MAR”, dated 12/1/25, were reviewed. The “PAF” indicated Pt 31 reported pain score of 7 (severe) at 6:52 p.m. The “MAR” indicated LNs administered an acetaminophen intravenous (IV medical technique that administers fluids, medications and nutrients directly into a person’s vein through a plastic tube) solution 1,000 mg at 6:52 p.m. The “PAF” indicated Pt 31’s pain reassessment was at 10 p.m. three hours and eight minutes later. CNS 1 stated LNs should have reassessed Pt 31’s pain before 10 p.m. ANM 5 emphasized the importance of managing Pt 31’s pain due to his injury. The CND expected nurses to document if the patient declined medication or chose to wait to see if pain relief improved over time. During an interview on 12/5/25 at 3:10 p.m. with the CNE, the CNE stated her expectation was for LNs to listen to patients and assess, treat, and reassess patients for pain according to physician orders, and patient needs. During a review of the hospital’s P&P titled, “Pain Assessment and Management [Hospital Area] Regional Policy”, dated 10/15/23, the P&P indicated, “ ...Pain and Sedation Reassessment ...To evaluate the effectiveness and side effects of any pain intervention, reassess 60 minutes or less after administering analgesia or providing non-pharmacological intervention to treat pain, considering the peak action of the administered medication or intervention ...” During a review of the hospital’s P&P titled, “Medication Administration [Area] Regional Policy”, 8/20/25, the P&P indicated, “ ...Eight (8) Rights of Safe Medication Administration ... Right patient ...Right medication ...Right dose ...Right route ...Right time ...Right documentation ...Right reason (indication) ...Right response (patient response) ... Questioning and clarifying unclear, incomplete, or inappropriate orders. ... If the patient refuses a medication, the nurse should document on the MAR “patient refused” and notify the provider. ... The physician then can decide to reorder, modify or discontinue the medication and provide follow up orders as needed ...” During a professional reference review titled, “Acute Pain Management Pearls: A Focused Review for the Hospital Clinician [health care professional],” dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, “... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute [sudden onset] pain triggers a complex neurohormonal cascade [a series of coordinated responses where hormones produced by neurons [make up brain and nervous system] that are released in succession to body responses] that is toxic [poisonous] to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological [mental or emotional state of a person] effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician [provider] and institutional [facility] priority as a key driver of patient outcomes...” 4. During a concurrent interview and record review on 12/2/25 at 11:07 a.m. with ANM 4, the 3 East MS Unit’s, “Adult Crash Cart Daily Checklist (CCDC)”, dated December 2025, was reviewed. The checklist had boxes to sign off when checking the defibrillator (a medical device that delivers an electric shock to the heart to reset its rhythm during a life-threatening heart rhythm), portable suction, airway mask (mask used during CPR), and the crash cart drawer plastic lock Identification (ID) numbers. The “CCDC” indicated, the crash cart checklist was blank on 12/1/25 indicating it had not been checked. ANM 4 stated the crash cart should be checked and signed off every day to ensure the equipment was present and in working order. During an interview on 12/5/25 at 3:07 p.m. with the CNE, the CNE stated ensuring the crash carts were stocked and functioning correctly was a daily Assistant Nurse Manager activity. The CNE stated her expectation was for the crash carts to be checked and the log signed off daily, to ensure the cart was ready for use in case of emergency. During a review of the hospital’s P&P titled, “Adult/Pediatric Crash Cart Stocking and Pediatric Emergency Jump Bag”, dated 6/18/25, the P&P indicated, “ ... To establish a standardized procedure for the intake, cleaning, inventory, restocking, and distribution of adult and pediatric crash carts to ensure readiness for emergency use. ... All crash carts must be verified for functionality, completeness, and cleanliness ... It governs all SPD staff, pharmacy personnel, and nursing units involved in the turnover and management of crash carts. ... Restock bins and drawers per the approved crash cart content checklist. ... Confirm all items are within expiration. Items with the earliest expiration must be recorded on the exterior sticker. ... Suction unit must remain plugged in. ... Nursing: Responsible for timely return of used crash carts and retention of defibrillator, cables, and logbooks ...” During a review of the professional reference titled “Audit of defibrillators at an urban public sector hospital”, dated 8/17/18, the professional reference indicated, “ ...Life-threatening emergencies are not limited to the emergency department. Any delay in intervention during an emergency often culminates [reach a climax] into a poor outcome. Early electrical defibrillation [a medical device that sends an electric shock to the heart to correct dangerously abnormal rhythms] is one of the most important interventions in patients with cardiac arrest [heart stops beating]. ... There is a need for ongoing training of hospital staff as well as the establishment of systems to prevent potential adverse [harmful] consequences resulting from device failure ...” 5. During a concurrent interview and record review on 12/3/25 at 1:30 p.m. with Clinical Nurse Specialist (CNS) 1, ANM 5, NM 2, and the Clinical Nurse Director (CND), Pt 27’s “H&P”, dated 11/30/25, and “Glasgow Coma Scale”, dated 12/1/25 and 12/2/25, were reviewed. The “H&P” indicated Pt 27 arrived at the hospital on 11/30/25 with complaint of shortness of breath. Pt 27 had a PMH of stage four (cancer has spread from original site to distant parts of body making it advanced) voice box cancer with lung metastasis (secondary growth), after laryngectomy (voice box removal). Pt 27 was admitted to the hospital as an inpatient on 11/30/25 for kidney failure. The document titled, “Glasgow Coma Scale”, dated 12/1/25 at 11:32 p.m. and 12/2/25 at 2:46 a.m. were reviewed. On both assessments the LN had assessed Pt 27’s “GCS” as 11, with the “Verbal response” scored as one, indicating none (no response), but had entered an abbreviation of “TC.” When asked about the abbreviation, ANM 5, CNS 1, and the CND did not know its meaning. NM 2 stated if could possibly stand for tracheostomy collar (a soft strap that goes around the neck to secure a breathing tube) but did not know if “TC” was the approved abbreviation. The CND stated that the hospital had an approved list of abbreviations, and CNS 1 said LNs should not use unapproved abbreviations in medical records. ANM 5 emphasized the importance of avoiding unapproved abbreviations to ensure clarity in documentation. During a review of the hospital’s P&P titled, “HIM Medical Record Documentation Requirements [Area] Regional Policy, dated 8/21/24, indicated “ ...Medical record documentation may contain approved abbreviations, acronyms and symbols as noted in the most current edition of Stedman’s “Abbreviations, Acronyms & Symbols ...” During a review of the hospital’s document titled, “Steadman’s Online Search Results tracheostomy Collar”, “undated”, the hospital document indicated, HHTC was the hospital approved abbreviation for high-humidity tracheostomy collar. During a review of the professional reference titled, “Inappropriate Medical Abbreviations”, dated 5/22/23, the professional reference indicated, “ ... To prevent any misunderstanding and jeopardize patient safety, the Joint Commission now requires healthcare institutions to develop a list of approved and not approved medical abbreviations. In addition, there should be a system or an audit process to ensure that there is compliance. The healthcare institution must ensure that the medical abbreviation in the approved list is also not on the Do not use a list or vice versa. Further, if a medical abbreviation is permitted, then it can have only one universal meaning. For example, DOA can mean Date of Admission or Dead on Arrival. The Joint Commission also recommends that healthcare institutions not use abbreviations on any patient-related documents. It is important to ensure that the patient and the family can understand the information provided to them without having to guess. Often patients have difficulty understanding discharge instructions, which can affect their ability to look after themselves or follow instructions ...””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 49884 Based on observation, interview, and record review the hospital failed to ensure medications were prepared and stored in accordance with the hospital’s policy and procedures (P&P) titled, “Medication Storage”, and “Medication Labeling”, and accepted standards of practice, when one of eight sampled medication rooms had one 250 milliliter (mL-a unit of measurement) bag of 5% dextrose (a sterile sugar solution in water) intravenous (IV-intravenous - medical technique that administers fluids, medications and nutrients directly into a person’s vein) solution laying on the counter unattended, without the protective overwrap and with a blank medication additive label (a special sticker, often bright and fluorescent, used in healthcare to clearly identify drugs added to IV bags or other solutions) attached. This failure had the potential for patient harm including wrong drug administration, incorrect dosage (over/underdosing), adverse reactions, and infections from germs. Findings: During a concurrent observation and interview on 12/3/25 at 11:10 a.m. with Assistant Nurse Manager (ANM) 4, and the Clinical Nursing Director, during a tour of the hospital’s Three East Medical Surgical (MS-area in hospital caring for patients with diverse medical and surgical conditions) Unit, the unit Medication Room was observed. One 250 milliliter (mL-a unit of measurement) bag of 5% dextrose (a sterile sugar solution in water) intravenous (IV-intravenous - medical technique that administers fluids, medications and nutrients directly into a person’s vein) solution was found lying unattended on the counter with a blank medication additive label attached, and no protective overwrap. ANM 4 stated the bag should not be left on the counter with a blank additive label, or without the protective overwrap. ANM 4 stated LNs would not know what medications were added or when the fluid was unwrapped and should not be given to a patient. The CND directed the ANM to discard the fluids. During a concurrent interview and record review on 12/5/25at 2:17 p.m. with the Infection Preventionist (IP), the photo taken 12/2/25, in the Three East MS Unit of the 250 mL bag of 5% dextrose IV fluids with a blank medication label found lying on the counter was reviewed. The IP stated that LNs should not leave IV fluids out of the package to avoid compromising sterility (free from germs). Additionally, IV fluids with a medication additive should not be left unattended due to potential medication compromise. Both actions pose patient safety concerns. During a review of the hospital’s P&P titled, “Medication Storage”, dated 9/20/23, the P&P indicated “ ...The purpose of this policy is to establish processes for appropriate medication storage, stocking and access. ... The IV solutions that are produced by manufacturers with an overwrap should be stored within the overwrap pouch. ...Medications that are contaminated, deteriorated, improperly labeled, illegibly labeled, recalled, outdated, or otherwise unusable shall not be kept in stock but shall be returned to the Inpatient Pharmacy ...” During a review of the hospital’s P&P titled, “Medication Labeling”, dated 3/19/25, the P&P indicated, “ ...Compounded Sterile Preparation (CSP): A preparation intended to be sterile that is created by combining, admixing, diluting [adding fluid], pulling, reconstituting [restoring something dried to its original state by adding liquid], repackaging or otherwise altering a drug product. ...Medications shall be properly labeled in compliance with the California State Board of Pharmacy and Federal agencies. ...At a minimum, all medications are labeled with the following ...Medication name, strength, dose, route ...Expiration date and time when expiration occurs in less than 24 hours. ...Date of preparation ... When preparing individualized medications for multiple specific patients or the person preparing the individualized medications is not the person Patient name. ... Patient location (room number). ... Direction for use or any applicable cautionary statement either on the label or attached as an auxiliary [additional] label ...” During a review of the professional reference titled, “Reducing levels of medical device contamination through package redesign and opening technique”, dated 11/7/18, the professional reference indicated, “ ...Healthcare associated infections (HAIs), infections patients get while receiving medical treatment, have been categorized among the ten leading causes of morbidity and mortality in the United States. ... HAIs can be transmitted directly, from a single person to the patient, or indirectly, through an intermediate object or person. When medical devices serve as a vehicle for indirect transmission, the initial contamination tends to occur from a small number of micro-organisms that are transferred to the device, either from healthcare provider’s hands or skin or other environmental sources ... packaging and aseptic technique both have the potential to play a role in contamination ...” During a review of the professional reference titled, “Nursing Rights of Medication Administration”, dated 9/4/23, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/) the professional reference indicated, “ ...Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ‘five rights’ or ‘five R’s’ of medication administration. These ‘rights’ came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider’s sole responsibility and patients did not have as much involvement in their own care. ... ‘Right patient’ ... ‘Right drug’ - ensuring that the medication to be administered is identical to the drug name that was prescribed. ... ‘Right Route’ - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. ... ‘Right dose’ - Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities [technique] of medication administration error. ... Patient safety and quality of care are essential components of nursing practice and priorities that demand consideration to enable the delivery of high-quality, patient-centered care, and overall well-being. Medical errors are unfortunately very common in clinical practice, and in addition to compromising a patient’s personal safety, they can also be extremely costly for hospitals. ADEs [adverse drug events] qualify as unintended injuries or insults directly related to medical interventions involving a drug resulting in disability at discharge, death, or extended hospital stay that is the result of health care management rather than by the patient’s underlying disease process”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 40644 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when: 1. Two (2) of 39 ice machines (IMs) observed on the hospital’s main campus were visibly soiled and were not maintained according to the manufacturer instructions for use (IFUs), and the Food and Drug (FDA) Federal Food Code guidelines. 2. One (1) of 10 medication rooms observed on the hospital’s main campus had a smudge of a reddish-brown substance on a cabinet, not in accordance with the Centers for Disease Control (CDC) guidelines and current standards of practice. 3. Registered Nurse (RN) 5 failed to follow the hospital Policy and Procedure (P&P) titled, “Hand Hygiene [Area] Regional Policy” for one of one sampled patient (Pt) Pt 31, when RN 5 did not change gloves, or perform hand hygiene (washing hands or using alcohol-based sanitizer) prior to or after hanging Pt 31’s fresh frozen plasma (liquid part of blood) for transfusion (receiving blood or blood components into the vein through a plastic tube). 4. One of one medication rooms observed in the post-partum unit (unit where mothers and babies are cared for after birth) contained a bucket full of used oxygen saturation probes (devices used to make sure the patient is getting enough oxygen) was sitting on the counter where medications are prepared. 5. One of one medication rooms observed in the nursery had dirty, peeling stickers adhering to cabinets and supply bins. These failures placed all patients and staff at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses. Findings: 1.During a concurrent observation and interview on 12/2/25 at 10:09 a.m. with Nurse Manager (NM) 4, and during a tour of the hospital Critical Care Unit’s (CCU- a specialized hospital department that provides care for patients with severe, life-threatening illnesses or injuries) nourishment room, the unit ice machine (IM) 1 was observed to have visible white-colored and textured stains/residue on the ice chute and water collection tray, and with dried splash marks on machine stainless steel surfaces. NM 4 stated the machine surfaces are cleaned daily by Environmental Services (EVS -cleaning) and the internal parts are managed by the Maintenance department staff. NM 4 stated the machine did not look like it had been wiped today and the residue on the chute (where the water and ice came out) and drip tray (where the water overflow fell) looked like hard water stains. NM 4 stated her expectation is that staff follow policy and procedure related to cleaning the IM to prevent cross contamination (the process by which germs, viruses, or other infectious agents are unintentionally transferred from one substance or object to another, with harmful effect) and patient, staff and/or visitor illness. During a concurrent observation and interview on 12/2/25 at 10:20 a.m., with NM 2, during a tour of the hospital Four West Telemetry Unit’s (a hospital floor where patients’ heart activity is continuously monitored) nutrition room, we observed visible, white-colored and textured stains and residue on the ice chute and water collection tray, along with dried splash marks on the machine’s stainless steel surfaces. NM 2 stated the buildup should not be on the ice machines and that EVS cleaned the outside of the machine daily. During an interview on 12/5/25 at 10:52 a.m. with the Environmental Services Supervisor (ESS), the ESS saw a photo of 4 West Telemetry Unit’s nutrition room’s ice machine. The ESS explained that EVS staff were responsible for cleaning the ice machine’s cover, chutes, and the grate and bin at the front that caught any overspill. The ESS noted that if there was any water scale (the dry white-color textured material) on the parts, the staff could scrub them, or the parts could be replaced. The ESS stated that ensuring the water scale was cleaned was important to prevent infection. During an interview on 12/5/25 at 10:57 a.m. with the Chief Engineer (CE), the CE stated he supervised the Maintenance Department. The CE stated the ice machines were on a preventative maintenance (PM-a strategy to regularly inspect, service, and maintain equipment to prevent breakdown) schedule. The CE stated Maintenance cleaned and disinfected as well as replaced parts on the ice machines on a schedule. The CE stated there were quarterly cleanings completed, and every six months maintenance completed. The CE stated Maintenance had a PM computer system to let the staff know which machines were due for service. The CE stated staff could also enter a work order into the computer system if an ice machine needed attention before service was due. During an interview on 12/5/25 at 10:57 a.m. with the Chief Engineer (CE), the CE stated he supervised the Maintenance Department. The CE stated the ice machines were on a preventative maintenance (PM-a strategy to regularly inspect, service, and maintain equipment to prevent breakdown) schedule. The CE stated Maintenance cleaned, disinfected, and replaced parts on the ice machines according to the schedule. The CE stated that they completed quarterly cleaning and maintenance every six months. The CE stated Maintenance used a PM computer system to notify staff which machines were due for service. The CE stated staff could enter a work order into the computer system if an ice machine needed attention before the scheduled service. During an interview on 12/5/25 at 2:20 p.m. with the Infection Preventionist (IP), the IP stated that when the ice machines had water scale buildup, a biofilm (a thin, slimy film of bacteria [germ] that sticks to a surface) could form because the area was not able to be cleaned and disinfected (clean to destroy bacteria) properly. The IP stated EVS wiped the outside stainless steel and the outside parts daily. The IP stated Engineering had a routine schedule to change and sanitize the interior parts and the plastic surface. The IP stated, if the plastic surface appeared to need changing before the scheduled time, IP or staff would notify Maintenance of the need to change it. According to the manufacturer’s “[Brand Name], Installation and User’s Manual for [type] Ice Maker- Dispensers”, indicated “ ... Maintenance and Cleaning ... There are five areas of maintenance: 1. Drip tray and drain system ... 3. Ice dispense bin ... It is important to keep the drip tray clean of trash. Remove any as soon as it is noticed. Pour hot water into the tray on a regular basis to keep the drain open. Over time the drip tray and cup rest may become coated with scale or dirt. It can be removed to be scrubbed at a wash sink. ...Twist dispenser chutes clockwise and pull down to remove. ...Wash out the drip tray and dispense chutes. Use ice machine scale remover if needed to dissolve scale ...” The ice machine is taken apart to clean and sanitize the interior parts. The Bin where the ice is held is cleaned with a scale remover and a clean cloth, then a sanitizing solution, before rinsing with clean water. According to the Centers for Disease Control (CDC), undated, retrieved 12/12/2025 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, “Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface) ...” During a review of the Food and Drug Administration (FDA) Federal Food Code, dated 2022, 4-602.11 indicated, “...ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms ...” 2. During a concurrent observation and interview on 12/2/25 at 10:23 a.m. with Assistant Nurse Manager (ANM) 3, during a tour of the hospital Four East Telemetry Unit’s medication room, an adult finger sized smudge of a reddish-brown substance was identified at eye level on a cabinet near the handle. The cabinet held blood collection tubes (vacuum-sealed plastic tubes with color-coded rubber or plastic tops). ANM 3 stated the smudge should not be on the cabinet and staff should use the disinfectant (a chemical that kills or inactivates harmful germs) wipes to clean the area. ANM 3 stated the substance could cause an infection control issue for staff or patients. During a concurrent interview and record review on 12/5/25 at 10:54 a.m. with the ESS, The ESS reviewed a photo taken on 12/2/25, of the cabinet in the medication room of the Four East Telemetry Unit with a reddish-brown smudge. The ESS stated, “Looks like blood to me,” when identifying the reddish-brown smudge on the cabinet. The ESS stated EVS only cleaned the floors and wiped the cabinets in the room, but all staff could have wiped the smudge off the cabinet for infection prevention. During a concurrent interview and record review on 12/5/25 at 2:25 p.m. with the IP, the IP reviewed the photo taken on 12/2/25, of the cabinet in the medication room of the Four East Telemetry Unit with the reddish-brown smudge. The IP stated any staff should have cleaned the area, the smudge was an infection control issue and should not be left on the door of the medication room cabinet. According to the CDC’s “Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 12/7/23, the CDC recommends, “ ...Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities ... Disinfect (or clean) environmental surfaces on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. ... Promptly clean and decontaminate spills of blood and other potentially infectious materials. Discard blood-contaminated items in compliance with federal regulations ...” During a review of the professional article titled, “The role of the surface environment in healthcare associated infections”, dated 8/26/13, the professional article indicated, “ ...Hospital surfaces are frequently contaminated with important healthcare-associated pathogens [disease causing agents]. Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider’s hands or gloves that may result in patient-to-patient transmission of hospital acquired pathogens. Improved cleaning and disinfection of room surfaces decreases the risk of healthcare-associated infections ...” 3. During an observation on 12/2/25 at 2:18 p.m. with RN 5, ANM 4, and Pt 31 in Pt 31’s hospital room, Pt 31 was lying at a 30-degree angle with his eyes closed. Pt 31 agreed to the observation of his plasma transfusion unit. RN 5, wearing gloves, typed at the computer on wheels workstation, then crossed to Pt 31’s bedside with soiled gloves to verify the plasma with ANM 4 and Pt 31. RN 5 scanned the plasma bag and Pt 31’s wristband, then spiked, hung, and set the transfusion rate (how fast the blood product goes into the patient) with the same soiled gloves. After increasing the infusion rate, RN 5 removed her gloves but did not perform hand hygiene before resuming typing on the computer, missing six hand hygiene opportunities during the blood product infusion. During an interview on 12/3/25 with NM 2, NM 2 stated RN 5 should have changed her gloves and performed hand hygiene prior to spiking the bag. NM 2 stated RN 5 should have performed hand hygiene after removal of the soiled gloves. NM 2 stated hand hygiene was infection prevention and protection against infection. During an interview on 12/3/25 at 4 p.m. with RN 5, RN 5 stated she should have changed gloves and performed hand hygiene (washing hands with soap and water or using alcohol-based sanitizer) prior to spiking (inserting the tubing port into the bag) and hanging the blood products. RN 5 stated she should have then removed her gloves and again performed hand hygiene before typing on the computer. RN 5 stated hand hygiene was important to prevent infections in patients, especially since Pt 31 was going to surgery later in the afternoon. During a review of the hospital P&P titled, “Hand Hygiene [Area] Regional Policy”, dated 5/17/23, the P&P indicated, “ ...The [Hospital name] region follows the World Health Organization (WHO) 5 Moments of Hand Hygiene ...Indications for hand hygiene include the WHO 5 Moments of Hand Hygiene and other instances as indicated below: ...Before or upon entry to patient’s room; before patient contact or donning [putting on] personal protective equipment (PPE) ...Before performing clean and/or aseptic procedures ...After body fluid exposure/risk or after removal of PPE ...After contact with patient and patient’s environment ...After or upon exiting the patient’s room ...The preferred method of hand hygiene is waterless alcohol-based hand rub/sanitizer. ...Use of soap and water is required in the following situations: ...Hands are visibly soiled ...” During a review of professional reference from the CDC titled, “Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, the professional reference indicated, “ ... Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with Handwashing with water and soap (e.g., plain soap or with an antiseptic). Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) ... Cleaning your hands reduces: The potential spread of deadly germs to patients. The spread of germs, including those resistant to antibiotics ... Know when to clean your hands ... Immediately before touching a patient ... Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices ... Before moving from work on a soiled body site to a clean body site on the same patient ... After touching a patient or patient’s surroundings ... After contact with blood, body fluids, or contaminated surfaces ... Immediately after glove removal ...”. 4. During a concurrent observation and interview on 12/2/25 at 10:23 a.m. with Assistant Nurse Manager (ANM) 7, during a tour of the hospital’s medication room in the post-partum unit, a bucket was observed to be sitting on the counter where medications are processed. The bucket was full of oxygen saturation probes. ANM 7 stated these were devices that have been used on patients, and that they are in the bucket waiting to be cleaned and reprocessed (Reprocessing - is a detailed multistep process to clean and then disinfect or sterilize reusable devices according to manufacturer’s instructions for use) for reuse. ANM 7 stated the probes are not clean, and should not be in the medication room, which is considered a clean room. During a concurrent interview and record review on 12/5/25 at 2:25 p.m. with the IP, the IP stated the medication room is not a safe place to store dirty items because of the risk of cross contamination. During a review of hospital P&P titled, “Cleaning, Disinfection and Storage of Reusable, Medical Devices, NCAL Regional Policy dated 07/16/2025, the P&P indicated, “... 5.3 Dirty or contaminated equipment will be separated from equipment that is clean or sterile. ... 5.4 Reusable medical devices must be cleaned as soon as possible and at the point of use to remove all organic matter and other residue to reduce the development of biofilms and to reduce the possibility of contaminating the environment and blood and body fluid exposure to staff ...” 5. During a concurrent observation and interview on 12/2/25 at 11 a.m. with Assistant Nurse Manager (ANM) 7, during a tour of the hospital’s medication room in the Nursery, the cabinets and storage bins were labeled with stickers that were peeling off and exposing the adhesive underneath. ANM 7 stated the peeling stickers could not be cleaned and needed to be replaced with stickers that can be disinfected. During a concurrent interview and record review on 12/5/25 at 2:30 p.m. with the IP, the IP stated peeling stickers in any area of the hospital create a risk of spreading infection because sticky surfaces cannot be cleaned. During an interview on 12/5/25 at 10:30 a.m. with the Area Safety Quality Officer (ASQO), the ASQO stated the hospital has a process for rounding on units to look for environmental safety concerns and they have identified the problem with peeling stickers during their environmental safety rounds. The ASQO stated their process is to refer their findings back to unit leadership. The ASQO stated, “We don’t have a process for following up to make sure the items we find are corrected.” During a review of hospital P&P titled, Cleaning, Disinfection and Storage of Reusable, Medical Devices, NCAL Regional Policy dated 07/16/2025, the P&P indicated, “... 5.11 Storage areas, containers, racks, cabinets and shelves used to store clean equipment, and supplies must be cleaned regularly and must be free of dust and debris...” 49884”

“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: 49884 Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital’s policies and procedures (P&P), when: 1. Licensed Nurses (LNs) did not adhere to the hospital’s P&P “Pain Assessment and Management NCAL Regional Policy” for four of 13 patients (Pt), Pt 13, Pt 14, Pt 15, and Pt 32. LNs did not assess and/or reassess pain for Pt 14 and Pt 15. LNs did not reassess pain or sedation level after opioid medication administration for Pt 32. LNs did not administer pain medications for Pt 32 and Pt 14 while they were in pain. LNs did not administer pain medications per physician order for Pt 13 and Pt 15. These failures placed Pt 13, Pt 14, Pt 15, and Pt 32 at risk for inadequate pain management or oversedation and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients. 2. One of 10 sampled patients (Pt 13) did not have a Braden Scale risk assessment (A tool for predicting pressure sore risk) completed by LNs upon admission to the Telemetry unit, according to the hospitals P&P titled, “PC-042 Wound Management”. This failure placed Pt 13 at risk for developing pressure injuries. 3. Five boxes of cleft lip/cleft palate (birth defect when a baby’s lip or top of mouth does not form properly, creating a space in the roof of the mouth or lip) nursers (special disposable bottles with nipples for babies) with the expiration date of 4/1/23 were observed in a storage room cupboard in the Labor and Delivery Recover Postpartum (LDRP) unit contrary to hospital P&P. This failure may harm cleft lip/cleft palate babies by the expired bottles and nipples not working properly which may lead to poor feeding by the baby causing weight loss in an already vulnerable patient. Findings: 1. During a review of Pt 13’s “H&P”, dated 7/18/24, indicated, Pt 13 had a past medical history of coronary artery (major blood vessel that supply the heart with blood) disease with a surgery to bypass a blocked or narrowed artery. Pt 13 was admitted to the hospital for a stroke (blood flow to the brain is cut off) on 7/18/24. During a review of Pt 13’s “Medication Order (MO 1)”, dated 7/24/24, the “MO 1” indicated, “ ... Acetaminophen Tablet 650 mg ... oral ... EVERY 6 HOURS AS NEEDED ... for mild pain (1-3) ...”. During a concurrent interview and record review on 7/25/24 at 3:25 p.m. with ANM 5, Pt 13’s “PAF”, dated 7/24/24 was reviewed. ANM 5 stated Pt 13’s pain was assessed on 7/24/24 at 8:43 a.m. as a seven (severe). ANM 5 stated Pt 13’s pain was assessed again on 7/24/24 at 9:38 a.m. as zero. During a concurrent interview and record review on 7/25/24 at 3:30 p.m. with ANM 5, Pt 13’s Medication Administration Record (MAR- a report detailing medications given to the patient)”, dated 7/24/24, was reviewed, the “MAR” indicated acetaminophen 650 mg was administered at 8:43 a.m. ANM 5 stated acetaminophen was a medication for mild (1-3) pain and Pt 13 reported a pain score of 7 (severe) pain. ANM 5 stated Pt 13 did not have any other pain medications ordered for him. ANM 5 stated LNs should have contacted Pt 13s physician to ensure the medication for mild pain was indicated for reported pain in the severe range or, get an order for a medication indicated for severe pain. ANM 5 stated LNs must follow physician orders, and if they question the physician orders must contact the physician for clarification. During a review of Pt 14’s “History & Physical (H&P)”, dated 7/20/24, indicated Pt 14 had a past medical history of cervical (neck) stenosis (bone narrowing) with end stage renal disease (kidney failure) admitted to the hospital for metabolic encephalopathy (brain disfunction caused by chemical imbalance in the blood) on 7/20/24. During a review of Pt 14’s “Medication Order (MO)1”, dated 7/24/24, the “MO 1” indicated, “ ... Acetaminophen [a pain reliever medication] Tablet 650 mg [milligrams, a unit of measure] ... oral ... EVERY 6 HOURS AS NEEDED ... mild pain (1-3) [on a scale of 0-10, zero being no pain, ten being the worst] ...”. During a concurrent interview and record review on 7/25/24 at 7:26 p.m. with Assistant Nurse Manager (ANM) 5, Pt 14’s “Pain Assessment Flowsheet (PAF)” dated 7/24/24 was reviewed. ANM 5 stated Pt 14’s pain was assessed on 7/24/24 at 3:39 p.m. as a 7 (severe). ANM 5 stated no pain medication was administered. The “PAF” indicated pain or sedation level (level of drug-induced sleep) was not assessed again until 11:52 p.m. and indicated a zero. ANM 5 stated her expectation was for LNs to assess patients for pain and administer pain medications when patients report pain. During a concurrent interview and record review on 7/29/24 at 3:15 with RN 4 Pt 14’s “PAF” dated 7/24/24 was reviewed. RN 4 stated she was Pt 14’s nurse on 7/24/24 from 3 p.m. to 10:30 p.m. RN 4 stated the Patient Care Technician (PCT - non licensed staff) took Pt 14’s vital signs (VS) at 3:39 p.m. and VS included a pain score. RN 4 stated LNs were responsible for following up with all patient VS that the PCT’s obtained. RN 4 verified no pain score was documented in Pt 14’s “VSF” and no pain medication was administered for the pain score of seven that was obtained at 3:39 p.m. RN 4 stated according to Pt 14’s documentation it appeared Pt 14’s severe pain was not addressed. RN 14 stated she should have assessed and documented pain assessments for Pt 14. RN 14 stated she also should have administered pain medications if Pt 14 continued to report pain. RN 14 stated she should have validated the PCT’s documentation for out of normal VS. RN 14 stated assessing pain was important because it affected the body and could cause a patient to become more agitated. During an interview on 7/30/24 at 9 a.m. with the Clinical Adult Nursing Director (CAND), the CAND stated, her expectation was for LNs to do full assessments on patients to determine if the patient had pain and administer medications based on the reported pain score. The CAND stated her expectation was for PCT’s to report all abnormal vital signs to the LN and for the LN to follow up with the patient. During a review of Pt 15’s “H&P”, dated 6/9/24, indicated Pt 15 was a female with a history of Cerebral Vascular Accident (CVA-stroke), tracheostomy (a surgical created airway in neck through the windpipe) Pt 15 was admitted to the hospital for stroke on 6/9/24. During a review of Pt 15’s “Medication Order (MO 1)”, dated 6/9/24, indicated, “ ... acetaminophen oral soln [solution-liquid] ... 650 mg ... PEG [through tube in stomach] ... EVERY 4 HOURS AS NEEDED ... mild pain (1-3) ...”. During a review of Pt 15’s “Medication Order (MO 2)”, Dated 6/9/24, indicated, “ ... End Date 7/16/24 ... oxycodone [a potent medication for pain] IR Tab 5mg ... EVERY 4 HOURS AS NEEDED for moderate pain (4-6), Severe Pain (7-10) ...”. During an interview and record review on 7/25/24 at 3:15 p.m. with ANM 5 Pt 15’s “MAR”, dated 7/6/24 to 7/7/24 and “PAF” dated 7/6/24/to 7/7/24 were reviewed. ANM 5 stated on 7/6/24 at 5:44 p.m. Pt 15 was administered acetaminophen 650 mg without documentation of a pain score. ANM 5 stated on 7/7/24 at 3:43 a.m. Pt 15 was administered acetaminophen 650 mg without documentation of a pain score. RNM 5 stated LNs must assess and document a pain score before administration of pain medications, to ensure the patient receives the right medication according to their reported pain score. During an interview and record review on 7/25/24 at 3:30 p.m. with ANM 5, Pt 15’s “MAR”, dated 7/24/24, and “PAF”, dated 7/24/22 were reviewed. ANM 5 stated Pt 15’s pain was assessed as 5 (moderate) on 7/24/24 at 7:10 a.m., and Pt 15 was administered 650 mg acetaminophen (for mild pain). The “PAF” indicated Pt 15’s pain was reassessed on 7/24/24 at 7:59 a.m. as zero. The ANM 5 stated LNs should have contacted Pt 15s physician to adjust the ordered medication’s scoring scale or asked for an order for a different pain medication. During an interview on 7/30/24 at 9:04 a.m. with the CAND, the CAND stated her expectation was for nursing staff to assess patients for pain and administer medications according to physician order. The CAND stated her expectation was for LNs to contact the physician if clinical judgment indicated adjusting the scale (such as administering acetaminophen for a score of 1-6) or asking for a different medication (when current medications were not helping pain). During a review of Pt 32’s “History & Physical (H&P)”, dated 7/19/24, indicated Pt 32 was admitted after a colostomy closure (a surgical procedure that reconnects the two ends of the large bowel and closes the stoma [a surgical opening in the abdomen, connecting the bowel to the skin surface]) on 7/91/24. During a review of Pt 32’s “Medication Order (MO) 1”, dated 7/19/24, the “MO 1” indicated, “ ... oxyCODONE ... Tab [tablet] 2.5 mg [milligrams, a unit of measure] ... EVERY 6 HOURS AS NEEDED ... for moderate (4-6) [on a scale of 0-10, zero being no pain, ten being the worst] BREAKTHROUGH Pain. First line medication [medication to try first] ...”. During a review of Pt 32’s “Medication Order (MO) 2”, dated 7/19/24, the “MO 2” indicated, “ ... oxyCODONE ... Tab 5 mg ... EVERY 6 HOURS AS NEEDED ... for severe (7-10) BREAKTHROUGH Pain. First line medication ...”. During a review of Pt 32’s “Medication Order (MO) 3”, dated 7/19/24, the “MO 3” indicated, “ ... HYDROmorphone [a strong opioid for pain] Inj [injection] 0.1 mg EVERY 2 HOURS AS NEDED ... For moderate (4-6) BREAKTHROUGH Pain. Second line medication. Use only if first line medication (oxycodone) is not tolerated, not ordered, or if pain is still moderate (4-6) 60 minutes after administration of oxycodone. If 2 doses are administered within 8 hours, contact physician to re-evaluate pain medication order ...”. During a review of Pt 32’s “Medication Order (MO) 4”, dated 7/19/24, the “MO 4” indicated, “ ... HYDROmorphone Inj [injection] 0.1 mg EVERY 2 HOURS AS NEDED ... For severe (7-10) BREAKTHROUGH Pain. Second line medication. Use only if first line medication (oxycodone) is not tolerated, not ordered, or if pain is still severe (7-10) 60 minutes after administration of oxycodone. If 2 doses are administered within 8 hours, contact physician to re-evaluate pain medication order ...”. During a concurrent interview and review on 7/25/24 at 2:50 p.m. with Nurse Manager (NM) 1 and Registered Nurse (RN) 6, Pt 32’s Pain Assessment Flowsheet (PAF) was reviewed. NM 1 stated Pt 32’s pain was assessed on 7/21/24 at 12:03 p.m. as a 7 (severe). NM1 stated Pt 32’s pain on 7/21/24 at 3:22 p.m. was rated as a 6 and at 5:55 p.m. as a 5. The “PAF” indicated pain or sedation level (level of drug -induced sleep) was not assessed again until 10:35 p.m. and indicated Pt 32 was sleeping. During a concurrent interview and review on 7/25/24 at 2:52 p.m. with Nurse Manager (NM) 1 and Registered Nurse (RN) 6, Pt 32’s “Medication Administration Record (MAR)”, dated 7/19/24 to 7/21/24, the “MAR” indicated hydromorphone 0.2 mg was administered at 12:03 p.m. The “MAR” indicated the first line drug, oxycodone was not given on 7/21/24. The “MAR” indicated no pain medication was administered to Pt 23 on 7/21/24 after 12:03 p.m. During an interview on 7/30/24 at 11:15 a.m. with the Interim Chief Nursing Officer (ICNO), the ICNO stated it was her expectation for Licensed Nurses (LN) follow physicians’ orders for pain medication as written and pain should be assessed/reassessed per the hospital P&P. the ICNO stated nurses have the autonomy to call and question the physician to meet a plan of care for patients. The ICNO stated on medical/surgical units LN should ask the patient about their pain during hourly rounding (checking on patients hourly). During a review of the facility’s P&P titled, “Pain Assessment and Management (PAM)”, dated 3/15/23, the “PAM” indicated, “ ... Procedures ... All patients will be assessed for pain ... Upon admission ... At least once each shift ... prior to, during and following any known pain-producing procedure ... With each new report of pain ... RN may use clinical judgement to determine the analgesic and dose to administer in accordance with the pain management orders ... Assess and document sedation level prior to and following the administration of opioids and routinely thereafter with each pain assessment ... Implement pharmacologic pain management interventions as needed to achieve patient comfort ... Reassess pain ... 60 minutes or less of the intervention as needed; to evaluate the effectiveness of pain management interventions ...”. During a professional reference review titled, “Pain management in hospitals: patients’ satisfaction and related barriers,” dated 9/25/18, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207353/) indicated, “ ... Suboptimal pain control has been frequently reported in healthcare settings and documented to negatively impact patients’ health. Patients’ perception regarding pain management may influence their satisfaction regarding treatment ...”. During a professional reference review titled, “Acute Pain Management Pearls: A Focused Review for the Hospital Clinician,” dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, “ ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute pain triggers a complex neurohormonal cascade that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and intuitional priority as a key driver of patient outcomes ...”. 2. During a review of Pt 13’s “H&P”, dated 7/18/24, indicated, Pt 13 with past medical history of coronary artery (major blood vessel that supply the heart with blood) disease with a surgery to bypass a blocked or narrowed artery. Pt 13 was admitted to the hospital for a stroke (blood flow to the brain is cut off) on 7/18/24. During a concurrent interview and record review on at with ANM 5 and the CAND, Pt 13’s “Admission Assessment Flowsheet (AAF)”, dated 7/18/24, was reviewed. ANM 5 stated Pt 13’s “Braden Score for Predicting Pressure Sore Risk [tool to predict the risk of pressure injuries based on 6 things, sensing, moisture, activity, mobility, nutrition, and friction]” was not completed for his admission to the unit on 7/18/24. ANM 5 stated the score was used for LNs to plan care and begin pressure injury prevention strategies for patients when they are admitted to the hospital or transferred into a different unit. ANM 5 stated prevention strategies were pressure reduction mattresses, a turn schedule, or pressure offloading devices. ANM 5 stated when patients had a low Braden score, they were at a higher risk for pressure injury. ANM 5 stated Pt 13 should have had a Braden assessment score completed, to assess his risk for pressure injury. ANM 5 stated Pt 13 had mobility issues and was at a higher risk than some patients for pressure injuries. During an interview on 7/30/24 at 9:04 a.m. with the CAND, the CAND stated a head-to-toe assessment included skin to ensure it was intact (had no breaks) and check all pressure points to know where there could be skin breakdown. The CAND stated her expectation was for LNs to give each patient a Braden Score, because it identified the risk of skin breakdown and risk to a patient’s skin integrity. During a review of the facility’s P&P titled, “PC-042Wound Management”, dated 8/17/22, indicated. “ ... The Braden Scale for Predicting Pressure Score Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client’s level of risk for developing pressure injuries/pressure injuries. Specific risk factors include alteration in sensory perception, moisture, activity, mobility, nutrition, and friction and shear ... A risk assessment (e.g. Braden Scale) shall be performed and documented upon admission ... A through full body skin assessment shall be performed upon all patients upon admission ...”. During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility’s policy and procedure (P&P) titled, “”PC-042Wound Management”, dated 8/17/22, indicated, “ ... Patient’s with a total score of less than nine are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk ...” for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear. During a professional reference review titled, “Use of the Braden Scale for pressure ulcer risk assessment in a community hospital setting: the role of total score and individual subscale scores in triggering preventive interventions”, dated 11/2014, (found at https://pubmed.ncbi.nlm.nih.gov/25377103/) indicated, “ ... Routine use of a pressure ulcer risk assessment tool is considered necessary for a comprehensive pressure ulcer prevention program. Planning preventive care according to the subscale scores of the Braden Scale may be more effective for prevention of HAPUs [Hospital Acquired Pressure Ulcers] in some cases ...”. 3. During an observation and interview on 7/24/24 at 10:20 a.m. with NM 4in the LDRP unit’s Postpartum (after baby delivery) clean storage room five expired boxes of cleft/lip palate nursers were observed in a cupboard. The expiration date on the boxes was 4/1/23. The NM 4 stated the nursers were special bottles with nipples used to feed babies born with the birth defect cleft lip or cleft palate. The NM 4 stated many cleft lip babies and most cleft palate (roof of the mouth) babies were not able to breastfeed, so they required special bottles and nipples for feeding. NM 4 stated central supply and LNs were responsible to ensure no expired supplies were in the supply room. NM 4 stated expired supplies must not be used for patients because the integrity (wholeness) of the materials may be affected. NM 4 stated sterilization (elimination of germs) of the supplies may be affected in expired supplies. During an interview on 7/30/24 at 11:20 a.m. with the ICNO, the ICNO stated expired devices should never be used on patients. The ICNO stated industry standard was no use of expired items in a medical setting. The ICNO stated the packaging of an expired product may not have the same integrity as an unexpired device and so the product inside the package may not work the same or could even harm the patient. During a review of the facility’s P&P titled, “STOREROOM OPERATIONAL READINESS PLAYBOOK”, dated 8/2023, indicated, “ ... Check for any expired or damaged items and report to supervisor to take appropriate action ...”. During a professional reference review titled, “Managing packaged sterile supplies and devices”, dated 6/2022, (found at https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-65-packaged-sterile-devices-6-20-22-final.pdf) indicated, “ ...Managing commercially prepared sterile supplies and devices can be challenging for healthcare organizations. In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates ...”. During a professional reference review titled, “Cleft Palate: Feeding your Baby”, dated 8/19, (found at https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/cleft-palate-feeding-your-baby) indicated, “ ... The palate, more commonly referred to as the roof of the mouth, separates the mouth from the nose. The palate is important for feeding ... A cleft is an opening or split in the palate. This cleft can make feeding hard for your baby. Most babies with a cleft of the palate are not able to use standard bottles or solely breast feed because they cannot create the suction needed to draw the milk out of the nipple. Special bottles and nipples are available to help infants with cleft palate feed and grow. These bottles may be used with formula or breast milk ...”.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45929 Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in accordance with hospital policy and professional standards when: 1. Three of four clean linen storage carts did not have the protective cloth cover over the clean patient linen in the Labor and Delivery, Recovery Postpartum (LDRP) unit and two of six clean linen storage carts did not have the protective cover closed on the 2nd and 4th floor Telemetry (heart monitoring) Units, contrary (opposite) to hospital Policies and Procedures (P&P). 2. One of two sharps containers (containers used for the safe disposal of needles and other sharp medical instruments) on the 4th floor Telemetry Unit in the medication preparation storage area was overfilled past the fill line marked on the side of the container, contrary to facility P&P. 3. Seven of 30 storage bins observed in the clean patient supply rooms in the LDRP Unit contained flaky white and brown debris and dust. The bins contained respiratory (breathing) supplies for nebulizer (device that changes liquid medicine into mist) treatments, breast milk storage bottles, nipples for bottles, Intravenous (IV-into the vein) Start Kits, patient hygiene supplies, cold packs, and pacifiers, contrary to hospital P&P. 4. Unused items were stored in the Emergency department (ED) dirty utility room (a room where used items are placed to be cleaned or disposed of) contrary to professional standards. 5. Multiple commodes (a reusable portable toilet) were stored in the Perioperative (Pre-Op) dirty utility room and not cleaned to Manufacturer’s Instructions for Use. These failures had the potential for cross contamination (the process by which bacteria [microscopic living organisms that cause infections] are unintentionally transferred from one object or to another object or person with a harmful effect) and transmission of infection. Findings: 1. During a concurrent observation and interview on 7/24/24 at 10:05 a.m. with Nurse Manager (NM) 4 on the Labor and Delivery area of the LDRP Unit, two different clean patient linen carts were observed without the protective cover down and closed. NM 4 stated facility staff restocking or removing linens should close the protective cover. NM4 stated uncovered linen could cause the linens to become dirty. NM4 stated dirty linens could cause infection in patients. NM 4 stated her expectation was for facility staff to close and secure the protective cover on the linen carts after stocking or removing patient linens, so linens remained clean and contaminant free. During a concurrent observation and interview on 7/24/24 at 10:30 a.m. with NM 4 in a clean storage room in the Postpartum side of the LDRP unit, a linen cart was observed without the protective cover down and closed. NM 4 stated facility staff should make sure linen carts remained covered. During a concurrent observation and interview on 7/24/24 at 10:40 a.m., in the 2nd floor telemetry unit supply room with Nurse Manager (NM) 3, the drape over the linen cart was left pulled open and clean linen exposed. NM 3 stated the linen should be covered to avoid cross contamination (the process by which microorganisms are unintentionally transferred from one object to another of person with a harmful effect) of clean linen. During a concurrent observation and interview on 7/24/24 at 10:41 a.m. with Assistant Nurse Manager (ANM) 5 and the Clinical Adult Nursing Director (CAND) in the clean storage room on the fourth floor Telemetry Unit, a clean patient linen cart was observed without the protective cover down and closed. The CAND stated an uncovered patient linen cart can lead to patient infection by linens becoming dirty and contaminated. The CAND stated her expectation was for facility staff to close the protective cover on the linen carts. During an interview on 7/29/24 at 4:10 p.m. with the Director of Risk Management, Patient Safety and Infection Prevention (DIP), the DIP stated clean linen should be covered to protect from dust and cross-contamination. During an interview on 7/30/24 at 11: 30 a.m. with the Interim Chief Nurse Executive (ICNE), the ICNE stated Linen carts are to be covered all the time if you are not gathering the linen, and if there is damaged linen, it must be taken out. The ICNE stated linen was covered to avoid dust because cross contamination can occur with dust and can create dust mites (microscopic relatives of ticks and spiders, invisible to the naked eye and live in materials and house dust) which could get on clean supplies and be carried to patient areas. During a review of the facility’s P&P titled, “Handling of Linen”, dated 11/16/22, indicated, “ ... Clean linen are transported and stored in a manner that ensures cleanliness and protection from dust and soil ... to prevent transmission of infection via contaminated linen ... Clean linen storage carts must be covered in a manner to protect linen from dust, debris, and other contaminants ... Carts that are going to be used to store linens ... must have covers during transportation and storage time ... The covers shall protect the linens at all time during storage ...”. 2. During a concurrent observation and interview on 7/24/24 at 10:50 a.m. with the ANM 4 and the CAND on 4th floor Telemetry Unit in the medication preparation room, the sharps container on the wall was filled past the fill line (a line indicating when to stop filling the container for safe closure) marked on the side of the container. ANM 4 stated Environmental Services (EVS) were supposed to exchange them out when full. ANM 4 stated EVS would not know the container was full unless nursing staff informed them. The CAND stated staff could accidentally get stuck by a sharp themselves with a potentially contaminated needle if they tried to push down the things in the container to fill past the fill line. The CAND stated staff could also poke themselves if sharps were on top of the many paper wrappers that were placed in a sharp’s container. The ANM 4 stated an over filled sharps container could cause injury due to a needle or other sharp sticking out of the top. During an interview on 7/29/24 at 4:10 p.m. with DIP, the DIP stated sharps containers should have been filled only to the fill line and then disposed of appropriately because when it was over filled one could not dispose of sharps properly and there is a risk of a unintentional needle stick and cross-contamination. During an interview on 7/30/24 at 11:30 a.m. with the ICNE, the ICNE stated, sharps containers must be emptied when the contents reach the fill line. The ICNE stated contents placed in the containers must be free to drop without staff taking a chance of pushing down the container contents and potentially causing a needlestick injury. The ICNE stated the EVS staff could also have been affected by an over filled container due to sharps bouncing out of the over filled container and causing a needlestick injury. The ICNE stated a sharp or needle may have an infectious bloodborne material (bacteria in human blood that can cause disease) on it and could be a source of cross-contamination. During a review of the facility’s P&P titled, “Blood Borne Pathogen Exposure Control Plan, EOC-SM-052, dated 10/18/2022, indicated “ ...At all times during the use of sharps, containers for contaminated sharps must be ... replaced when no more than ¾ full ...”. During a review of professional reference titled, “Sharps Safety Guidelines,” dated 12/26/22, (found at https://www.infectioncontroltoday.com/view/sharps-safety-guidelines) the professional reference indicated, “ ... Punctures and cuts can introduce bloodborne pathogens into the body, such as hepatitis B virus (HPV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) ... Most sharps-related injuries can be prevented and occur during or immediately after use it is important to understand safe sharps waste disposal ... Containers should also be marked with a line to indicate when the container is three-fourths full. Once the container reaches that point, do not place any more sharps in the container-this line is to prevent injuries. One of the leading causes of sharps injuries is overfilled containers. Never force items into the sharps container ...”. 3. During a concurrent observation and interview on 7/24/24 at 10:10 a.m. with NM 4 in the LDRP Labor and Delivery (L&D) clean supply room, three plastic bins containing new patient supplies were observed with white and brown dust and debris on the bottom of each bin. The supply bins held individually packaged items such as nebulizer masks (masks to administer breathing treatments), cold packs (ice packs), and patient hygiene supplies (mouthwash, body soap, lip balm). NM 4 stated environmental services (EVS) were responsible for cleaning the bins, but unit staff should report to EVS when the bins needed cleaning. NM4 stated, the bins should be clean to prevent infection in patients. During a concurrent observation and interview on 7/24/24 at 10:20 a.m. with NM 4 in the LDRP Postpartum (PP) clean supply room, six plastic bins containing new patient supplies were observed with white and brown dust and debris on the bottom of each bin. The supply bins held individually packaged items such as, breastmilk storage bottles, nipples (for babies), pacifiers, and disposable feeding bottles. NM 4 verified the dirt and dust in the supply bins and stated the bins should not be dusty and dirty, for reasons of infection control. During an interview on 7/30/24 at 11:17 with the Interim Chief Nurse Executive (ICNE), the ICNE stated the supply bins should be cleaned like all areas of the hospital, to prevent infections in patients. During a review of the facility’s policy and procedure titled, “Cleaning and Disinfection of Reusable Equipment, medical devices, and surgical instruments (C&D)”, dated 11/15/23, the “C&D” indicated, “ ... The cleaning of storage areas, containers, racks, cabinets and shelves used to store clean equipment and supplies must be assigned and schedules to prevent cross-contamination from dust and any residue ... Infection Control staff will provide consultation regarding equipment supplies, and procedures used for sterilization, disinfection and decontamination purposes ...”. 4. During a concurrent observation and interview on 7/24/24 at 9:50 a.m. with the ED Manager (EDM) in the ED dirty utility room there was unused Spill Kit (an organized set of equipment designed to deal with hazardous spills) in the cabinet of the room. The EDM stated everything in the dirty utility room is dirty and they are dirty when taken out of the room. During an interview on 7/29/24 at 4:10 p.m. with the DIP, the DIP stated there should be a separation between clean and dirty items to avoid cross-contamination. The DIP stated it was her expectation that clean supplies should be kept in a clean area to avoid contamination. During a review of a professional reference from the Agency for Healthcare Research and Quality (AHRQ) titled, “Infection Prevention (IP)” (undated), “IP” indicated, “ ... Providing a sanitary environment ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty areas are used for contaminated equipment ...”. 5. During a concurrent observation and interview on 7/24/24 at 10:15 a.m. with Nurse Manager (NM) 5 and Assistant Nurse Manager (ANM) 7 in Pre-Op Unit, multiple commodes were stored in the dirty utility room. NM 5 stated commodes were used for patients and have been storing them in the dirty utility room “ ... forever ...”. NM 5 and ANM 7 stated everything in the dirty utility room was dirty and should not be used for patients. During an interview on 7/29/24 at 2:30 p.m. with ANM 7, ANM 7 stated nothing should be removed from the dirty utility room and used for patients. ANM 7 stated the commodes were cleaned by wiping with cleaning Sani (a type of pre-moistened wipe that can be used for cleaning) wipes. ANM7 stated reusable equipment like commodes should be cleaned according to manufacturer’s instructions and stored in the clean utility room. ANM 7 stated policy was not followed for cleaning and storing of the commodes. During an interview on 7/29/24 at 2:45 p.m. with NM 5, NM 5 stated nothing should be removed from the dirty utility room and used for patients. NM 5 stated reusable equipment like commodes should be cleaned according to manufacturer’s instructions after patient use and stored in the clean utility room. NM 5 stated commodes were cleaned before patient use and not after patient use. NM 5 stated policy was not followed for cleaning and storing of the commodes. During a review of the “Instructions For Use (IFU)”, undated, the IFU indicated, “ ... Use a mild soap and water solution, rinse with clean water then dry with a soft cloth. Ensure the product is well rinsed before using ...”. During an interview on 7/29/24 at 4:10 p.m. with the DIP, the DIP stated there should be a separation between clean and dirty items to avoid cross-contamination. The DIP stated it was her expectation that clean supplies should be kept in a clean area to avoid contamination. The DIP stated she expected staff to follow manufacturer’s instructions for cleaning reusable patient care items, reusable items should be clean immediately after use, and stored in the clean room. During a review of the facility’s policy and procedure titled, “Cleaning and Disinfection of Reusable Equipment, medical devices, and surgical instruments (C&D)”, dated 11/15/23, the “C&D” indicated, “ ... Reusable patient care equipment, medical devices and surgical instruments will be cleaned, disinfected and/or sterilized following manufacturer’s instructions to decrease the risk of transmission of infection to patients and staff ... All staff must be trained in the use, cleaning, disinfection and/or sterilization and storage following manufacturer’s instruction for use (IFU) prior to use ... Purpose ... To provide guidance on how to effectively and safely clean and store reusable instruments and equipment to help prevent the transmission of infections ... Definitions ... Cleaning is the physical removal or organic material, lubricant or soil form objects by using water and detergents or soap and is required before any further processing ... Disinfection is the elimination of many, or all, pathologic microorganisms ... on inanimate objects and is done with liquid chemicals ... Reprocessing- is a detailed multistep process to clean, and then disinfect or sterilize reusable devices according to manufacturer’s IFUs ... Reusable medical devices- are devices that can be reprocessed following manufacturer’s IFUs and reused on multiple patients ...Dirty or contaminated equipment will be separated from equipment that is clean or sterile ... Patient care equipment will be cleaned on a regular basis, after each use ...””

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 45929 Based on interviews and record review, the facility failed to immediately make available the full extent of its patient care resources when a patient (Patient 1) was not triaged (preliminary assessed patient needs in order to determine the urgency of their need for treatment) in the Emergency Department (ED) appropriately in accordance with standard pain scale and hospital triage policy & procedure. This failure resulted in a delay in a medical screening exam (an initial exam by a qualified medical professional performed when a patient requests care in an emergency department) and care for Patient (PT) 1. Findings: During a review of Pt 1’s “Ambulance Run Sheet (RS, a form documenting the patient status from pick up to deliver to hospital ED)”, dated 5/13/24, the “RS” indicated Pt 1 was a 55-year-old male. The “RS” indicated, “ ... CC [chief complaint] shoulder pain with nausea ... AOS [arrived on scene] to pt [patient] sitting on his couch. Pt appears in some obvious distress. (-) [negative for] chest pain, sob [shortness of breath], weakness, dizziness, v/d [vomiting/diarrhea]. (+) [positive for] shoulder blade pain with intermittent [come and goes] nausea. Pt denies recent illmess [sic] or trauma [injury]. Pt states he has a hx [history] of bilateral shoulder pain but elevated a few days ago. Today while at work, pain between shoulder blades came back worse than normal. Pt also complains of intermittent nausea. Pt is ambulatory [walks] without assistance ...”. The “RS” indicated Pt 1’s blood pressure (BP) was 164/103 at 2;11 p.m.; 198/88 at 2:15 p.m.; 187/118 at 2:19 p.m.; and 164/105 at 234 p.m. (normal adult BP was less than 120/80 mmHg (millimeters of mercury, a unit of measure). The “RS” indicated, “ ... Protocol: Nausea/Vomiting ...” and Pt 1 was given ondansetron (a medication to treat nausea) 4 milligrams (mg, a unit of measure) at 2:28 p.m. and arrived at the facility’s ED at 3:06 p.m. The “RS” indicated, “ ... Note: Times listed may be estimates entered at a later time ...”. During a review of Pt 1’s “ED Timeline (EDT)”, dated, 5/13/24, the “EDT” indicated Pt 1 arrived in the ED at 2:43 p.m. as entered by Clerk (CL) 1. The “EDT” indicated CL1 documented, “ ... Chief Complaints ... BACK PAIN ...” The “EDT” indicated triage was started by Registered Nurse (RN) 7 at 2:49 p.m. The “EDT” indicated, “ ... General Appearance-Distress Level: MILD ... Information provided by: Patient; Paramedic/Emergency Medical Technician ... BP: 174/104 ... Pain Scale Type: Numeric 0-10(per patient) ... Pain Score: 8 ... Acceptable Level (Pain): 1 ... Location: Shoulder; Back ... Chief Complaints Updated ... BACK PAIN (BIBA [brought in by ambulance] from home, c/o [complaint of] pain between shoulder blades; nontraumatic [non-injury]; hx of shoulder pain.) ... Priority ...How many resources are needed? ... One, assign Level 4 ... ESI [Emergency Severity Index, a five-level emergency department triage algorithm, based on the severity of a patient’s medical condition and the number of resources their care is anticipated to require, 1 being the highest severity and 5 the lowest] ... Priority: 4NonUrg [non-urgent] ... 2:52 p.m. ...”. The “EDT” indicated Pt 1 received oral pain medication, laboratory specimens, an electrocardiogram (EKG, electrical activity of the heart), and a chest x-ray. During a concurrent interview and record review on 7/17/24 at 11:16 a.m. with RN 7, Pt 1’s “EDT” was reviewed. RN 7 stated he triaged Pt 1 and stated the Pt arrived at 2:43 p.m. by ambulance with a complaint of pain between the shoulder blades. Pt 1 stated Pt 1’s pain level was 8/10 and BP was 174/104. RN 7 stated he assigned Pt 1 an ESI Priority Level 4. RN 7 stated Level 1 was for an emergency patient needing resuscitation; Level 2 was for a high priority patient needing to start actions, abnormal vital signs. RN 7 stated he though Pt 1’s elevated BP due to the shoulder pain. RN 7 stated, “ ... I was not told or informed of him being diaphoretic and nauseated prior to his arrival to the ER [Emergency Room]. It was later stated. ... After triage patient went back to the lobby ...”. During a concurrent interview and record review on 7/30/24 at 9:20 a.m. with the Emergency Department Director (EDD), Pt 1’s “RS” was reviewed. The EDD stated the “RS” was not entered in the electronic medical record in real time, but the triage nurse should have received a report from the paramedic who brought Pt 1 to the ED. The EDD stated the report would include Pt 1’s history and any protocols or medications given in route. The EDD stated depending on the nature of the patient’s complaint, more questions could be warranted. The EDD stated since Pt 1 came in by ambulance with a history of shoulder pain, the triage nurse should ask what was different about it today that made you call an ambulance? The EDD stated RN 7 signed the “RS” meaning RN 7 got report and would have known about the Pt 1’s nausea and the ondansetron given. The EDD stated it was her expectation for RN 7 to ask appropriate questions. During a review of Pt 1’s ED Progress Note (EDPN), dated 5/13/24 at 3:39 p.m., the “EDPN” indicated, 55 y/o male presents to the emergency room complaining of shoulder pain to upper back. No hx of sustaining an injury or fall. He states that earlier today he felt diaphoretic and nausea: pt spouse call ambulance, concerned about possible heart attack sx [symptoms]. No CP [chest pain] and no SOB at this time. Will do a cardiac work up. Pt states that the shoulder pain has been off and on for 2 months ...”. During a review of Pt 1’s “History & Physical (H&P)”, date /13/24 at 8:04 p.m., the “H&P” indicated, “ ... around 11:15, started experience this constant 8/10 intense sharp pain in between his shoulder blades that radiates up to his neck causing him nausea without vomiting ... pain did not go away and therefore caused him to go to the ED as urged by wife ... 2 months ago that he would have it on and off, intermittent pain in between his shoulder blades ... but this occurrence was different as it never went away ... notable labs include troponin 36 followed by 96 [troponin, a proteins found in the cells of the heart muscle, as heart muscle is damaged, troponin leaks into the bloodstream and levels will rise] ... Assessment and Plan ... ACS [Acute coronary syndrome, a medical emergency that occurs when blood flow to the heart is suddenly reduced or stopped] ....hypertensive urgency [severe elevation in blood pressure without signs or symptoms of organ damage] ...”. During a review of Pt 1’s “Rapid Response (RR)”, date 5/14/24, the “RR” indicated, “ ... Patient BIBA for C/C [chief complaint] of shoulder pain that radiate to neck which caused him to have nausea. Arrived in ED hypertensive. Patient was transferred to telemetry floor [patient care unit that monitors the heart] around 2300 [11:00 p.m.]. Code Blue {patient requiring resuscitation] announced overhead at 0022 [12:22 a.m.] Writer arrived at bedside with patient unresponsive and ongoing CPR [cardiopulmonary resuscitation] ... OUTCOME: Expired [died] ...”. During a review of Pt 1’s “Death Note (DN)”, dated 5/14/24, the “DN” indicated, “ ... Immediate Cause of Death: Cardiopulmonary arrest ... Due to: Chest pain ... Due to: Elevated troponins ...”. During a review of the facility’s policy and procedure titled, “Triage”, dated 11/20/19, “Triage” indicated, “ ... Purpose ... patients presenting to the Emergency Department are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) ... A RN will triage all patients arriving to the Emergency Department to identify life-threatening conditions and prioritize patients according to acuity ... The following steps should occur ... Determine chief complaint; vital signs are not required during the initial triage unless the information is necessary to determine acuity ... ESI ED resources are as follows ... below are considered individual resources ... Labs ... ...ABGs [arterial blood gases, measure ] ... Respiratory treatments ... EKG ... x-rays ... CT/MRI/Ultrasound/Angiography [imaging services] ... IV Fluids ...IV IM [intermuscular, injection in the muscle] ... Specialty consultations ... Simple Procedures ... Level I Presentation ... Unresponsive ... Apneic [not breathing] ... Pulseless ... Level II Presentation ... When Level II condition is identified, the triage process stops, the patient is taken directly to a room and immediate physician intervention is requested ... High risk situations ... New onset confusion ... Severe pain/distress ... Level III presentation ... Patients requiring two or more resources with vital signs not in danger zone ... Level IV Presentation ...Patients requiring 1 resource only ... Level V Presentation ... Patients requiring no resources ...”. During a review of a professional reference titled, “Pain Levels (PL)” (undated), “PL” indicated, “ ... The pain scale actually has standard explanations which divides pain into three categories ranging from mild for lower numbers, moderate to cover the middle numbers, and severe for numbers above seven ... Severe Pain is that which is disabling, preventing you performing normal activities during the day or night. At level 7, pain stops you sleeping. Either you can’t get to sleep at all or it will wake you during the night, and keeping up with social relationships is very difficult. When it intensifies to level 8, pain makes even holding a conversation extremely difficult and your physical activity is severely impaired ...””