Centinela Hospital Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient’s Rights was met, as evidenced by: 1. The facility failed to ensure a second attempt to complete an electrocardiography (EKG, an electrogram of the heart to evaluate heart rhythm) test was completed on 12/24/2025, as ordered by the physician and in accordance with the facility’s policy regarding ED scope of service, for one of 38 sampled patients (Patient 15), when Patient 15 initially refused the EKG test due to abdominal pain of 10/10 (considered as severe pain) on a pain scale (a numeric pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). This deficient practice resulted in Patient 15 not receiving all necessary diagnostic testing as ordered and put Patient 15 at risk for delay in diagnosis and treatment. (Refer to A-0129) 2. The facility failed to ensure that the use of restraints (devices, medications, or techniques used as a last resort to temporarily limit a patient’s movement or freedom to ensure safety) for one (1) of 3 sampled patients (Patient 1), was implemented only after less restrictive interventions (strategies that do not limit movement, such as verbal de-escalation [calming the patient through conversation] or environmental changes), were attempted prior to application of restraints, in accordance with the facility’s “Restraint” policy and procedure (official written guidelines for staff on the use of restraints). Patient 1 was given Haldol (Haloperidol, an antipsychotic [mental stabilizer] medication used to calm severe agitation [extreme restlessness or irritability, often with aggression] or treat mental health conditions. When given to control behavior rather than treat a psychiatric illness, it is considered a chemical restraint) on two separate occasions and later placed in soft wrist restraints (fabric cuffs applied to limit arm movement) without documentation in the medical record describing the least restrictive measures used or considered prior to giving the medication (Haldol) or applying the restraints. This deficient practice created the potential for medication to be used without documented justification and without sufficient documentation to evaluate the patient’s response and ongoing monitoring needs, which may result in patient harm. (Refer to A-0165) 3. The facility failed to ensure its policy and procedure (P&P, official facility rules) for restraints included guidance on monitoring and assessment after administration of a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition) for one (1) of three sampled patients (Patient 1) who received Haldol (an antipsychotic medication used to treat agitation [restlessness or aggressive behavior] or psychosis [loss of contact with reality]). This deficient practice resulted in the potential for harm due to lack of timely reassessment (checking the patient’s condition again within the required time frame) for adverse effects (harmful or undesired reactions to medication) and inadequate monitoring (failure to observe and record patient’s condition) of vital signs (basic body measurements including temperature, heart rate, breathing rate, and blood pressure) and neurological status (patient’s alertness, orientation, and nervous system function) after administration of a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s medical condition). As a result, Patient 1 remained deeply sedated (very sleepy or unresponsive due to medication) for about 8 hours (from 6:08 a.m.- 2:50 p.m.), missed meals and was at risk for aspiration (food or liquid entering the airway, which can cause choking or pneumonia [lung infection]). Because the facility’s policy (official rules and procedures) lacked clear guidance (specific instructions), future patients who receive chemical restraints may not be appropriately assessed or monitored, placing them at risk for unrecognized complications and delayed interventions (late medical responses to prevent harm). (Refer to A-0175) 4. The facility failed to ensure that one (1) of three (3) sampled patients (Patient 1), was reassessed for response to the chemical restraint (medication used to restrict a patient’s movement or behavior, not a standard treatment for the patient’s condition) and bilateral (both sides) wrist restraint (a device used to limit movement of both wrists), used on Patient 1. This deficient practice has the potential to result in unrecognized adverse effects (harmful or undesired outcomes) and unsafe patient care. (Refer to A-0188) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met, as evidenced by: 1. The facility failed to ensure nursing staff followed the facility’s “Scope of Vocational Nursing Practice/RN Supervision” policy for staffing when a Licensed Vocational Nurse (LVN, a nurse who has completed a vocational nursing program and is licensed by the state to provide basic nursing care under the supervision of a Registered Nurse [RN] or physician) was assigned to patients without the required RN (a nurse who has completed advanced education and training, holds a state license, and is authorized to perform comprehensive patient assessments, formulate and update nursing care plans, administer medications including intravenous [IV] therapy, and supervise other nursing staff) attestation (formal acknowledgment and sign-off) that the RN assessed the patient (checked the patient’s condition), updated the plan of care (document outlining patient treatment goals and interventions), and concurred (agreed) with the data collected and documented by the LVN. This deficient practice occurred for five (5) of five (5) sampled patients (Patients 3, 4, 5, 6, and 7) assigned to LVN 1 on 1/6/2026. This deficient practice placed patients at risk for incomplete assessments (missing critical health information). For example, Patient 3’s Glasgow Coma Scale (GCS, a neurological scale used to measure level of consciousness) score dropped significantly during the same day without any supporting documentation to explain the change. Without RN attestation each shift, changes in patient condition may not be promptly recognized, and care plans may not reflect current needs. This could lead to inaccurate care plans and delayed interventions (late medical responses), which may affect the quality and safety of care and could result in harm (injury or negative health outcome). (Refer to A-0395) 2. The facility failed to ensure Registered Nurse provided supervision and performed assessment for one of 38 sampled patients (Patient 14), who was assigned to a Licensed Vocational Nurse (LVN), in accordance with the facility’s policy regarding assessment and reassessment, when Patient 14 experienced a change in condition (clinically important change from a patient’s established and documented baseline [an observation or value that represents the normal or beginning level of a measurable quality] in physical, cognitive, behavioral, or functional domains) as manifested by (showing) having shortness of breath (sensation of being unable to get enough air), decrease in blood pressure, heart rate and oxygen saturation (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) on 2/2/2024 at 6:50 p.m. This deficient practice had the potential to result in delay in evaluating Patient 14’s condition change and determining appropriate interventions including activating Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), consequently putting Patient 14’s safety at risk. RRT was called on 2/2/2024 at 7:15 p.m. Patient 14 was intubated (to insert a flexible plastic tube [endotracheal tube] through the mouth or nose into the windpipe [trachea] to maintain an open airway and deliver oxygen) during RRT and sent to ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) for further management. (Refer to A-0395) 3. The facility failed to ensure that the patient care assignment for three (3) of three (3) sampled patients (Patient 24, Patient 31, and Patient 32), who were on one-to-one observation (continuous, direct supervision by a staff member assigned to a single patient for safety), ensured that the patients (Patient 24, Patient 31, and Patient 32) were continuously monitored, in accordance with the facility’s policy and procedure (P&P) titled, “Observation Attendant (Sitter) Usage Assessment and Implementation.” Specifically, staff members were assigned to monitor all three patients located in two separate rooms, which may have limited the ability to maintain continuous visual observation (uninterrupted direct sight of the patient at all times) of each patient as outlined in facility policy. This deficient practice places patients at risk for harm, including self-injury (when a patient intentionally hurts themselves) or elopement (when a patient leaves the hospital or care area without permission or supervision). (Refer to A-0397) 4. The facility failed to ensure that one of 38 sampled patient’s (Patient 25) physician was notified, in accordance with the facility’s protocol regarding physician notification, regarding Patient 25’s refusal of a blood sugar check prior to discharge, when Patient 25’s last known blood sugar level was 320 (normal range is 70-100 milligrams per deciliter) at 12:21 p.m. (10/7/2025) and received insulin (medication used to control blood sugar). This deficient practice had the potential to delay necessary interventions for managing high or low blood sugar levels, which may lead to patient harm. (Refer to A-0398) 5. The facility failed to ensure that nursing staff followed the facility’s policies and procedures for one of 38 sampled patients (Patient 33) when: 5.a. Nursing staff failed to report and document notifying the physician about a critical high troponin value (a protein released when the heart muscle is damaged), as required by the facility’s policy on critical value notifications. 5.b. Pain assessment (evaluation of pain, typically on a scale from 0 to 10) was not completed and documented, in accordance with the facility’s procedure on pain assessment documentation. 5.c. Nursing staff failed to monitor, interpret (to analyze the heart’s electrical activity in real-time to identify the heart rate, rhythm regularity, and any abnormal patterns), and communicate to the physician, changes in Patient 33’s cardiac status (the current functional state, health, and efficiency of a patient’s heart and blood vessels) and heart rate observed on a telemetry monitor (a device used to remotely monitor a patient’s heart rhythm), in accordance with the facility’s policy regarding change of condition notification of a physician. The cumulative effect of these deficient practices had the potential to compromise Patient 33’s health and safety, delay treatment, resulting in an increased risk of exacerbation (sudden worsening) of Patient 33’s condition, unmanaged pain and discomfort, and increased likelihood of complications such as cardiac events or other critical developments. (Refer to A-0398) 6. The facility failed to ensure one of 38 sampled patient’s (Patient 34) nursing documentation regarding Patient 34’s leaving against medical advice (AMA, when a patient chooses to leave the hospital before the treating physician recommends discharge) included a documentation of discussion with the patient regarding the risks of leaving against medical advice, in accordance with the facility’s protocol in ensuring medical record completeness for AMA documentation. This deficient practice had the potential to compromise Patient 34’s right to make a fully informed decision and understanding of the potential consequences of leaving AMA. Additionally, the lack of proper documentation regarding the discussion of risks when leaving against medical advice could negatively impact Patient 34’s record keeping that may have compromised the continuity of care and Patient 34’s medical history and treatment decisions. (Refer to A-0398) 7. The facility failed to ensure that nursing staff followed the facility’s policy titled, “RN Standardized Procedure: Hyper/Hypoglycemia,” for one of 38 sampled patients (Patient 26) when: 7.a There was no nurse to physician communication regarding Patient 26’s low blood sugar 7.b. Patient 26’s blood sugar was in the 60s and was not monitored every 15 minutes until the blood sugar was within normal range (70-100 milligrams [mg, a unit of measure] per deciliter [dL, a unit of measure]) These deficient practices had the potential for Patient 26’s blood sugar to drop further which may lead to a severe negative outcome such as a rapid response (a hospital system designed to identify and respond to patients with early signs of clinical deterioration) and/or death. (Refer to A-0398) 8. The facility failed to ensure its nursing staff followed up with the Speech Therapist (a licensed healthcare professional who diagnoses and treats communication, language, cognitive, and swallowing disorders in individuals of all ages) to make sure a STAT (a medical abbreviation for immediately or without delay) swallow evaluation (to evaluate a person’s ability to swallow food) was done per physician order, in a timely manner, for one of 38 sampled patients (Patient 16), in accordance with facility’s policy regarding chain of command. This deficient practice resulted in Patient 16 not getting food from 9/11/2025 until 9/12/2025 evening while in the facility. (Refer to A-0398) 9. The facility failed to ensure nursing staff followed the six (6) Rights (The 6 Rights of Medication Administration are essential safety checks to prevent medication errors: Right Drug, Right Dose, Right Time, Right Route, Right Patient and Right Documentation) of medication administration on one of 38 sampled patients (Patient 19), in accordance with facility and procedure (P&P) titled, “Medication Administration (Management),” when Registered Nurse (RN) 4 failed to document the administration of Patient 19’s clonidine (medication to lower blood pressure) on 8/19/2025. This deficient practice had the potential for double dosing Patient 19 due to lack of proper documentation. (Refer to A-0398) 10. The facility failed to ensure nursing staff administered pain medication according to the prescribed pain scale (tool for self-reporting pain intensity) for one of 38 sampled patients (Patient 20). RN 18 gave acetaminophen (pain reliever medication to treat mild pain) 650 milligrams (mg, a unit of measure) ordered for mild pain (1-3 out of 10) to treat Patient 20’s moderate pain (4-6 out of 10), contrary to the physician’s order. This deficient practice had the potential for Patient 20 to suffer from inadequate pain relief and worsening of pain. (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46238 Based on interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure that a documentation regarding a discussion, between a medical provider and one of 38 sampled patients (Patient 34), pertaining to the risks of leaving against medical advice (AMA, a term used when a patient chooses to leave a hospital or medical facility despite the medical advice provided by their healthcare professionals, suggesting that it is not in their best interest to do so), was completed, in accordance with the facility’s policy regarding completion of medical records and medical record contents. This deficient practice had the potential to compromise Patient 34’s right to be informed of the risks of leaving AMA when not deemed stable for discharge from the hospital. Additionally, the providers’ lack of documentation regarding Patient 34’s condition at the time Patient 34 left the hospital against medical advice could potentially compromise the safety of Patient 34 if Patient 34 was not stable when leaving the facility. (Refer to A-0438) 2. The facility failed to ensure its physician consultant documented consultative notes after seeing one of 38 sampled patients (Patient 13), in accordance with the facility’s policy regarding completion of medical record. This deficient practice resulted in Patient 13’s medical record not reflecting Patient 13’s condition and response to treatment on 9/17/2025. The lack of documentation can negatively impact the sharing of vital information between care providers to ensure continuity, safety, and accuracy of patient care across multidisciplinary teams. (Refer to A-0464) 3. The facility failed to ensure Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) form was completed and filed for one of 38 sampled patient’s (Patient 14) medical record after a RRT was summoned on 2/2/2024. This deficient practice resulted in Patient 14’s medical record that did not reflect Patient 14’s condition during RRT, what was done during the RRT and Patient 14’s response to RRT interventions. The lack of documentation can negatively impact the sharing of vital information between care providers to ensure continuity, safety, and accuracy of patient care across multidisciplinary teams. (Refer to A-0467) 4. The facility failed to ensure two of 38 sampled patients’ (Patient 25 and Patient 33), “Discharge Summary (a record containing the patient’s condition and outcome of hospitalization, and any needs after discharge), contained the required elements such as course of hospitalization and outcome, in accordance with the facility’s Medical Staff General Rules and Regulations.” This deficient practice had the potential to compromise Patient 25’s and Patient 33’s health and recovery depriving healthcare providers of essential information necessary for continuity of care, effective communication among caregivers, and appropriate future medical treatment. (Refer to A-0468) 5. The facility failed to ensure its physician resident (MD 13) and supervising physician (MD 14) documented accurate and appropriate information on the discharge summary (a narrative document for communicating clinical information about what happened to the patient in the hospital) for one of 38 sampled patients (Patient 13), when MD 13 documented Patient 13’s discharge condition as stable and to return to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) if signs or symptoms reoccur despite Patient 13 having died at the facility on 9/17/2025. This deficient practice resulted in Patient 13’s discharge summary not accurately reflecting Patient 13’s status and condition. This inaccurate documentation had the potential to jeopardize future patient safety of other patients affecting patient management and continuity of patient care. (Refer to A-0468) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure a second attempt to complete an electrocardiography (EKG, an electrogram of the heart to evaluate heart rhythm) test was completed on 12/24/2025, as ordered by the physician and in accordance with the facility’s policy regarding ED scope of service, for one of 38 sampled patients (Patient 15), when Patient 15 initially refused due to abdominal pain of 10/10 (considered as severe pain) on a pain scale (a numeric pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). This deficient practice resulted in Patient 15 not receiving all necessary diagnostic testing as ordered and put Patient 15 at risk for delay in diagnosis and treatment. Findings: During a review of Patient 15’s “ED (emergency department [ED], hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) physician notes,” dated 12/24/2025, the ED physician notes indicated, Patient 15 presented to the facility’s ED with a chief complaint of abdominal pain. The ED physician notes also indicated an electrocardiography (EKG, an electrogram of the heart to evaluate heart rhythm) testing was ordered on 12/24/2025 at 7:25 a.m. During an interview on 12/30/2025 at 8:53 a.m. with Patient 15, Patient 15 stated the following: Patient 15 visited the facility’s emergency room on 12/24/2025. Nurse wanted to do EKG for Patient 15, but Patient 15 was in a lot of pain and could not cooperate. The Nurse noted that Patient 15 “refused EKG” instead of addressing Patient 15’s pain before conducting the EKG test. During an interview on 1/6/2026 at 10:40 a.m. with the Clinical Supervisor (CNS 1) of Emergency Department, CNS 1 stated if a patient refused to have EKG done due to pain, nursing staff should consult the ED physician for a pain treatment order then attempt to do EKG again. During a concurrent interview and record review on 1/7/2026 at 9:40 a.m. with CNS 1, Patient 15’s Nurses Notes, dated 12/24/2025, was reviewed. The Nurses Notes indicated the following: on 12/24/2025 at 6:56 a.m., Patient 15 was brought in by ambulance from home with chief complaint of abdominal pain that was sharp and burning. Patient 15 also had pain in mid back and left arm. Patient 15’s pain level was 10 out of 10 (a numeric pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). Patient 15 was resistant to EKG. CNS 1 confirmed Patient 15 was experiencing 10 out of 10 pain and refused EKG. During a review of Patient 15’s Nurses Notes, dated 12/24/2025, the Nurses Notes indicated, at 8 a.m. Patient 15 stated Patient 15 was no longer in pain. During an interview on 1/7/2026 at 10:11 a.m. with the Patient Experience Manager and Coach (PEMC), PEMC stated Patient 15 informed PEMC on 12/24/2025, that Patient 15 felt “she (Patient 15) was being rushed.” PEMC further stated Patient 15 was not happy with the care received in the morning (12/24/2025). During a concurrent interview and record review on 1/9/2026 at 10:59 a.m. with CNS 1, Patient 15’s physician order of EKG, dated 12/24/2025, was reviewed. The physician order indicated status as “logged.” CNS 1 stated “logged” meant the EKG was not done. CNS 1 further stated the following: nursing staff should have re-attempted EKG for Patient 15 after Patient 15’s pain was relieved. EKG was a diagnostic test to help the physician for decision making and diagnosing the patient. During a review of the facility’s policy and procedure (P&P) titled, “Scope of Service - Emergency Department,” dated 10/2025, the P&P indicated, “The Emergency Department is committed to providing high quality nursing care to patients of all ages. Our mission, which reflects [the facility’s] Mission, is to provide comprehensive quality healthcare in a compassionate, convenient, and cost-effective manner. We recognize the physical, psychological, and spiritual needs for ill and injured patients with a wide variety of diagnoses ... The staff of [the facility] emergency department believe: 1. That it is our responsibility to respect the patient’s rights as described in the policy “Patient Rights and Responsibilities” 2. That the patient is dependent on our caring and expertise. 3. That the patient is a person who brings us their illness or injury, and it is our responsibility to gain their trust and provide them with competent care and comfort. 4. That the patient is deserving of comprehensive quality healthcare in a compassionate, convenient, and cost-effective manner ... The availability of life support equipment and skilled, competent staff to initiate emergency interventions is consistent in the Emergency Department on a 24 hour, seven day a week basis. Clinical functions (diagnostic, therapeutic or preventative) available in the Emergency Department: 1. Cardiac monitoring ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights & Responsibilities,” dated 1/2025, the P&P indicated, “The hospital mission call us to render personalized and compassionate care to patients in aways that respect the dignity of each person ... Patient Rights 1. Considerate and respectful care ...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure that the use of restraints (devices, medications, or techniques used as a last resort to temporarily limit a patient’s movement or freedom to ensure safety) for one (1) of 3 sampled patients (Patient 1), was implemented only after less restrictive interventions (strategies that do not limit movement, such as verbal de-escalation [calming the patient through conversation] or environmental changes), were attempted prior to application of restraints, in accordance with the facility’s “Restraint” policy and procedure (official written guidelines for staff on the use of restraints). Patient 1 was given Haldol (Haloperidol, an antipsychotic [mental stabilizer] medication used to calm severe agitation [extreme restlessness or irritability, often with aggression] or treat mental health conditions. When given to control behavior rather than treat a psychiatric illness, it is considered a chemical restraint) on two separate occasions and later placed in soft wrist restraints (fabric cuffs applied to limit arm movement) without documentation in the medical record describing the least restrictive measures used or considered prior to giving the medication (Haldol) or applying the restraints. This deficient practice created the potential for medication to be used without documented justification and without sufficient documentation to evaluate the patient’s response and ongoing monitoring needs, which may result in patient harm. Findings: During a review of Patient 1’s “History and Physical (H&P, a document that summarizes the patient’s medical history and current condition),” dated 12/17/2025, the H&P indicated: “The patient (Patient 1) is an 86-year-old female with no significant PMH (Past Medical History, without major chronic illnesses), apart from recurrent UTIs (Urinary Tract Infections, infections in the bladder or urinary system). She (Patient 1) presented with worsened altered mental status (thinking and awareness were more impaired than usual) over the past two days. According to her daughter, the patient (Patient 1) has been progressively more confused, with slowed cognition (slower thinking) and motor activity (slower physical movements) and has been unable to perform her ADLs (Activities of Daily Living, such as bathing, dressing, and eating), which was a deviation from her (Patient 1’s) baseline (change from normal level of functioning).” During a concurrent interview and record review on 1/7/2026 at 9:31 a.m. with the Program Coordinator for Quality Assurance (PCQA), Patient 1’s “Medication Administration Record (MAR, a log of all medications given to a patient),” dated 12/18/2025 through 12/22/2025, was reviewed. The MAR indicated: - Haldol 2 milligrams (mg, a unit of measurement) by intramuscular injection (IM, into the muscle) was given on 12/18/2025 at 6:08 a.m. and 12/22/2025 at 9:40 a.m. - There was an additional PRN (as needed) order for Haldol 2 mg IM entered on 12/22/2025 at 9:25 a.m. for agitation (extreme restlessness or irritability, often with aggression) but was never given and later discontinued at 4:31 p.m. -PCQA confirmed that the MAR did not include documentation of any alternative interventions attempted before giving the medication, such as: Verbal de-escalation (calming the patient through conversation), Environmental modification (moving the patient to a quieter area), Family involvement (calling family to help calm the patient). During the same concurrent interview and record review on 1/7/2026 at 9:31 a.m. with the PCQA, Patient 1’s medical record (MR), “Nursing Notes,” dated from 12/16/2025 through 12/26/2025, was reviewed. The PCQA confirmed that there was no documented evidence that least restrictive alternative measures were attempted prior to the administration of Haldol on 12/18/2025 and on 12/22/2025 including the application of both wrist restraints on Patient 1. During a review of Patient 1’s MR “Nursing Notes,” dated 12/18/2025 at 6:00 a.m., the note indicated: “MD communication: MD 2 was notified that Patient 1 was combative (physically aggressive) and punched the nurse. MD 2 approved Haldol 5 mg as a one-time dose.” The nursing notes also indicated at 8:44 a.m.: “Informed the daughter (Patient 1’s daughter) that Patient 1 was placed in soft wrist restraints.” During a review of Patient 1’s restraint order, dated 12/18/2025 at 8:42 a.m., the order indicated soft wrist restraints (fabric cuffs applied to limit arm movement) were applied to both wrists and were active for up to 24 hours. During a concurrent interview and record review on 1/9/2026 at 9:38 a.m. with Registered Nurse (RN 10), Patient 1’s MR document titled, “Nursing Notes,” dated from 12/16/2025 through 12/26/2025, were reviewed. The notes indicated there was no documented evidence that less restrictive measures were attempted before applying both wrist restraints. RN 10 stated less restrictive measures include: Increased rounding (checking on the patient more often), Reorientation (reminding the patient where they are and what is happening), Family engagement (involving family to help calm the patient). During the same concurrent interview and record review on 1/9/2026 at 9:38 a.m. with RN 10, Patient 1’s “Intervention Restraint” flowsheet, dated 12/18/2025, was reviewed. The flowsheet indicated there was no documentation of: -Circulation checks (ensuring blood flow to hands), -Toileting or nutrition offered every two hours, -Periodic removal or reassessment to determine if restraints could be discontinued. During an interview on 1/6/2026 at 11:18 a.m. with MD 1 (Emergency Department Physician who cared for Patient 1), MD 1 stated: “If the patient is agitated and combative (very restless and physically aggressive), we first try talking to them and reducing stimulation (making the environment quieter). If those measures fail, we may give a small dose of medication to calm the patient. Haldol is usually used because it helps control agitation and calm the patient down.” MD 1 confirmed that Haldol (Haloperidol, an antipsychotic medication) was considered a chemical restraint when used to manage behavior rather than treat a psychiatric condition. During an interview on 1/7/2026 at 10:23 a.m. with MD 2 (Physician who cared for Patient 1), MD 2 stated: “Haldol was ordered IM because the patient was very agitated and there was no IV access (IV means intravenous, into the vein). Prior to giving Haldol, other interventions would include moving the patient closer to the nurse station and encouraging family to come in and talk to her. Haldol was given here as a chemical restraint (the use of medication, such as antipsychotics or sedatives, to intentionally control behavior, restrict freedom of movement, or sedate a person, rather than to treat a specific medical symptom).” During a concurrent interview and record review on 1/9/2026 at 10:27 a.m. with the Director of Medical-Surgical (DOT 3), Patient 1’s MR, document titled, “Intervention Restraint,” was reviewed. The MR indicated there were no documented alternative measures used prior to application of both wrist restraints on 12/18/2025, administering Haldol on 12/18/2025, and on 12/22/2025. DOT 3 stated: “Policy requires starting with least restrictive measures before any type of restraint; this was not documented.” DOT 3 emphasized that interventions such as reorientation, distraction, and family involvement should have been attempted and documented prior to restraint application. During a review of Patient 1’s Neurology Progress Notes, dated 11/20/2025, the note indicated MD 6 suspected that dementia (a condition that causes memory loss and thinking problems) might not have been fully diagnosed yet. The note also indicated d that, for the neurological assessment (tests of brain and nerve function), “The examination shows improvement from the initial evaluation, suspected to be secondary to receiving haloperidol (haldol) for agitation.” During a review of the facility’s policy and procedure (P&P) titled, “Restraints,” dated April 2024, the P&P indicated: The use of restraints poses an inherent risk to the physical safety and psychological well-being of the patient and staff. Therefore, restraints are only used in an emergency situation, when less restrictive interventions are ineffective ...Definitions: Restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Chemical Restraint: A drug or medication when it is used as a restriction to manage the patient’s behavior, or restrict the patient’s freedom and is not a standard treatment or dosage for the patient’s condition: If the medication is treating symptoms of the patient’s illness in a dosage range appropriate to the patient’s illness, it does not constitute chemical restraint. If the medication is unrelated to the patient’s illness, or a medication is used in an extreme dosage range, it does constitute chemical restraint. Less Restrictive Alternative Interventions: Strategies that seek to identify opportunities to reduce restraint use and associated risks by implementation of preventative strategies, innovative alternatives, and process improvements. Nonphysical techniques are always the preferred interventions in management of the behavior. The least restrictive, safe, and effective intervention method must be used. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights & Responsibilities,” dated January 2025, the P&P indicated the following: Receive care in a safe setting. Patients have the right to be free from seclusion or restraint for behavioral management unless medically necessary to protect your physical safety or the safety of others.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to ensure its policy and procedure (P&P, official facility rules) for restraints included guidance on monitoring and assessment after administration of a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition) for one (1) of three sampled patients (Patient 1) who received Haldol (an antipsychotic medication used to treat agitation [restlessness or aggressive behavior] or psychosis [loss of contact with reality]). This deficient practice resulted in the potential for harm due to lack of timely reassessment (checking the patient’s condition again within the required time frame) for adverse effects (harmful or undesired reactions to medication) and inadequate monitoring (failure to observe and record patient’s condition) of vital signs (basic body measurements including temperature, heart rate, breathing rate, and blood pressure) and neurological status (patient’s alertness, orientation, and nervous system function) after administration of a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s medical condition). As a result, Patient 1 remained deeply sedated (very sleepy or unresponsive due to medication) for about 8 hours (from 6:08 a.m.- 2:50 p.m.), missed meals and was at risk for aspiration (food or liquid entering the airway, which can cause choking or pneumonia [lung infection]). Because the facility’s policy (official rules and procedures) lacked clear guidance (specific instructions), future patients who receive chemical restraints may not be appropriately assessed or monitored, placing them at risk for unrecognized complications and delayed interventions (late medical responses to prevent harm). Findings: During a concurrent interview and record review on 1/7/2026 at 9:50 a.m. with the Program Coordinator for Quality Assurance (PCQA, person responsible for monitoring quality of care), Patient 1’s medical record (MR, official patient chart) titled, “Vital Signs (essential, routine, and, or continuous, measurements of the body’s most basic, life-sustaining functions-pulse rate, blood pressure, respiratory rate, and temperature),” dated from 12/16/2025 through 12/26/2025, was reviewed. The PCQA confirmed that there was no documented assessment (written evaluation of the patient’s condition) within 15 minutes after giving Haldol as required for monitoring chemical restraints (medication used to control behavior, not as a standard treatment for the patient’s condition). The PCQA validated that vital signs were only recorded during routine checks, not in response to the medication administration. During the same concurrent interview and record review on 1/7/2026 at 9:50 a.m. with the PCQA, Patient 1’s “Medication Administration Record (MAR, a document that tracks all medications given to a patient),” dated 12/18/2025 through 12/22/2025, was reviewed. The MAR indicated Haldol 2 milligrams (mg, a unit of measurement) via IM (intramuscular, via the muscle), was given on 12/18/2025 at 6:08 a.m. and 12/22/2025 at 9:40 a.m. There were no vital signs recorded prior to or after administration of Haldol on either date. During a concurrent interview and record review on 1/8/2026 at 10:45 a.m. with the Director of Medical Surgical Units (DOT 3, a nurse leader), Patient 1’s “Neurological Assessments (evaluations of alertness, orientation, and nervous system function),” dated from 12/16/2025 through 12/26/2025, was reviewed. The record indicated neurological assessments were done every four hours. DOT 3 confirmed this did not meet the expected monitoring frequency for chemical restraint. DOT 3 stated, “A neurological assessment must be completed within 15 minutes after giving a chemical restraint such as Haldol and then every two hours until the patient is stable (no longer at risk for harm from the medication). These assessments are critical to ensure the patient is not over-sedated (excessively sleepy or unresponsive due to medication) and remains safe.” During a review of Patient 1’s “Nursing Note (official nurse documentation),” dated 12/18/2025, the note indicated at 1:35 p.m., “Attempt to wake patient (Patient 1) up for lunch. Lunch tray presented to patient but is asleep. Called patient’s name several times. Tapped her shoulders, hands and feet but she did not wake up for lunch.” At 2:20 p.m., “Attempted to wake patient up for lunch. Patient startle for a second but appears to be in deep sleep again.” At 2:50 p.m., “Informed patient daughter that the patient may get aspiration (food or liquid entering the airway, which can cause choking or pneumonia) if we force her to wake up and try to feed her.” There was no documentation of vital signs (temperature, heart rate, breathing rate, and blood pressure) or neurological assessment within 15-30 minutes after Haldol administration. During an interview on 1/6/2026 at 10:36 a.m. with Registered Nurse (RN) 10 (a licensed nurse who provides patient care), RN 10 stated that if a psych medication (medication used to treat mental health conditions) that the patient has never been on was administered, the patient must be assessed (evaluated for changes in condition) afterward, and the family must be notified that this medication was given. RN 10 stated, “If the patient is alert to AOX4 (alert and oriented to person, place, time, and situation), they can refuse. If not oriented, depend on status, but always attempt to call POA (Power of Attorney, a person legally authorized to make decisions for the patient) or family.” During an interview on 1/6/2026 at 11:48 a.m. with Registered Nurse (RN) 7, RN 7 stated that Haldol was given for agitation or psychosis (loss of contact with reality). RN 7 stated, “Prior to administering Haldol, check the indication (reason for use) for the medication and confirm the patient meets the criteria (requirements for use). Check vital signs first, then give IM Haldol. Vitals must be rechecked after 15-30 minutes. If Haldol is given to a patient with a POA, the RN will call the MD (Medical Doctor) or the family. Families must be informed when Haldol is administered for agitation because the patient may experience changes in vital signs or become unstable (at risk for harm). This communication is necessary to share the care plan (treatment plan) with the family.” During an interview on 1/6/2026 at 12:08 p.m. with Registered Nurse (RN) 8, RN 8 stated that after administering Haldol, vital signs must be rechecked because Haldol can affect vitals and cause extreme lethargy (severe drowsiness or lack of energy). RN 8 stated, “If giving Haldol for the first time, the POA is involved in patient care. There is no formal consent required, but a note will be written in the charge nurse’s documentation (official nursing record). Haldol is considered a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition). Consent from the POA is not required, but I will reach out to the POA as a courtesy.” During an interview on 1/9/2026 at 10:17 a.m. with Registered Nurse (RN) 15, RN 15 stated that after Haldol is given, safety bed alarm (device to alert staff if patient tries to get out of bed) should be assessed and vital signs should be checked. RN 15 stated, “Check vitals before giving the medication and check vitals 15 minutes after giving the medication, this includes checking for alertness and orientation (awareness of person, place, time, and situation). I would check every 2 hours.” RN 15 also stated that there should be documentation that alternative measure is used. The reason we need to assess the patient after (after medication administration) is because of dizziness (feeling faint or unsteady). If you gave Haldol and the patient sleeps throughout shift, we must notify the MD (Medical Doctor). Because the patient may need a lower dose.” During a concurrent interview and record review on 1/9/2026 at 9:55 a.m. with PCQA, the facility’s policy and procedure (P&P, official facility rules) titled, “Assessment and Reassessment of the Patient,” dated January 2025, was reviewed. The P&P indicated, “Standard of Practice: The patient will be reassessed by an RN (Registered Nurse, a licensed nurse who provides patient care) based under the following circumstances: To evaluate the effectiveness of health care interventions (actions taken to improve health).” However, PCQA confirmed the P&P did not specify the frequency (how often) or content (what should be checked) of reassessment after administration of a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition). During a concurrent interview and record review on 1/9/2026 with the Clinical Educator for Telemetry and Medical Surgical Units (CNS 3), the facility’s policy and procedure (P&P, official facility rules) titled “Restraints,” dated April 2024, was reviewed. The P&P indicated that after application of a physical restraint (device or method used to restrict a patient’s movement), the patient was to be assessed every 15 minutes for nutrition and hydration and re-evaluated every 2 hours for circulation (blood flow). However, the P&P did not address how often to monitor or reassess a patient after administration of a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition), nor did it specify how often vital signs should be taken after such administration. CNS 3 confirmed that the facility does not have any policy or procedure guidelines that described the required monitoring and assessment after administering a chemical restraint. During an interview on 1/9/2026 at 2:27 p.m. with the Chief Medical Officer (CMO, the physician responsible for clinical oversight), the CMO stated the current policy addressed procedures but did not include pharmacological restraints (medications used to control behavior, not as a standard treatment for the patient’s condition). The CMO stated, “Typically, nursing reassessment (evaluation by a nurse for changes in the patient’s condition) occurs within one hour. For benzodiazepines (a class of medications used to reduce anxiety or agitation, with a half-life of about 1 hour), reassessment should occur within 30 minutes to 1 hour, and more frequently if doses are repeated. For Haldol IM, there is no immediate effect; it can take 2-3 hours to work. Reassessment should focus on behavioral changes (such as agitation [restlessness or aggressive behavior]) and signs of tardive dyskinesia (involuntary movements). For any chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition), reassessment is critical to monitor tolerance (how well the patient handles the medication) and adverse effects (harmful or undesired effects).””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure that one (1) of three (3) sampled patients (Patient 1), was reassessed for response to the chemical restraint (medication used to restrict a patient’s movement or behavior, not a standard treatment for the patient’s condition) and bilateral (both sides) wrist restraint (a device used to limit movement of both wrists), used on Patient 1. This deficient practice has the potential to result in unrecognized adverse effects (harmful or undesired outcomes) and unsafe patient care. Findings: During a review of Patient 1’s “History and Physical (H&P, a document that summarizes the patient’s medical history and current condition), dated 12/17/2025, the H&P indicated: “The patient (Patient 1) is an 86-year-old female with no significant PMH (Past Medical History, without major chronic illnesses), apart from recurrent UTIs (Urinary Tract Infections, infections in the bladder or urinary system). She (Patient 1) presented with worsened altered mental status (thinking and awareness were more impaired than usual) over the past two days. According to her daughter, the patient (Patient 1) has been progressively more confused, with slowed cognition (slower thinking) and motor activity (slower physical movements) and has been unable to perform her ADLs (Activities of Daily Living, such as bathing, dressing, and eating), which was a deviation from her (Patient 1’s) baseline (change from normal level of functioning).” During a concurrent interview and record review on 1/7/2026 at 9:31 a.m. with the Program Coordinator for Quality Assurance (PCQA), Patient 1’s “Medication Administration Record (MAR),” dated 12/18/2025 through 12/22/2025, was reviewed. The MAR indicated: Haldol 2 milligrams (mg, a unit of measurement) by intramuscular injection (IM, into the muscle) was given on 12/18/2025 at 6:08 a.m. and 12/22/2025 at 9:40 a.m. PCQA confirmed that Patient 1 was ordered Haldol due to Patient 1 displaying a combative behavior. During a review of Patient 1’s MR “Nursing Notes,” dated 12/18/2025 at 6:00 a.m., the note indicated: “MD communication: MD 2 was notified that Patient 1 was combative and punched the nurse. MD 2 approved Haldol 5 mg as a one-time dose.” The nursing notes also indicated at 8:44 a.m.: “Informed the daughter (Patient 1’s daughter) that Patient 1 was placed in soft wrist restraints (a device used to limit movement of both wrists).” During a review of Patient 1’s medical record, document titled “Orders,” there was a restraint order dated 12/18/2025 at 8:42 a.m., the order indicated soft wrist restraints were applied to both wrists and were active for up to 24 hours. During an interview on 1/6/2026 at 10:36 a.m. with Registered Nurse (RN) 10, RN 10 stated, “If psych (psychiatric) medication (medication used to treat mental health conditions) that the patient has never been on is administered, the patient must be assessed (evaluated for changes in condition) afterward, and the family must be notified that this medication was given. If the patient is alert to AOX4 (alert and oriented to person, place, time, and situation), they can refuse. If not oriented, depend on status, but always attempt to call POA (Power of Attorney, a person legally authorized to make decisions for the patient) or family.” During an interview on 1/6/2026 at 11:48 a.m. with Registered Nurse (RN) 7, RN 7 stated, “They do give Haldol (an antipsychotic medication used to treat agitation [restlessness or aggressive behavior] or psychosis [loss of contact with reality]). Prior to administering Haldol, check the indication (reason for use) for the medication and confirm the patient meets the criteria (requirements for use). Check vital signs (basic measurements of the body’s essential functions, including temperature, heart rate, breathing rate, and blood pressure) first, then give IM (intramuscular, meaning injected into a muscle) Haldol. Vitals must be rechecked after 15-30 minutes. If Haldol is given to a patient with a POA, the RN will call the MD (Medical Doctor) or the family. Families must be informed when Haldol is administered for agitation because the patient may experience changes in vital signs or become unstable (at risk for harm). This communication is necessary to share the care plan (treatment plan) with the family.” During an interview on 1/6/2026 at 12:08 p.m. with Registered Nurse (RN) 8, RN 8 stated, “Assess if it is appropriate to give Haldol. After administering Haldol, vital signs must be rechecked because Haldol can affect vitals and cause extreme lethargy (severe drowsiness or lack of energy). If giving Haldol for the first time, the POA is involved in patient care. There is no formal consent required, but a note will be written in the charge nurse’s documentation (official nursing record). Haldol is considered a chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition). Consent from the POA is not required, but I will reach out to the POA as a courtesy.” During an interview on 1/6/2026 at 2:00 p.m. with the Director of Pharmacy Services and Clinical Pharmacist, the Director of Pharmacy Services stated, “After administration of any drugs that the patient has not received or any drug given as a chemical restraint, the patient should be reassessed for any adverse reaction (harmful or undesired effect).” During a concurrent interview and record review on 1/7/2026 at 9:50 a.m. with the Program Coordinator for Quality Assurance (PCQA, person responsible for monitoring quality of care), Patient 1’s medical record (MR, official patient chart) titled “Vital Signs,” dated from 12/16/2025 through 12/26/2025, was reviewed. The MR indicated that on 12/18/2025, routine vital signs were taken at 8:00 a.m.; however, when Patient 1 was administered the first dose of Haldol at 6:08 a.m., there were no vital signs recorded prior to administration or after administration of Haldol. The MR further indicated that on 12/22/2025, there were no vital signs taken before or after the administration of Haldol at 9:40 a.m. The PCQA confirmed that there was no documented assessment within 15 minutes after giving Haldol, as required for monitoring chemical restraint. The PCQA validated that vital signs were only recorded during routine checks, not in response to the medication administration. During a concurrent interview and record review on 1/8/2026 at 10:45 a.m. with the Director of Medical Surgical Units (DOT 3), Patient 1’s medical record titled “Neurological Assessments (evaluation of alertness, orientation, and nervous system function),” dated from 12/16/2025 through 12/26/2025, was reviewed. The record indicated that Patient 1’s neurological assessments were done every four hours, which DOT 3 confirmed did not meet the expected monitoring frequency for chemical restraint (medication used to control behavior, not as a standard treatment for the patient’s condition). DOT 3 confirmed that Patient 1’s medical record did not include neurological assessments after Haldol (an antipsychotic medication used to treat agitation or psychosis) was administered on 12/18/2025 and 12/22/2025. DOT 3 stated, “A neurological assessment must be completed within 15 minutes after giving a chemical restraint such as Haldol and then every two hours until the patient is stable. These assessments are critical to ensure the patient is not over-sedated (excessively sleepy or unresponsive due to medication) and remains safe.” During a concurrent interview and record review on 1/7/2026 at 9:50 a.m. with the PCQA, Patient 1’s “Nursing Note (official nurse documentation),” dated 12/18/2025, was reviewed. The note indicated: - At 1:35 p.m., “Attempt to wake patient (Patient 1) up for lunch. Lunch tray presented to patient but is asleep. We have permission to wake her up in order to feed her per dietician (nutrition specialist). Called patient’s name several times. Tapped her shoulders, hands and feet but she did not wake up for lunch.” - At 2:20 p.m., “Attempted to wake patient up for lunch. Patient startle for a second but appears to be in deep sleep again.” - At 2:50 p.m., “Informed patient daughter that the patient may get aspiration (food or liquid entering the airway, which can cause choking or pneumonia) if we force her to wake up and try to feed her.” - At 3:07 p.m., “Received phone call from patient’s daughter (name of daughter), she doesn’t want any psychiatric medications in any circumstance.” During a concurrent interview and record review on 1/7/2026 at 9:55 a.m. with the Program Coordinator for Quality Assurance (PCQA), the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated January 2025, was reviewed. The P&P indicated, “Standard of Practice: The patient will be reassessed by an RN (Registered Nurse) based under the following circumstances: To evaluate the effectiveness of health care interventions (actions taken to improve health).” The PCQA confirmed that there was no documented assessment within 15 minutes after giving Haldol (an antipsychotic medication used to treat agitation or psychosis), as required by the P&P. During the same concurrent interview and record review on 1/9/2026 at 9:38 a.m. with RN 10, Patient 1’s “Intervention Restraint” flowsheet, dated 12/18/2025, was reviewed. The flowsheet indicated there was no documentation of: - Circulation checks (ensuring blood flow to hands), - Toileting or nutrition offered every two hours, and - Periodic removal or reassessment to determine if restraints could be discontinued. During an interview on 1/9/2026 at 10:17 a.m. with Registered Nurse (RN) 15, RN 15 stated, “After Haldol is given, assess safety bed alarm (device to alert staff if patient tries to get out of bed) and check vital (vital signs). RN 15 stated, “Check vitals before giving the medication and check vitals 15 minutes after giving the medication, this includes checking for alertness and orientation (awareness of person, place, time, and situation). I would check every 2 hours.” The reason we need to assess the patient after (after medication administration) is because of dizziness (feeling faint or unsteady). If you gave Haldol and the patient sleeps throughout shift, we must notify the MD (Medical Doctor). Because the patient may need a lower dose.” During an interview on 1/9/2026 at 1:52 p.m. with the Clinical Educator for Telemetry (monitoring of heart rhythm) and Medical Surgical Units (CNS 3), CNS 3 stated, “After the restraint is applied, go back and assess the patient every 15 minutes for nutrition (food intake) and hydration (fluid intake) per reviewed P&P (policy and procedure, official facility rules). The P&P said re-eval every 2 hours to check circulation (blood flow). Reposition the patient every 2 hours. Hygiene (cleanliness) and elimination (urination and bowel movements) every 15 mins. Vitals should be taken per unit routine. For patient safety, a medication that may affect the vitals should have a process in reassessment criteria (steps for checking patient’s response).” During a review of the facility’s policy and procedure (P&P) titled, “Restraints,” dated April 2024, the P&P indicated the following: Initial Assessment: A Physician, N.P., or P.A. who is primarily responsible for the patient’s care or a qualified competent RN conducts an in-person face-to-face evaluation of the patient within 1- hour of initiation ... The in-person face-to-face is conducted to review the patient’s immediate status, i.e., the physical and psychological status of the patient; the patient’s reaction to the intervention; the patient’s medical and behavioral conditions; to make necessary revisions to the patient’s plan of care, to identify alternatives to help the patient regain control; to assess the need to continue or terminate the restraint; and to sign the order. A qualified competent RN assesses the patient’s behavior, and the environment. Precipitating events are identified and eliminated whenever possible. One-to-one, face-to-face care is initiated and continues for the first hour of restraint. After one hour, observation is done every 15 minutes ... The RN is responsible for ensuring that every 15-minute documentation of patient monitoring is completed. It is the RN’s responsibility to assess the patient: - To determine if the indication for restraint and the contributing factors continue to be present, - To continue to attempt alternative interventions, - To determine readiness for restraint discontinuation, and - To communicate to the patient the behavioral criteria required to discontinue restraint.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure nursing staff followed the facility’s “Scope of Vocational Nursing Practice/RN Supervision” policy for staffing when a Licensed Vocational Nurse (LVN, a nurse who has completed a vocational nursing program and is licensed by the state to provide basic nursing care under the supervision of a Registered Nurse [RN] or physician) was assigned to patients without the required RN (a nurse who has completed advanced education and training, holds a state license, and is authorized to perform comprehensive patient assessments, formulate and update nursing care plans, administer medications including intravenous [IV] therapy, and supervise other nursing staff) attestation (formal acknowledgment and sign-off) that the RN assessed the patient (checked the patient’s condition), updated the plan of care (document outlining patient treatment goals and interventions), and concurred (agreed) with the data collected and documented by the LVN. This deficient practice occurred for five (5) of five (5) sampled patients (Patients 3, 4, 5, 6, and 7) assigned to LVN 1 on 1/6/2026. This deficient practice placed patients at risk for incomplete assessments (missing critical health information). For example, Patient 3’s Glasgow Coma Scale (GCS, a neurological scale used to measure level of consciousness) score dropped significantly during the same day without any supporting documentation to explain the change. Without RN attestation each shift, changes in patient condition may not be promptly recognized, and care plans may not reflect current needs. This could lead to inaccurate care plans and delayed interventions (late medical responses), which may affect the quality and safety of care and could result in harm (injury or negative health outcome). 2. Ensure Registered Nurse provided supervision and performed assessment for one of 38 sampled patients (Patient 14), who was assigned to a Licensed Vocational Nurse (LVN), in accordance with the facility’s policy regarding assessment and reassessment, when Patient 14 experienced a change in condition (clinically important change from a patient’s established and documented baseline [an observation or value that represents the normal or beginning level of a measurable quality] in physical, cognitive, behavioral, or functional domains) as manifested by (showing) having shortness of breath (sensation of being unable to get enough air), decrease in blood pressure, heart rate and oxygen saturation (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood) on 2/2/2024 at 6:50 p.m. This deficient practice had the potential to result in delay in evaluating Patient 14’s condition change and determining appropriate interventions including activating Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), consequently putting Patient 14’s safety at risk. RRT was called on 2/2/2024 at 7:15 p.m. Patient 14 was intubated (to insert a flexible plastic tube [endotracheal tube] through the mouth or nose into the windpipe [trachea] to maintain an open airway and deliver oxygen) during RRT and sent to ICU (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill) for further management. Findings: 1.a. During a concurrent interview and record review on 1/6/2026 at 11:40 a.m. with the Director of Nursing (DON, nurse leader responsible for oversight of nursing care), the unit nursing assignment for the Medical-Surgical Unit (hospital unit where patients receive general medical and surgical care), 6th floor, was reviewed. The DON stated the census (number of patients) was 32, with 8 RNs (including the resource nurse and charge nurse), 1 LVN, and 2 CNAs (Certified Nursing Assistants, staff who provide basic patient care). The assignment sheet indicated under “LVN coverage,” [RN 6 name] / [LVN 1 name]. The DON stated RN 6 was covering LVN 1’s assignment and was responsible for IV (intravenous, through a vein) medication administration and must evaluate LVN 1’s assessment once per shift (a scheduled work period). The DON confirmed that the facility’s process was that an RN must attest (formally acknowledge and sign off) that they (the RNs) reviewed the LVN’s assessment. During a concurrent interview and record review on 1/7/2026 starting at 1:00 p.m. with RN 10 (a licensed nurse who provides patient care), the electronic medical records for patients (Patients 3, 4, 5, 6, and 7) assigned to LVN 1 on 1/6/2026 were reviewed. During concurrent interview and record review on 1/7/2026 at 1:05 p.m. with RN 10, Patient 3’s “History and Physical (H&P, a document that summarizes a patient’s medical history and current condition),” dated 1/6/2026, indicated Patient 3’s medical history included HTN (hypertension, high blood pressure) and seizure disorder (a condition characterized by recurrent seizures). The patient (Patient 3) presented to the ED (Emergency Department) for Left hand pain (pain in the left hand) after a slip fall. The patient complained of pain in the left 3rd and 4th digits (third and fourth fingers) with deformity (abnormal shape or position) noted, as well as numbness (loss of sensation) and tingling (pins-and-needles sensation). Hand surgery (a surgical specialty focused on treating conditions of the hand) was consulted by the ED. During concurrent interview and record review on 1/7/2026 at 1:07 p.m. with RN 10, Patient 3’s medical record document (MR) titled “Shift Assessment (a nursing record that documents patient condition during a specific work shift),” dated 1/6/2026, was reviewed. The shift assessment at 4:00 a.m., documented by RN 19, indicated Patient 3’s Glasgow Coma Scale (GCS, a neurological scale used to measure a patient’s level of consciousness) total score was 15 (normal level of consciousness). At 4:00 p.m., LVN 1 documented Patient 3’s GCS was 9 (indicating a decreased level of consciousness). RN 10 confirmed that there was no other documentation to support the reason why the GCS score dropped to 9. During a concurrent interview and record review on 1/7/2026 at 1:07 p.m. with RN 10, Patient 3’s medical record (MR, official patient chart) titled “Nursing Notes,” dated 1/6/2026 for the day shift (7:00 a.m. -7:00 p.m.), was reviewed. The MR indicated there was no RN attestation (formal acknowledgment and sign-off) for the shift assessment or care plan update. RN 10 stated the attestation should indicate that the RN assessed the patient (checked the patient’s condition), updated the plan of care (document outlining treatment goals and interventions), and concurred (agreed) with the data collected and documented by the LVN (Licensed Vocational Nurse, a nurse with limited scope of practice who works under RN supervision). During an interview on 1/7/2026 at 4:05 p.m. with the Clinical Supervisor of Telemetry (CST, nurse leader overseeing heart monitoring unit), the CST stated the reason for RN sign-off on LVN assessments, care plans, and IV medication was because of California state requirements. CST said LVNs did not have the scope of practice (legal authority) to perform admission assessments (initial evaluation of patient condition) or independently manage IV medications. These tasks required RN oversight to ensure patient safety. During a review of the facility’s policy and procedure (P&P, official facility rules) titled, “Scope of Vocational Nursing Practice/RN Supervision,” dated October 2025, the P&P indicated, “The RN will provide supervision of the LVN as required by state and federal regulations. Initial admission assessment (first evaluation of patient condition) and care plan formulation (creating a treatment plan) must be performed by the RN. The RN must document each patient at least once per shift (a scheduled work period) or per unit policy, whichever is greater. This assessment may include data collected by the LVN, which the RN has reviewed and discussed with the LVN. The LVN cannot independently formulate a nursing care plan (document outlining patient treatment goals and intervention). A registered nurse shall directly provide patient assessments and document findings in the patient’s medical record for each shift and upon receipt of the patient when transferred to another care area.” During a review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated October 2025, the P&P indicated, “(Name of the facility) shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII, California Licensing and Certification of Health Facilities in the General Acute Care Hospitals.” 1.b. During a concurrent interview and record review on 1/7/2026 at 1:08 p.m. with RN 10, Patient 4’s “History and Physical (H&P), dated 12/31/2025, was reviewed. The H&P indicated Patient 4’s past medical history included congestive heart failure (a condition in which the heart cannot pump blood effectively) and end-stage renal disease (the final stage of chronic kidney disease where the kidneys no longer function adequately). The H&P further indicated that Patient 4 presented to the ER due to abdominal pain (pain in the stomach area). During a concurrent interview and record review on 1/7/2026 at 1:09 p.m. with RN 10, Patient 4’s medical record (MR) titled “Nursing Notes,” dated 1/6/2026, was reviewed. The MR indicated there was no RN attestation for the shift assessment (evaluation of patient’s condition during a specific nursing shift) or care plan update (revision of the patient’s individualized treatment plan). RN 10 confirmed that there was no documented evidence that a RN reviewed Patient 4’s MR for 1/6/2026 during the day shift. During an interview on 1/7/2026 at 4:05 p.m. with the Clinical Supervisor of Telemetry (CST, nurse leader overseeing heart monitoring unit), the CST stated the reason for RN sign-off on LVN assessments, care plans, and IV medication was because of California state requirements. CST said LVNs did not have the scope of practice (legal authority) to perform admission assessments (initial evaluation of patient condition) or independently manage IV medications. These tasks required RN oversight to ensure patient safety. During a review of the facility’s policy and procedure (P&P, official facility rules) titled, “Scope of Vocational Nursing Practice/RN Supervision,” dated October 2025, the P&P indicated, “The RN will provide supervision of the LVN as required by state and federal regulations. Initial admission assessment (first evaluation of patient condition) and care plan formulation (creating a treatment plan) must be performed by the RN. The RN must document each patient at least once per shift (a scheduled work period) or per unit policy, whichever is greater. This assessment may include data collected by the LVN, which the RN has reviewed and discussed with the LVN. The LVN cannot independently formulate a nursing care plan (document outlining patient treatment goals and intervention). A registered nurse shall directly provide patient assessments and document findings in the patient’s medical record for each shift and upon receipt of the patient when transferred to another care area.” During a review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated October 2025, the P&P indicated, “(Name of the facility) shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII, California Licensing and Certification of Health Facilities in the General Acute Care Hospitals.” 1.c. During a concurrent interview and record review on 1/7/2026 at 1:10 p.m. with RN 10 Patient 5’s “History and Physical (H&P), dated 12/23/2025, was reviewed. The H&P indicated Patient 5 presented to the emergency department post mechanical fall (a descent to the ground caused by an external factor such as tripping, slipping, or loss of balance, rather than a medical condition.) During a concurrent interview and record review on 1/7/2026 at 1:10 p.m. with RN 10, Patient 5’s medical record (MR) titled “Nursing Notes,” dated 1/6/2026, was reviewed. The MR indicated there was no RN attestation for the shift assessment or care plan update. RN 10 confirmed that there was no documented evidence that a RN reviewed Patient 5’s MR for 1/6/2026 during the day shift. During an interview on 1/7/2026 at 4:05 p.m. with the Clinical Supervisor of Telemetry (CST, nurse leader overseeing heart monitoring unit), the CST stated the reason for RN sign-off on LVN assessments, care plans, and IV medication was because of California state requirements. CST said LVNs did not have the scope of practice (legal authority) to perform admission assessments (initial evaluation of patient condition) or independently manage IV medications. These tasks required RN oversight to ensure patient safety. During a review of the facility’s policy and procedure (P&P, official facility rules) titled, “Scope of Vocational Nursing Practice/RN Supervision,” dated October 2025, the P&P indicated, “The RN will provide supervision of the LVN as required by state and federal regulations. Initial admission assessment (first evaluation of patient condition) and care plan formulation (creating a treatment plan) must be performed by the RN. The RN must document each patient at least once per shift (a scheduled work period) or per unit policy, whichever is greater. This assessment may include data collected by the LVN, which the RN has reviewed and discussed with the LVN. The LVN cannot independently formulate a nursing care plan (document outlining patient treatment goals and intervention). A registered nurse shall directly provide patient assessments and document findings in the patient’s medical record for each shift and upon receipt of the patient when transferred to another care area.” During a review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated October 2025, the P&P indicated, “(Name of the facility) shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII, California Licensing and Certification of Health Facilities in the General Acute Care Hospitals.” 1.d. During a concurrent interview and record review on 1/7/2026 at 1:11 p.m. with RN 10 Patient 6’s “History and Physical (H&P),” dated 7/23/2025, was reviewed. The H&P indicated Patient 6’s past medical history included Type 2 diabetes mellitus (chronic condition causing high blood sugar), Hyperlipidemia (high cholesterol levels), bipolar disorder (mental health condition with episodes of mood swings), and Dementia (progressive decline in memory and cognitive function). The H&P also indicated Patient 6 was non-compliant with medications (does not take prescribed drugs as directed), Patient 6 was brought in with chief complaints of a mechanical fall (fall caused by tripping or loss of balance, not due to a medical condition). During a concurrent interview and record review on 1/7/2026 at 1:12 p.m. with RN 10, Patient 6’s medical record (MR) titled “Nursing Notes,” dated 1/6/2026, was reviewed. The MR indicated there was no RN attestation for the shift assessment or care plan update. RN 10 confirmed that there was no documented evidence that a RN reviewed Patient 5’s MR for 1/6/2026 during the day shift. During an interview on 1/7/2026 at 4:05 p.m. with the Clinical Supervisor of Telemetry (CST, nurse leader overseeing heart monitoring unit), the CST stated the reason for RN sign-off on LVN assessments, care plans, and IV medication was because of California state requirements. LVNs did not have the scope of practice (legal authority) to perform admission assessments (initial evaluation of patient condition) or independently manage IV medications. These tasks required RN oversight to ensure patient safety. During a review of the facility’s policy and procedure (P&P, official facility rules) titled, “Scope of Vocational Nursing Practice/RN Supervision,” dated October 2025, the P&P indicated, “The RN will provide supervision of the LVN as required by state and federal regulations. Initial admission assessment (first evaluation of patient condition) and care plan formulation (creating a treatment plan) must be performed by the RN. The RN must document each patient at least once per shift (a scheduled work period) or per unit policy, whichever is greater. This assessment may include data collected by the LVN, which the RN has reviewed and discussed with the LVN. The LVN cannot independently formulate a nursing care plan (document outlining patient treatment goals and intervention). A registered nurse shall directly provide patient assessments and document findings in the patient’s medical record for each shift and upon receipt of the patient when transferred to another care area.” During a review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated October 2025, the P&P indicated, “(Name of the facility) shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII, California Licensing and Certification of Health Facilities in the General Acute Care Hospitals.” 1.e. During a concurrent interview and record review on 1/7/2026 at 1:13 p.m. with RN 10, Patient 7’s “History and Physical (H&P),” dated 12/25/2025, was reviewed. The H&P indicated Patient 7 “is a 61-year-old male with a history of Alzheimer’s dementia (progressive memory loss) presented to the ER (Emergency Room) for medical clearance after a 5150 hold (involuntary psychiatric hold for grave disability). Patient reportedly left the facility and was walking in traffic before being detained by law enforcement.” During a concurrent interview and record review on 1/7/2026 at 1:15 p.m. with RN 10, Patient 7’s medical record (MR) titled “Nursing Notes,” dated 1/6/2026, was reviewed. The MR indicated there was no RN attestation for the shift assessment or care plan update. RN 10 confirmed that there was no documented evidence that a RN reviewed Patient 7’s MR for 1/6/2026 during the day shift. During an interview on 1/7/2026 at 4:05 p.m. with the Clinical Supervisor of Telemetry (CST, nurse leader overseeing heart monitoring unit), the CST stated the reason for RN sign-off on LVN assessments, care plans, and IV medication was because of California state requirements. LVNs did not have the scope of practice (legal authority) to perform admission assessments (initial evaluation of patient condition) or independently manage IV medications. These tasks required RN oversight to ensure patient safety. During a review of the facility’s policy and procedure (P&P, official facility rules) titled, “Scope of Vocational Nursing Practice/RN Supervision,” dated October 2025, the P&P indicated, “The RN will provide supervision of the LVN as required by state and federal regulations. Initial admission assessment (first evaluation of patient condition) and care plan formulation (creating a treatment plan) must be performed by the RN. The RN must document each patient at least once per shift (a scheduled work period) or per unit policy, whichever is greater. This assessment may include data collected by the LVN, which the RN has reviewed and discussed with the LVN. The LVN cannot independently formulate a nursing care plan (document outlining patient treatment goals and intervention). A registered nurse shall directly provide patient assessments and document findings in the patient’s medical record for each shift and upon receipt of the patient when transferred to another care area.” During a review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated October 2025, the P&P indicated, “(Name of the facility) shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII, California Licensing and Certification of Health Facilities in the General Acute Care Hospitals.” 2. During a review of Patient 14’s Emergency Department (hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Physician Documentation (ED note, medical notes completed by Emergency Department physician),” dated 2/2/2024, the ED note indicated, Patient 14 presented at facility’s ED with chief complaint of chest pain and nausea (feeling of throwing up). The ED physician note also indicated Patient 14 was admitted to facility’s Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit for further cardiac (heart) observation (monitoring) and treatment. During a review of Patient 14’s “Admission Initial Assessment (patient’s head to toe assessment performed during admission to establish patient’s baseline),” dated 2/2/2024, the “Admission Initial Assessment” indicated, Patient 14’s vital signs (measurements of the body’s most basic function including body temperature, heart rate, blood pressure, respirations and pain level) were: blood pressure (BP) 102/59 millimeters of mercury (mmHg, unit of measure), heart rate 85 beats per minute (bpm), temperature 36.5 degrees Celsius (C, unit of measure), and respiratory rate 18 breaths per minute. During a review of the facility’s Telemetry Unit assignment titled, “Assignment by Room/Bed and Staff Coverage (unit assignment, document to indicate nursing staff assignment to patient),” dated 2/2/2024, the unit assignment record indicated that Patient 14 was assigned to Licensed Vocational Nurse (LVN) 2 and LVN 2 was covered by Charge Nuse (a Registered Nurse who oversaw the patient unit [CN 6]) on 2/2/2024 day shift (7 a.m. to 7 p.m.). During an interview on 1/6/2026 at 11:48 a.m. with Registered Nurse (RN) 17, RN 17 stated the covering RN would take over when the LVN’s patient had a change in condition (clinically important change from a patient’s established and documented baseline [an observation or value that represents the normal or beginning level of a measurable quality] in physical, cognitive, behavioral, or functional domains), performed assessment and was responsible for communicating with the physician. During an interview on 1/6/2026 at 12:02 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated LVN 2 would notify the covering RN or the physician when LVN 2’s patient experienced change in condition. During an interview on 1/6/2026 at 4:23 p.m. with the Director (DOT 6) of Intensive Care Unit (Intensive Care Unit, specialist hospital wards that provide treatment and monitoring for people who are very ill), DOT 6 stated the following: Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) was an early activation in response to a patient’s change in condition to provide interventions to prevent Code Blue (hospital emergency code use to summon help when a patient’s heart stop or a patient stop breathing). Change in condition was when there were acute (new onset, sudden) changes outside the patient’s baseline. It could be sudden increase or decrease of blood pressure, heart rate, respiration rate and decrease in oxygen saturation (O2 Sat, refer to the percentage of oxygen molecules bound to the hemoglobin [type of red blood cell] in the blood). During an interview on 1/7/2026 at 10:32 a.m. with the Director (DOT 1) of Telemetry, DOT 1 stated the following: it was not under LVN’s scope of practice (services and activities a licensed professional is legally allowed to perform) to perform assessment and reassessment on patients. DOT 1 stated LVNs could only collect patient’s data for the Registered Nurses to review. During a concurrent interview and record review on 1/6/2026 at 3:02 p.m. with Clinical Nurse Supervisor (CNS) 1, Patient 14’s nurse notes, dated 2/2/2024, were reviewed. The nurse notes indicated the following: -At 6:50 p.m. - “patient (Patient 14) resting in bed complained of being cool and shortness of breath. Blood pressure was 82/59 mmHg, heart rate was 56 [bpm] (normal range 60 to 100) and oxygen saturation of 89% (normal range 95 - 100 %, levels below 90 % may indicate hypoxia [low oxygen level] and require medical attention) Charge nurse (CN 6) aware ... Nurse Practitioner (NP) was paged. Waiting for the return call;” -At 7 p.m. - “BP 80s (referring to the systolic blood pressure, the top number of blood pressure [normal range 90 - 140]). Physician (MD 10) called and made aware, new orders given and carried out.” -At 7:05 p.m. - “charge nurse (CN 6) called to house sup (house supervisor) for ICU bed. Physician (MD 10) ordered transfer [Patient 14] to ICU;” -At 7:15 p.m. - “called RRT, BP still low and HR 50s;” -At 7:50 p.m. - “patient (Patient 14) was intubated by MD. BP continue low 60s HR 56;” -At 8:20 p.m. - “patient (Patient 14) transferred to MICU (Medical ICU, a branch of ICU) via bed in stable condition.” -CNS 1 stated the following: Patient 14 had a change in condition at 6:50 p.m. due to changing vital signs and experiencing shortness of breath. All nurse notes entries from 7 p.m. to 8:20 p.m. were made by LVN 2. There was no Registered Nurse assessment or note regarding Patient 14’s change in condition. During an interview on 1/7/2025 at 11:06 a.m. with Nurse Practitioner (NP), NP stated the following: Patient 14 had a change in condition on 2/2/2024 at 6:50 p.m. and RRT was called at 7:15 p.m. If nursing staff could not get a response from the provider, the nursing staff should call RRT right away. NP stated, “the RRT call seemed a little too late for this patient (Patient 14).” During an interview on 1/8/2026 at 11:25 a.m. with Registered Nurse (RN) 9, RN 9 stated the following: when the LVN’s patient had change in condition, the LVN must inform the covering RN. The covering RN would perform assessment on the patient and determine what was going on and escalate care as indicated including notifying physicians and activating RRT. The covering RN should document the assessment and interventions. RN 9 further stated, “If it was not documented, it was not done.” During an interview on 1/8/2026 at 3:19 p.m. with the Director of Nursing (DON), DON stated RN assessment was needed when patient experienced change in condition. DON further stated, the RN would assess the situation and determine if MD notification, RRT and/or other interventions would be warranted. During a review of Patient 14’s “Consultation Note,” dated 2/2/2024, the “Consultation Note” indicated, “ [MD 11] was called to the tele (telemetry unit) and found patient (Patient 14) to have altered mental status (thinking and awareness were more impaired than usual) and respiratory failure (a serious condition that makes it difficult for patient to breathe on their own) ... was called to help and intubating (to insert a flexible plastic tube [endotracheal tube] through the mouth or nose into the windpipe [trachea] to maintain an open airway and deliver oxygen) this patient (Patient 14) ... Intubation was performed without complications ... care transferred back to primary team, patient (Patient 14) moved to ICU.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated, “Purpose: To identify patient specific problems for the development and implementation of a plan of care, incorporating assessment and continuing reassessment findings in order to adjust the plan of care accordingly of the needs of the patient ... Guidelines ... 3. All patients will receive an initial assessment to determine care needs and further assessment ... 5. A registered nurse assesses the patient’s needs for nursing care in all settings where nursing care is provided ... 9. Reassessment occurs at regular intervals and will be defined by each discipline, based on patient’s diagnosis, care setting, significant changes in condition, and response to any previous care in order to determine the patient’s response to intervention.” During a review of the facility’s policy and procedure (P&P) titled, “Licensed Vocational Nurse, Scope of Practice,” dated 4/2024, the P&P indicated, “The responsible RN must delegate tasks within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ... Nursing Process/Documentation ... 5.1 Initial admission assessment and care plan formulation must be performed by the RN. 5.2 The RN must document on each patient at least once per shift or per unit policy, whichever is greater. This assessment may include data which is collected by the LVN, which the RN has reviewed and discussed with the LVN ... 5.8 A registered nurse shall directly provide patient assessment and the findings will be documented in the patient’s medical record, for each shift and upon receipt of the patient when he/she is transferred to another patient care area. 5.9. Supervision of the LVN: RN intervenes as necessary if task if being performed improperly. Ensures appropriate documentation of delegated tasks. Monitor performance to assure compliance with established practice standards, policies and procedures.” During a review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team (RRT),” dated 7/2023, the P&P indicated, “The purpose of Rapid Response Team (RRT) is to provide expert assessment, early intervention and stabilization for patients and prevent clinical deterioration or arrest ... 5. Criteria for RRT activation includes, but is not limited to, the following: 5.1 Hemodynamically unstable: 5.1.1 HR (heart rate) less than 40 and/or greater than 150; 5.1.2. 10 -20 mmHg from baseline blood pressure ... 5.6 Patient is in distress; increase in patient deterioration; or staff member concern about the patient’s condition.””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 46333 Based on observation, interview, and record review, the facility failed to ensure that the patient care assignment for three (3) of three (3) sampled patients (Patient 24, Patient 31, and Patient 32), who were on one-to-one observation (continuous, direct supervision by a staff member assigned to a single patient for safety), ensured that the patients (Patient 24, Patient 31, and Patient 32) were continuously monitored, in accordance with the facility’s policy and procedure (P&P) titled, “Observation Attendant (Sitter) Usage Assessment and Implementation.” Specifically, staff members were assigned to monitor all three patients located in two separate rooms, which may have limited the ability to maintain continuous visual observation (uninterrupted direct sight of the patient at all times) of each patient as outlined in facility policy. This deficient practice places patients at risk for harm, including self-injury (when a patient intentionally hurts themselves) or elopement (when a patient leaves the hospital or care area without permission or supervision). Findings: 1.a. During a concurrent observation and interview on 1/6/2026 at 10:38 a.m. in the hallway of the Emergency Department (ED, the hospital area where urgent and emergency care is provided), with the Director of Nursing (DON, the nurse leader responsible for nursing services), the DON stated, “This is where behavioral health patients (patients with mental health or behavioral conditions) are placed, beds 19 through 22.” Surveyor observed Patient 31 and Patient 32 in Room 20, and Patient 24 in Room 21, which was adjacent (next to) Room 20. One staff member, EMT 3 (Emergency Medical Technician, a trained healthcare worker who provides emergency medical care and transportation for patients in urgent situations), was seated in the hallway with their back to Room 21 (where one patient was lying in bed with covers over the head) and facing toward Room 20 (where two patients were lying in bed).There were approximately 20-minute periods when Patient 24 was not in direct visual contact (not able to be seen directly at all times) with EMT 3 (during the time when EMT 3 was positioned with their back facing Patient 24’s room). The DON stated that the sitter (a staff member assigned to provide constant observation for safety) may observe several patients at a time, as long as those patients did not come into the hospital due to suicidal reasons (suicidal ideation, meaning thoughts or plans to harm oneself). During an observation on 1/6/2026 at 11:00 a.m. in the hallway of the ED, EMT 3 continued (about 20 minutes later) in the same position, standing outside the doorway of Room 20 and Room 21, about 15 - 17 feet (4.5-5 meters) from the three patients (Patient 24, Patient 31, and Patient 32), with their (EMT 3) back facing toward Room 21, and a portable computer in front of them (EMT 3). During a concurrent interview and record review on 1/6/2026 at 11:00 a.m. with EMT 3 (in the presence of the DON), Patient 24, Patient 31, and Patient 32’s electronic medical record (EMR, the digital version of a patient’s paper chart) document titled “Reason for Visit,” was reviewed. EMT 3 confirmed that the medical record for all three patients indicated that they were in the ED due to suicidal concern (suicidal ideation, meaning thoughts or plans to harm oneself). EMT 3 also stated that currently they (EMT 3) were sitting for all three patients in two separate rooms. EMT 3 stated that usually sitters will monitor up to two patients who were on suicidal watch (close observation for patients at risk of self-harm) at a time. EMT 3 stated that they do not have direct visual of all three patients because they (referring to the patients) were in two separate rooms. During a review of Patient 24’s “Orders,” dated 1/6/2026 at 12:32 a.m., the physician orders indicated that Patient 24 was ordered to have a sitter (a staff member assigned to provide constant observation for safety). During a review of Patient 24’s “History and Physical (H&P, a summary of the patient’s medical history and examination),” dated 1/6/2026, the H&P indicated that Patient 24 presented to the ED for suicidal ideation (thoughts or plans to harm oneself). The H&P further indicated, “Patient states that they have a history of previous suicide attempts (past actions to try to end their own life) and that during their last attempt, they attempted to run into traffic.” During a review of Patient 24’s EMR, document titled “Care Activity - Assessments,” dated 1/6/2026, the assessment indicated, “Observation levels: Line of Sight” (the patient must be kept in direct view at all times). During a review of Patient 24’s EMR, document titled “CSSRS Screener (Columbia-Suicide Severity Rating Scale, an evidence-based assessment tool that evaluates suicidal ideation and behavior. Questions are phrased for use in an interview format but can be completed as a self-report measure if necessary),” dated 1/6/2026, the CSSRS screen results indicated that Patient 24 was at “High Risk” (a patient identified as having a significant risk of attempting to end their own life) for suicide. During an interview on 1/15/2026 at 4:18 p.m. with the Clinical Supervisor, Telemetry (a hospital unit that monitors patients’ heart rhythms), the Clinical Supervisor stated, “A sitter (a staff member assigned to provide constant observation) for a suicidal patient (a patient identified as being at risk of self-harm or suicide) cannot be assigned to different rooms for safety reasons. You must have line of sight (the ability to see the patient directly at all times) at all times. The patient is at risk of harming themself (self-injury) if visual observation is not continuous (uninterrupted). For patients who have screened as high risk for suicide (patients identified through assessment as having a significant risk of attempting to end their own life), they require one-to-one observation, direct, constant observation (continuous, face-to-face monitoring without breaks) and must have suicide prevention strategies (specific interventions to reduce the risk of self-harm, such as removing dangerous objects and providing a safe environment) initiated.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights & Responsibilities,” dated January 2025, the P&P indicated the following: Patient have the right to receive care in a safe setting. During a review of the facility’s policy and procedure (P&P) titled, “Observation Attendant (Sitter) Usage Assessment and Implementation,” dated October 2025, the P&P indicated, “The Suicide Risk Assessment Policy will be followed for all patients who are a danger to self/others, suicidal, suicidal ideation (i.e., 5150 HOLD patient [a legal hold for patients at risk of harming themselves or others]). The screening/risk assessment will determine the level of constant observation ...Continuous Direct Observation is indicated to prevent patients, who are uncooperative, unable or unwilling to follow instructions, from injuring themselves and/or others, and to promote healing. Initiation of one-to-one (1:1) observation occurs only after multiple alternatives have been tried except in cases of suicidal/homicidal ideation where 1:1 observation becomes an immediate need ...One-to-one (1:1) observation means one competent observer to one patient a) within line of sight and close proximity, b) with no physical barriers, and c) in the same room/area (with a 360-degree view of patient and their surroundings). Close proximity requires that observation be close enough for the observer to react to the patient’s behavior as it occurs, without delay (i.e., within a full leg’s length distance, approximately 3-5 feet).” During a review of the facility’s policy and procedure (P&P) titled, “Suicidal/Homicidal Ideation Risk Assessment,” dated October 2025, the P&P indicated, “The facility will properly identify and assess the level of suicide risk a patient presents with, implement safety precautions, provide interventions appropriate to the level of risk identified, and develop a safe and individualized discharge plan utilizing all necessary resources ... If a person screens positive during the initial screening, a determination will be made as to the degree of risk (low, moderate, high) and the required observation level along with the implementation of the appropriate suicide prevention strategies associated with the level of risk. High Risk Severity: Patient with suicidal ideation with intent or intent with a plan in the past month or suicidal behavior within the past 3 months. Patient requires direct, constant observation as well as have suicide prevention strategies initiated.” 1.b. During a review of Patient 31’s “Orders,” dated 1/6/2026 at 12:32 a.m., the physician orders (instructions from a doctor regarding patient care) indicated that Patient 31 was ordered to have a sitter (a staff member assigned to provide constant observation for safety). During a review of Patient 31’s “History and Physical (H&P),” dated 1/6/2026, the H&P indicated that Patient 31 presented to the Emergency Department (ED, the hospital area where urgent and emergency care is provided) for suicidal ideation (thoughts or plans to harm oneself). The H&P further indicated, “The patient (Patient 31) endorses active plan to cut himself. He states his last suicide attempt was approximately 1 year ago where he tried to cut himself. The patient (Patient 31) also endorses hearing auditory hallucinations (hearing voices or sounds that are not actually present) that are instructing him to kill himself.” During a review of Patient 31’s electronic medical record (EMR) document titled “Care Activity - Assessments,” dated 1/6/2026, the assessment indicated, “Observation levels: Line of Sight” (the patient must be kept in direct view at all times). During a concurrent interview and record review on 1/8/2026 at 11:44 a.m. with Registered Nurse (RN) 10, Patient 31’s EMR, document titled “CSSRS Screener,” dated 1/6/2026, was reviewed. RN 10 confirmed that the CSSRS screen results indicated that Patient 31 was at “High Risk” (a patient identified as having a significant risk of attempting to end their own life) for suicide. During an interview on 1/15/2026 at 4:18 p.m. with the Clinical Supervisor, Telemetry, the Clinical Supervisor stated, “A sitter for a suicidal patient cannot be assigned to different rooms for safety reasons. You must have line of sight (the ability to see the patient directly at all times) at all times. The patient is at risk of harming themself (self-injury) if visual observation is not continuous (uninterrupted). For patients who have screened as high risk for suicide (patients identified through assessment as having a significant risk of attempting to end their own life), they require one-to-one observation, direct, constant observation (continuous, face-to-face monitoring without breaks) and must have suicide prevention strategies (specific interventions to reduce the risk of self-harm, such as removing dangerous objects and providing a safe environment) initiated.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights & Responsibilities,” dated January 2025, the P&P indicated the following: Patient have the right to receive care in a safe setting. During a review of the facility’s policy and procedure (P&P) titled, “Observation Attendant (Sitter) Usage Assessment and Implementation,” dated October 2025, the P&P indicated, “The Suicide Risk Assessment Policy will be followed for all patients who are a danger to self/others, suicidal, suicidal ideation (5150 HOLD patient [a legal hold for patients at risk of harming themselves or others]). The screening/risk assessment will determine the level of constant observation ...Continuous Direct Observation is indicated to prevent patients, who are uncooperative, unable or unwilling to follow instructions, from injuring themselves and/or others, and to promote healing. Initiation of one-to-one (1:1) observation occurs only after multiple alternatives have been tried except in cases of suicidal/homicidal ideation where 1:1 observation becomes an immediate need ...One-to-one (1:1) observation means one competent observer to one patient a) within line of sight and close proximity, b) with no physical barriers, and c) in the same room/area (with a 360-degree view of patient and their surroundings). Close proximity requires that observation be close enough for the observer to react to the patient’s behavior as it occurs, without delay (i.e., within a full leg’s length distance, approximately 3-5 feet).” During a review of the facility’s policy and procedure (P&P) titled, “Suicidal/Homicidal Ideation Risk Assessment,” dated October 2025, the P&P indicated, “The facility will properly identify and assess the level of suicide risk a patient presents with, implement safety precautions, provide interventions appropriate to the level of risk identified, and develop a safe and individualized discharge plan utilizing all necessary resources ... If a person screens positive during the initial screening, a determination will be made as to the degree of risk (low, moderate, high) and the required observation level along with the implementation of the appropriate suicide prevention strategies associated with the level of risk. High Risk Severity: Patient with suicidal ideation with intent or intent with a plan in the past month or suicidal behavior within the past 3 months. Patient requires direct, constant observation as well as have suicide prevention strategies initiated.” 1.c. During a review of Patient 32’s “Orders,” dated 1/5/2026 at 9:08 a.m., the physician orders (instructions from a doctor regarding patient care) indicated that Patient 32 was ordered to have a sitter (a staff member assigned to provide constant observation for safety). During a review of Patient 32’s “History and Physical (H&P),” dated 1/5/2026, the H&P indicated that Patient 32’s medical history included schizophrenia (a chronic mental health disorder characterized by hallucinations, delusions, and disorganized thinking), who presented for suicidal ideation (thoughts or plans to harm oneself) and auditory hallucinations (hearing voices or sounds that are not actually present). Patient 32 was placed on a 5150 hold (a legal hold for patients at risk of harming themselves or others) for danger to self. During a review of Patient 32’s EMR, document titled “Care Activity - Assessments,” dated 1/5/2026 through 1/6/2026, the assessment indicated, “Observation levels: Line of Sight” (the patient must be kept in direct view at all times). During a concurrent interview and record review on 1/8/2026 at 11:44 a.m. with Registered Nurse (RN) 10, Patient 32’s EMR, document titled “CSSRS Screener,” dated 1/6/2026, was reviewed. RN 10 confirmed that the CSSRS screen results indicated that Patient 32 was at “High Risk” (a patient identified as having a significant risk of attempting to end their own life) for suicide. During an interview on 1/15/2026 at 4:18 p.m. with the Clinical Supervisor, Telemetry, the Clinical Supervisor stated, “A sitter for a suicidal patient cannot be assigned to different rooms for safety reasons. You must always have line of sight. The patient is at risk of harming themself if visual observation is not continuous for patients who have screened as high risk for suicide, they require one-to-one observation, direct, constant observation and must have suicide prevention strategies initiated.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights & Responsibilities,” dated January 2025, the P&P indicated the following: Patient have the right to receive care in a safe setting. During a review of the facility’s policy and procedure (P&P) titled, “Observation Attendant (Sitter) Usage Assessment and Implementation,” dated October 2025, the P&P indicated, “The Suicide Risk Assessment Policy will be followed for all patients who are a danger to self/others, suicidal, suicidal ideation (5150 HOLD patient [a legal hold for patients at risk of harming themselves or others]). The screening/risk assessment will determine the level of constant observation ...Continuous Direct Observation is indicated to prevent patients, who are uncooperative, unable or unwilling to follow instructions, from injuring themselves and/or others, and to promote healing. Initiation of one-to-one (1:1) observation occurs only after multiple alternatives have been tried except in cases of suicidal/homicidal ideation where 1:1 observation becomes an immediate need ...One-to-one (1:1) observation means one competent observer to one patient a) within line of sight and close proximity, b) with no physical barriers, and c) in the same room/area (with a 360-degree view of patient and their surroundings). Close proximity requires that observation be close enough for the observer to react to the patient’s behavior as it occurs, without delay (i.e., within a full leg’s length distance, approximately 3-5 feet).””

“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: 50594 Based on interview and record review, the facility failed to: 1. Ensure that one of 38 sampled patient’s (Patient 25) physician was notified, in accordance with the facility’s protocol regarding physician notification, regarding Patient 25’s refusal of a blood sugar check prior to discharge, when Patient 25’s last known blood sugar level was 320 (normal range is 70-100 milligrams per deciliter) and received insulin (medication used to control blood sugar). This deficient practice had the potential to delay necessary interventions for managing high or low blood sugar levels, which may lead to patient harm. 2. Ensure that nursing staff followed the facility’s policies and procedures for one of 38 sampled patients (Patient 33) when: 2.a. Nursing staff failed to report and document notifying the physician about a critical high troponin value (a protein released when the heart muscle is damaged), as required by the facility’s policy on critical value notifications. 2.b. Pain assessment (evaluation of pain, typically on a scale from 0 to 10) was not completed and documented, in accordance with the facility’s procedure on pain assessment documentation. 2.c. Nursing staff failed to monitor, interpret (to analyze the heart’s electrical activity in real-time to identify the heart rate, rhythm regularity, and any abnormal patterns), and communicate to the physician, changes in Patient 33’s cardiac status (the current functional state, health, and efficiency of a patient’s heart and blood vessels) and heart rate observed on a telemetry monitor (a device used to remotely monitor a patient’s heart rhythm), in accordance with the facility’s policy regarding change of condition notification of a physician. The cumulative effect of these deficient practices had the potential to compromise Patient 33’s health and safety, delay treatment, resulting in an increased risk of exacerbation (sudden worsening) of Patient 33’s condition, unmanaged pain and discomfort, and increased likelihood of complications such as cardiac events or other critical developments. 3. Ensure one of 38 sampled patient’s (Patient 34) nursing documentation regarding Patient 34’s leaving against medical advice (AMA, when a patient chooses to leave the hospital before the treating physician recommends discharge) included a documentation of discussion with the patient regarding the risks of leaving against medical advice, in accordance with the facility’s protocol in ensuring medical record completeness for AMA documentation. This deficient practice had the potential to compromise Patient 34’s right to make a fully informed decision and understanding of the potential consequences of leaving AMA. Additionally, the lack of proper documentation regarding the discussion of risks when leaving against medical advice could negatively impact Patient 34’s record keeping that may have compromised the continuity of care and Patient 34’s medical history and treatment decisions. 4. Ensure that nursing staff followed the facility’s policy titled, “RN Standardized Procedure: Hyper/Hypoglycemia,” for one of 38 sampled patients (Patient 26) when: 4.a There was no nurse to physician communication regarding Patient 26’s low blood sugar 4.b. Patient 26’s blood sugar was in the 60s and was not monitored every 15 minutes until the blood sugar was within normal range (70-100 milligrams [mg, a unit of measure] per deciliter [dL, a unit of measure]) These deficient practices had the potential for Patient 26’s blood sugar to drop further which may lead to a severe negative outcome such as a rapid response (a hospital system designed to identify and respond to patients with early signs of clinical deterioration) and/or death. 5. Ensure its nursing staff followed up with the Speech Therapist (a licensed healthcare professional who diagnoses and treats communication, language, cognitive, and swallowing disorders in individuals of all ages) to make sure a STAT (a medical abbreviation for immediately or without delay) swallow evaluation (to evaluate a person’s ability to swallow food) was done per physician order, in a timely manner, for one of 38 sampled patients (Patient 16), in accordance with facility’s policy regarding chain of command. This deficient practice resulted in Patient 16 not getting food from 9/11/2025 until 9/12/2025 evening while in the facility. 6. Ensure nursing staff followed the six (6) Rights (The 6 Rights of Medication Administration are essential safety checks to prevent medication errors: Right Drug, Right Dose, Right Time, Right Route, Right Patient and Right Documentation) of medication administration on one of 38 sampled patients (Patient 19), in accordance with facility and procedure (P&P) titled, “Medication Administration (Management),” when Registered Nurse (RN) 4 failed to document the administration of Patient 19’s clonidine (medication to lower blood pressure) on 8/19/2025. This deficient practice had the potential for double dosing Patient 19 due to lack of proper documentation. Findings: 1. During a review of Patient 25’s “Face sheet (provides demographic information such as admission and discharge date and time),” undated, the record indicated Patient 25 was admitted to the facility on 10/5/2025 and discharged on 10/7/2025 at 5:00 p.m. During a record review of Patient 25’s “History and Physical,” dated 10/5/2025, the record indicated Patient 25 was admitted to the facility for failure to thrive (a syndrome of decline in older adults marked by weight loss, poor appetite, inactivity, and social withdrawal). Patient 25 had a medical history of diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN, high blood pressure). During a review of Patient 25’s “Point of Care Testing (medical diagnostic testing to check a patient’s blood sugar level),” dated 10/5/2025, the record indicated Patient 25 had an order for fingerstick (finger is poked by a needle to get a blood sample to read the blood sugar) before meals and at bedtime (ACHS). During a concurrent interview and record review on 1/7/2025 at 2:20 p.m. with Registered Nurse (RN) 3, Patient 25’s “Point of Care (POC) Glucose (blood sugar) - History,” and “Medication Administration Record (MAR),” both dated 10/7/2025, were reviewed. The “POC Glucose-History” record indicated Patient 25’s last blood sugar check was at 12:21 p.m., with a blood sugar level of 320 (normal range is 70-100 milligrams per deciliter). The “MAR” indicated Patient 25 received Insulin Human Lispro (medication used to control blood sugar) 10 units (a unit of measure) subcutaneous (under the skin) for the blood sugar level of 320. RN 3 confirmed there was no recheck of blood sugar level after Patient 25 received 10 units of insulin and prior to discharge (10/7/2025). During the same concurrent interview and record review on 1/7/2025 at 2:20 p.m. with RN 3, RN 3 stated she (RN 3) would have rechecked Patient 25’s blood sugar and talked to the doctor prior to discharging Patient 25 regarding Patient 25’s refusal to have the blood sugar checked prior to discharge. RN 3 also stated that documentation was crucial for ensuring safety and demonstrating the staff’s efforts to address the concern with Patient 25’s refusal regarding blood sugar check prior to discharge. RN 3 stated that it was important to record a patient’s (Patient 25) refusal because patients have rights. RN 3 further stated there might have been a lack of knowledge about managing conditions like blood sugar control and hyperglycemia (high blood sugar level) on the part of Patient 25, hence the refusal. During a concurrent interview and record review on 1/8/2025 at 10:58 a.m. with Registered Nurse (RN) 9, Patient 25’s “Point of Care (POC) Glucose (blood sugar) - History,” dated 10/7/2025, was reviewed. RN 9 confirmed Patient 25 refused the 4:40 p.m. blood sugar check and 12:21 p.m. was the last blood sugar check prior to discharge on 10/7/2025 at 5:00 p.m. During the same interview and record review on 1/8/2025 at 10:58 a.m. with RN 9, RN 9 stated the provider should be contacted and informed if the patient refused labs (laboratory tests), medications, or other care, and the patient refusal should be documented. RN 9 stated it would be important to notify the physician regarding treatment refusal prior to the patient leaving because the doctor would need to know what was going on with the patient, and if there was anything else that could have been done. RN 9 stated that without communication with the physician, the patient’s condition could have worsened, making treatment difficult. During a review of the facility’s policy and procedure (P&P), titled “Chain of Command,” dated 10/2025, the P&P indicated that: “-The Medical Staff Rules and Regulations define the Attending (treating) and the On-Call physician’s responsibility to respond, examine and treat patients with medical conditions in a timely manner. Registered Nurses (RN) and other associates (including non-nursing disciplines) work collaboratively with physicians to assist the patient in reaching optimal health outcomes during their hospital stay. -In situations requiring acute medical care and the presence of a physician, it will be the responsibility of the RN or other associates (including non-nursing disciplines) caring for the patient to contact the treating primary or on-call physician immediately and report the condition of the patient. -If unable to elicit timely (specified time frame) and appropriate physician response, the RN or other associates (including non-nursing disciplines) shall implement the chain of command. -Patient care shall not be delayed. There shall be prompt progression through the chain of command to meet patients’ needs. -Documentation in the medical record should reflect all notifications or attempted notifications, the individuals contacted, and the times. -All refusals or failures by the primary or on-call physician to respond will be reported to the Quality/Risk Departments and the Medical Staff Office for appropriate follow-up action. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Documentation,” dated 10/2025, the P&P indicated, “Narrative charting must address problems identified in the problem list. Nursing care and activities must be implemented to resolve identified problems and patient responses documented. Documentation should also include at a minimum, notification of physicians ...” 2.a. During a review of Patient 33’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 11/21/2025, the H&P indicated that Patient 33 was admitted to the facility due to weakness. The H&P also indicated that Patient 33 had a past medical history (PMH, a summary of a patient’s previous health issues, surgeries, and treatments) of end-stage renal disease (ESRD, the final phase of chronic kidney disease where the kidneys can no longer support the body’s needs), was on hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and had hypertension (persistently elevated blood pressure). Patient 33 was also found to be hyperkalemic (having an abnormally high level of potassium in the blood) and had missed a few dialysis sessions (a treatment that filters and purifies the blood using a machine, which is necessary when the kidneys are not functioning properly). During further review of Patient 33’s History and Physical (H&P), dated 11/21/2025, the H&P also indicated that Patient 33 required a cardiology (the medical specialty focusing on the diagnosis, treatment, and prevention of diseases related to the heart and blood vessels) consultation due to atrial fibrillation with rapid ventricular response (AFib with RVR, an irregular and often rapid heart rate that can lead to poor blood flow and requires prompt medical attention to manage and stabilize the heart rate). During a review of Cardiology Consultation Note, dated 11/22/2025, the note indicated that the cardiologist made the following recommendations: The cardiologist recommended continuous cardiac telemetry monitoring, which uses devices to automatically transmit the patient’s heart rhythm and electrical activity to healthcare professionals for real-time observation. The note further indicated that the plan included trending troponin (Troponins are proteins released into the blood when the heart muscle is damaged, making them essential biomarkers for detecting heart attacks) levels (trending troponin levels meant measuring blood levels of this protein over several hours to detect if heart muscle damage is actively occurring, rising, or falling. Elevated levels indicate heart damage, most commonly due to a heart attack) every 2 hours for 3 cycles or until peak levels were reached. During a review of Patient 33’s Blood Result Values, dated 11/22/2025, at 3:36 p.m., the results indicated that Patient 33’s troponin level was 314 ng/L (nanograms per liter, a unit used to measure the concentration of troponin in blood; Normal levels range from 3-53 ng/L, so 314 ng/L is considered critically high. Prompt communication to the nurse ensures immediate awareness and appropriate follow-up, as elevated troponin may indicate a heart attack or other cardiac stress). This critical troponin result was communicated to the nurse at 4:45 p.m. on 11/22/2025. During an interview on 1/6/2026 at 10:53 a.m. with the Director of Laboratory Services (DOT 8), DOT 8 reviewed the troponin order placed by the cardiologist on 11/22/2025 and confirmed that the cardiologist (MD 5) did not order trending troponin but placed an order for obtaining a troponin level as a random order. DOT 8 also verified that a troponin of 314 ng/L was considered high, and critical high results were communicated to the nurse with the date and time documented. During a review of Patient 33’s Nursing Progress note, dated 11/22/2025 at 6:00 p.m., the note indicated the following: “[phone number] called provider to inform of troponin level 314 ...left message ... will continue to monitor ...not in distress ...call light in reach ...” During a review of Patient 33’s Nursing Progress note, dated 11/24/2025, at 8:47 p.m., the note indicated the following: “attending (MD 10) was notified of troponin of 314 ...voice message left for MD 10 ...” During a concurrent interview and record review on 1/6/2025 at 11:03 a.m. with the Program Coordinator for Quality Assurance (PCQA), the PCQA confirmed that the documentation of leaving voice messages to the physician on 11/22/2025 at 6:00 p.m. and on 11/24/2025 at 8:47 p.m. did not indicate that the physician actually received and confirmed receiving the critical value results for troponin levels. During an interview on 1/6/2026 at 11:54 a.m. with the charge nurse (CN 5), CN 5 stated that when she (CN 5) receives a critical lab result, she (CN 5) documents the notification to the physician and monitors the patient to ensure stability. CN 5 said that she (CN 5) should keep trying to contact the physician, and if unable to reach them, escalate to the house supervisor using the chain of command, usually after 30-60 minutes. During an interview on 1/7/2026 at 10:53 a.m. with the Director of Telemetry Services (DOT 1), DOT 1 stated that when there was a critical lab value reported to nurses: -“If they call a physician and there is no answer within 30 minutes ... High troponin, for instance, call the physician, activate the chain of command: charge nurse, then house supervisor, and clinical supervisor ... and then supervising physician and then chair of the department ... The nurses should document the attempts ... Total time to report the results is about an hour ... And escalation would be documented as well. It is the expectation ...” -DOT 1 also said that a delay in communicating critical lab values can compromise patient safety and cause delays in treatment. During a review of the facility’s policy and procedure (P&P) titled “Critical Values,” dated 10/2025, the P&P indicated the following: 1. The “Critical Test Result” form is placed on the physician progress notes. a. The form is completed by the licensed nurse accepting the result. It includes the patient’s name, date/time of test, results of the test, name of the person reporting the result, time reported, and name of the licensed nurse receiving the report. 2. The time of physician notification and response is documented on the critical value form. a. If the physician does not respond within 30 minutes, the chain of command is activated. 3.Action taken and/or physician’s response/order is written in the physician orders sheet. 4.All critical test results will be communicated to the appropriate provider within one hour of receiving the test results. During a review of the facility’s policy and procedure (P&P) titled “Chain of Command,” dated 10/2025, the P&P indicated that: “-The Medical Staff Rules and Regulations define the Attending (treating) and the On-Call physician’s responsibility to respond, examine and treat patients with medical conditions in a timely manner. Registered Nurses (RN) and other associates (including non-nursing disciplines) work collaboratively with physicians to assist the patient in reaching optimal health outcomes during their hospital stay. -In situations requiring acute medical care and the presence of a physician, it will be the responsibility of the RN or other associates (including non-nursing disciplines) caring for the patient to contact the treating primary or on-call physician immediately and report the condition of the patient. -If unable to elicit timely (specified time frame) and appropriate physician response, the RN or other associates (including non-nursing disciplines) shall implement the chain of command. -Patient care shall not be delayed. There shall be prompt progression through the chain of command to meet patients’ needs. -Documentation in the medical record should reflect all notifications or attempted notifications, the individuals contacted, and the times. -All refusals or failures by the primary or on-call physician to respond will be reported to the Quality/Risk Departments and the Medical Staff Office for appropriate follow-up action. 2.b. During a review of Patient 33’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 11/21/2025, the H&P indicated that Patient 33 was admitted to the facility due to weakness. The H&P also indicated that Patient 33 had a past medical history (PMH, a summary of a patient’s previous health issues, surgeries, and treatments) of end-stage renal disease (ESRD, the final phase of chronic kidney disease where the kidneys can no longer support the body’s needs), was on hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and had hypertension (persistently elevated blood pressure). Patient 33 was also found to be hyperkalemic (having an abnormally high level of potassium in the blood) and had missed a few dialysis sessions (a treatment that filters and purifies the blood using a machine, which is necessary when the kidneys are not functioning properly). During an interview on 1/7/2025 at 10:59 a.m. with the Director of Telemetry (DOT 1), DOT 1 said: “Pain is part of VS (Vital Signs, a set of key clinical measurements including temperature, pulse, respiration, blood pressure, and pain level). Pain is assessed every 4 hours, at every shift, and re-assessment is required. Pain level, type of pain, location, duration, and effect of pain must be documented. When pain is present, we determine whether intervention is needed or if further intervention is required, and we report to the physician because additional treatment may be necessary. Pain can be a symptom of an underlying condition, so it is important to assess and address pain promptly.” During a concurrent interview and record review on 1/5/2026 at 11:47 a.m. with Program Coordinator Quality Assurance (PCQA), Patient 33’s pain assessment records, dated 11/20/2025 through 11/25/2025, were reviewed. The records indicated the following: -On 11/20/2025 at 8:00 p.m.: Pain was documented as 10/10 (Pain scale: Numeric Rating Scale from 0-10, where 0 = no pain and 10 = worst possible pain; a score of 10/10 indicates severe, unbearable pain). Medication given. No further information regarding pain assessment criteria was recorded (Pain assessment should also include location, type/character of pain, duration, factors that worsen or relieve pain, and effect on function). -On 11/21/2025 at 4:00 p.m.: Pain level documented as 9/10 (very severe pain). Medication given. No other information was recorded in this pain assessment regarding other pain assessment criteria such as location, type of pain, or duration. -On 11/22/2025 at 12:00 a.m.: Pain was 10/10. Medication given. No other information was recorded in this pain assessment. -On 11/22/2025 at 8:00 p.m.: Pain was 10/10. Medication given. No other information was recorded in this pain assessment. -On 11/23/2025: Pain was 8/10 (moderate to severe pain). Medication given. No other information was recorded in this pain assessment. -On 11/25/2025: Pain was 9/10. Medication given. No other information was recorded in this pain assessment. -PCQA then reviewed nursing notes, dated 11/20/2025 through 11/25/2025, to ensure there was no clarification documentation entered by the nurses to explain the location of Patient 33’s pain on the days when Patient 33 complained of pain. PCQA stated that on 11/23/2025 at 8:00 p.m., Patient 33 complained of pain in the left arm, and on 11/24/2025 at 1:00 a.m., Patient 33 complained of pain in the left arm again, and the physician (MD 10) was notified. During further interview on 1/5/2026 at 11:47 a.m. with the Program Coordinator for Quality Assurance (PCQA), PCQA said that nurses should document the location of pain and complete the pain assessment. PCQA stated that, aside from two instances of documented left arm pain (on 11/23/2025 and 11/24/2025), there was no other explanation Patient 33’s pain origin and location based on documented assessments from 11/20/2025 to 11/25/2025. During a review of the facility’s policy and procedure (P&P) titled “Pain Management,” dated 10/2025, the P&P indicated that, “The single most reliable indicator of the existence and intensity of pain is the patient’s self-report. A comprehensive pain assessment is conducted as appropriate to the patient’s condition and the scope of care, treatment, and services. Patients will define their goals for pain relief and participate in a plan of care to achieve these goals.” 2.c. During a review of Patient 33’s History and Physical (H&P, the most formal assessment of the patient and the problem), dated 11/21/2025, the H&P indicated that Patient 33 was admitted to the facility due to weakness. The H&P also indicated that Patient 33 had a past medical history (PMH, a summary of a patient’s previous health issues, surgeries, and treatments) of end-stage renal disease (ESRD, the final phase of chronic kidney disease where the kidneys can no longer support the body’s needs), was on hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and had hypertension (persistently elevated blood pressure). Patient 33 was also found to be hyperkalemic (having an abnormally high level of potassium in the blood) and had missed a few dialysis sessions (a treatment that filters and purifies the blood using a machine, which is necessary when the kidneys are not functioning properly). During further review of Patient 33’s History and Physical (H&P), dated 11/21/2025, the H&P also indicated that Patient 33 required a cardiology consultation due to atrial fibrillation with rapid ventricular response (AFib with RVR, an irregular and often rapid heart rate that can lead to poor blood flow and requires prompt medical attention to manage and stabilize the heart rate). During a review of the Cardiology Consultation Note, dated 11/22/2025, the note indicated that the cardiologist recommended continuous cardiac telemetry monitoring (a system that uses devices to automatically transmit the patient’s heart rhythm and electrical activity to healthcare professionals for real-time observation). During a concurrent interview and record review on 1/6/2026 at 11:05 a.m. with nurse practitioner (NP), Patient 33’s cardiac telemetry strips (printed recordings of the patient’s heart rhythm captured by a cardiac monitor, used to assess heart rate and rhythm), dated 11/25/2025, were reviewed. The review indicated the following: -The first strip, on 11/25/2025 at 12:00 a.m., showed Patient 33’s heart rhythm as atrial flutter (an abnormal rhythm where the atria beat rapidly, causing irregular heart function) with a heart rate (HR) of 63 bpm (beats per minute). -The next strip, at 7:17 a.m., indicated that Patient 33’s heart rhythm changed to sinus bradycardia (a slower-than-normal heart rhythm), and the HR was 39 bpm (resting heart rate for adults is 60-100 bpm). -At 11:29 a.m., the strip indicated that Patient 33’s heart rate was 59 bpm. -NP looked at the strips and said: “No one notified me about the changes in cardiac telemetry, and nobody mentioned this to me at all ... and stated that she (NP) was not aware of the below normal heart rate on 11/25/2025 [on the day of Patient 33’s discharge] ...” During a concurrent interview and record review on 1/6/2026 at 11:30 a.m. with the Program Coordinator for Quality Assurance (PCQA), Patient 33’s cardiac telemetry strips (printed recordings of the patient’s heart rhythm captured by a cardiac monitor, used to assess heart rate and rhythm), dated 11/25/2025, were reviewed. The PCQA confirmed that on 11/25/2025, only three strips were available for review from midnight until the time Patient 33 was discharged home at 3:06 p.m. The first strip, on 11/25/2025 at 12:00 a.m., showed Patient 33’s heart rhythm as atrial flutter (an abnormal rhythm where the atria beat rapidly, causing irregular heart function) with a heart rate (HR) of 63 bpm (beats per minute). The next strip, at 7:17 a.m. (on 11/25/2025), indicated that Patient 33’s heart rhythm changed to sinus bradycardia (a slower-than-normal heart rhythm), and the HR was 39 bpm (normal resting heart rate for adults is 60-100). At 11:29 a.m. (on 11/25/2025), the strip indicated that Patient 33’s heart rate was 59 bpm. The PCQA verified that no physician notification was recorded by the nurses regarding the change in Patient 33’s heart rate and rhythm on 11/25/2025. During an interview on 1/6/2026 at 11:47 a.m. with the charge nurse (CN 5), CN 5 stated the following regarding telemetry monitoring (refers to the continuous remote monitoring and transmission of a patient’s heart rhythm and rate from a cardiac monitor to a central monitoring station): “-The telemetry floor is monitored at the nurses’ station, and each patient has a telemetry monitor connected to them. -Each unit has a monitor tech, and patients are monitored 24 hours a day. -The monitor tech prints telemetry strips (printed recordings of a patient’s heart rhythm captured by a cardiac telemetry monitor) every 4 hours. -If there is an arrhythmia (an abnormal heart rhythm that can indicate cardiac instability), the attending physician or cardiologist is notified immediately. During the night shift, the attending MD must be notified. -If the monitor tech sees something abnormal, they notify the primary RN, and the primary RN notifies the doctor.” During the same interview on 1/6/2026 at 11:47 a.m. with the charge nurse (CN 5), CN 5 reviewed Patient 33’s telemetry strip, dated 1/25/2025 at 7:17 a.m. and stated that the heart rate (HR) was 39 (normal range: 60-100 beats per minute), the PR interval (the time it takes for electrical signals to travel from the atria to the ventricles; a prolonged PR interval can indicate a conduction delay or heart block) was prolonged, and the HR was concerning because it was too low, especially compared to previously documented heart rate and rhythm throughout Patient 33’s hospital stay. CN 5 also said that the telemetry strip was printed because the heart rate was concerning and likely represented a change in Patient 33’s condition (a change in condition refers to any significant alteration in a patient’s clinical status that may indicate deterioration or require intervention), which should have been communicated to the physician. During an interview on 1/6/2026 at 2:05 p.m. with cardiologist (MD 5), MD 5 said: “I saw the patient (Patient 33) for atrial flutter (an abnormal heart rhythm where the atria beat rapidly, causing irregular heart function). I placed him (Patient 33) on anticoagulation (medication to prevent blood clots) and Cardizem (a calcium channel blocker used to slow heart rate and control rhythm), and he converted on his own (meaning the patient’s heart rhythm returned to normal without the need for electrical or chemical intervention). I recommended to continue the medications after discharge and follow up with cardiology. I cleared him for discharge.” MD 5 also reviewed the cardiac telemetry strips, dated 11/25/2025, and said that he (MD 5) did not recall being notified of the variability (meaning changes in heart rhythm and rate over time), but said that it was possible to see the variability on patients with flutter and afib (atrial fibrillation, an irregular, often rapid heart rhythm where the atria beat chaotically, which can cause fluctuations in heart rate and rhythm). During an interview on 1/7/2026 at 10:31 a.m. with the Director of Telemetry Services (DOT 1), DOT 1 said the following regarding cardiac telemetry strips : “Cardiac telemetry strips are printed every 4 hours and placed in patient’s medical records. Nurses don’t have to sign the strips; they need to review them. If there is something new or a change, they are required to contact the physician, notify the charge nurse and physician, and obtain orders to intervene. They would then document in their nurse’s notes (there was no documentation in the nurses notes that the nurse reviewed the rhythm strip for Patient 33).” During a review of the facility’s policy and procedure (P&P) titled “Scope of Service - Telemetry Services,” dated 10/2025, the P&P indicated that “Cardiac rhythm strips will be interpreted and documented every four (4) hours ...” During a review of the facility’s policy and procedure (P&P) titled “Chain of Command,” dated 10/2025, the P&P indicated that: “-The physicians manage the medical and surgical care of patients during hospitalization. -Registered Nurses (RN) and other associates (including non-nursing disciplines) work collaboratively with physicians to assist the patient in reaching optimal health outcomes during their hospital stay. In situations requiring acute medical care and the presence of a physician, it will be the responsibility of the RN or other associates (including non-nursing disciplines) caring for the patient to contact the treating primary or on-call physician immediately and report the condition of the patient. 4. Patient care shall not be delayed. There shall be prompt progression through the chain of command to meet patients’ needs. 5. Documentation in the medical record should reflect all notifications or attempted notifications, the individuals contacted, and the times.” 3. During a review of Patient 34’s History and Physical (H&P, a comprehensive document that includes the patient’s medical history and the findings of a physical examination), dated 9/3/2025, the H&P indicated that Patient 34 was admitted on 9/3/2025 due to jaundice (a medical condition with yellowing of the skin or whites of the eyes, typically caused by liver disease or obstruction of the bile duct) and abdominal pain (discomfort or pain felt in the stomach area, which could be related to various underlying conditions). The H&P also indicated that the surgery team was consulted, and the recommendation was to transfer Patient 34 to a higher level of care (HLOC, a term used to refer to a medical facility or unit that provides a more intensive level of medical treatment and monitoring). During a review of case management notes from 9/4/2025 to 9/23/2025, the following was noted: -9/4/2025: Discharge plan indicated Patient 34 was to be discharged home once cleared. -9/5/2025: Patient 34 needed ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that uses a flexible tube with a camera and X-rays to check and treat problems in the liver, gallbladder, bile ducts, and pancreas). -9/8/2025: No order for higher level of care (HLOC) needed as per physician. -9/16/2025: Patient 34 requiring inpatient hospitalization, IV antibiotics (intravenous antibiotics) and cardiac telemetry (continuous monitoring of heart activity). -9/20/2025: CM made multiple inquiries to liver transplant centers (facilities specializing in liver transplants) for HLOC transfer. Patient 34 was not accepted due to lack of insurance coverage. During a review of Patient 34’s Discharge Summary (a summary of the patient’s hospital stay, including why they were admitted, what was done for them, and instructions for after they leave), dated 9/29/2025, the record indicated that Patient 34 was admitted for several reasons, including but not limited to liver cancer (a type of cancer that starts in the liver cells), sepsis (a serious infection that spreads through the body), and cholecystitis (inflammation of the gallbladder, usually from a gallstone blocking the duct). During further review of Patient 34’s Discharge Summary, dated 9/29/2025, the record indicated the following: “ ...During the hospital course, the initial imaging (scans) showed possible cholecystitis (gallbladder inflammation). The surgery team was consulted and recommended transfer to HLOC (higher level of care) as the patient had extremely elevated bilirubin (high levels of a yellow substance in the blood, often linked to liver problems) not consistent with isolated cholecystitis. A second surgical consult was requested which repeated the same recommendations ...The GI (gastrointestinal, digestive system that breaks down food and liquids into components that the body can use for energy, growth, and tissue repair) ) team was consulted for further management of jaundice ...The decision was made to perform a liver biopsy (a medical procedure that removes a small sample of liver tissue for microscopic examination to diagnose, stage, or monitor liver disease ) on 9/24/2025, which showed ‘moderately differentiated tumor with pseudoglandular formation (tumors that looks like glandular tissue but is not truly glandular) suggestive of hepatocellular carcinoma (a type of liver cancer) ...’ The patient (Patient 34) was managed in a telemetry unit (a unit with continuous heart monitoring), was on room air (breathing without assistance) throughout his stay, and never required oral or IV (Intravenous, through the veins) pressors (medications to raise blood pressure).” During a concurrent interview and record review on 1/6/2026, at 10:42 a.m. with Program Coordinator Quality Assurance (PCQA), Patient 34’s discharge summary, dated 9/29/2025, was reviewed. PCQA said that the note had no record that the physician discussed the AMA (against medical advice) with Patient 34 in the discharge summary. The PCQA also verified that the note did not mention that Patient 34 left the facility against medical advice and if Patient 34 was stable or unstable to safely depart the hospital even if it was against medical advice. During a concurrent interview and record review on 1/6/2026, at 10:42 a.m. with Program Coordinator Quality Assurance (PCQA), Patient 34’s nursing note, dated 9/25/2025, at 4:30 p.m., was reviewed. The note indicated the following: “patient (Patient 34) and family at bedside ...Patient (Patient 34) stated will be going AMA (against medical advice). Registered Nurse (RN) obtained consent to leave AMA ...” PCQA verified that the RN did not document if Patient 34 was seen by the physician before leaving the hospital and/or if the physician was notified of Patient 34 leaving against AMA and/or if risks and benefits of leaving against medical advice were discussed with Patient 34. PCQA also confirmed that Patient 34’s record did not contain further notes regarding AMA. During a review of Patient 34’s AMA (against medical advice) form, signed by Patient 34 on 9/25/2025 at 4:56 p.m., the section indicating whether the patient left the hospital without seeing the physician, or after seeing the physician and being informed about the risks and consequences involved in leaving the hospital, was not marked by Patient 34 or the nurse. The form was signed by the physician on 10/6/2025, which was 11 days after Patient 34 left the facility. The AMA form was reviewed in the presence of the Director of Nursing (DON), who verified that the section indicating whether the patient (Patient 34) left the hospital without seeing the physician, or after seeing the physician and being informed about the risks and consequences involved in leaving the hospital, was not marked by Patient 34 or the nurse. During an interview on 1/6/2026 at 12:07 p.m. with the charge nurse (CN 5), CN 5 said that the AMA (Against Medical Advice) form had two boxes for the nurse or the patient to check, and one of the boxes should be marked when the form was being completed. CN 5 said, “Marking the correct box would indicate whether the patient was seen by the physician or not seen by the physician prior to leaving against medical advice.” During an interview on 1/8/2026 at 11:11 a.m. with the Director of Nursing (DON), the DON said that the AMA (Against Medical Advice) form was completed between the provider and the patient, and the patient should check off the box to indicate if they were seen by the physician or not seen by the physician before leaving against medical advice. The DON said that nurses should document in the nursing progress notes or in the physician notification section (if the physician was notified that the patient wants to leave AMA). The DON also said that nursing documentation should reflect the discussion regarding risks and benefits of leaving against medical advice and should note if the patient refused to speak with the physician. During a review of the facility’s Policy and Procedure (P&P) titled “Against Medical Advice (AMA), Leaving and Elopement,” dated 9/2025, the P&P indicated that, “1. The attending physician is contacted immediately by nursing personnel. 2.The RN/LVN informs the patient or their legal representative that the physician has been contacted and explains any of the alternatives risks to and continued consequences of leaving, the benefits of continued hospitalization and any alternatives to continued hospitalization. 1. Documentation should include but not limited to the following: -Notification of the Attending Physician -Notification of Legal Representative/Significant Other -Notification of Security and/or Law Enforcement Officer -Patient and/or Legal Representative/Significant Other of risk and consequences of leaving AMA” 4.a. During a review of Patient 26’s “History and Physical,” dated 8/10/2025, the record indicated Patient 26 was admitted to the facility for shortness of breath (sensation of being unable to get enough air). The H&P also indicated Patient 26 had a medical history of diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and kidney stones (hardened salt and other minerals that build up in the kidney, often causing pain). During a review of Patient 26’s “Point of Care Testing (medical diagnostic testing to check a patient’s blood sugar level),” dated 8/12/2025, the record indicated Patient 26 had an order for fingerstick (finger is poked by a needle to get a blood sample to read the blood sugar) before meals and at bedtime (ACHS). During a concurrent interview and record review on 1/7/2026 at 10:35 a.m. with Registered Nurse (RN) 3, Patient 26’s “Point of Care (POC) Glucose (blood sugar) - History,” dated 8/12/2025, was reviewed. The record indicated the following: -At 5:53 a.m., Patient 26’s blood sugar was 104. -At 12:39 p.m., Patient 26’s blood sugar was 62 and juice, food or D50 (sugar in a medication form used to raise blood sugar) was given -At 2:44 p.m., Patient 26’s blood sugar was 60 and juice, food or D50 was given -At 2:55 p.m., Patient 26’s blood sugar was 62 and juice, food or D50 was given -At 3:43 p.m., Patient 26’s blood sugar was 90 (within normal range of 70-100 mg/dL). During a concurrent interview and record review on 1/7/2026 at 10:50 a.m. with RN 3 Patient 26’s “Nurse Notes,” dated 8/12/2025, was reviewed. RN 3 confirmed there was no nurse to physician communication regarding Patient 26’s low blood sugar. RN 3 stated the nurse should have informed the physician about Patient 26’s low blood sugar in case the physician needed to change the plan of care for the patient. RN 3 also stated Patient 26 could have become confused or the condition could have led to a rapid response (a hospital system designed to identify and respond to patients with early signs of clinical deterioration) due to the low blood sugar level. During an interview on 1/9/2025 at 11:35 a.m. with Director of Medical-Surgical (DOT) 3, DOT 3 stated nurses should communicate with the physician regarding a patient’s low blood sugar level and there were specific orders (standardized procedure) for the nursing staff to implement as part of the process. During a review of the facility’s policy and procedure (P&P) titled, “RN Standardized Procedure: Hyper/Hypoglycemia,” dated 10/2025, the P&P indicated, “The RN responsible for whom a Standardized Procedure has been implemented is responsible for notifying the physician in the situations outlined in the Standardized Procedures ...Document date, time, procedure, patient symptoms, response to treatment, physician notification ...” 4.b. During a review of Patient 26’s “History and Physical,” dated 8/10/2025, the record indicated Patient 26 was admitted to the facility for shortness of breath (sensation of being unable to get enough air). The H&P also indicated Patient 26 had a medical history of diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and kidney stones (hardened salt and other minerals that build up in the kidney, often causing pain). During a review of Patient 26’s “Point of Care Testing (medical diagnostic testing to check a patient’s blood sugar level),” dated 8/12/2025, the record indicated Patient 26 had an order for fingerstick (finger is poked by a needle to get a blood sample to read the blood sugar) before meals and at bedtime (ACHS). During a concurrent interview and record review on 1/8/2026 at 2:10 p.m. with Clinical Nurse Supervisor (CNS) 2, Patient 26’s “Point of Care (POC) Glucose (blood sugar, normal levels of 70-99 mg/dL) - History,” dated 8/12/2025, was reviewed. The record indicated the following: -At 5:53 a.m., Patient 26’s blood sugar was 104. -At 12:39 p.m., Patient 26’s blood sugar was 62 and juice, food or D50 (sugar in a medication form used to raise blood sugar) was given -At 2:44 p.m., Patient 26’s blood sugar was 60 and juice, food or D50 was given -At 2:55 p.m., Patient 26’s blood sugar was 62 and juice, food or D50 was given -At 3:43 p.m., Patient 26’s blood sugar was 90. CNS 2 confirmed there was no recheck of Patient 26’s blood sugar level after 12:39 p.m. until 2:44 p.m. During an interview on 1/8/2025 at 2:58 p.m. with CNS 2, CNS 2 stated the goal was patient safety, and if the blood sugar was not rechecked, “we would not know the status (if there is any improvement in the blood sugar level). If the patient was hypoglycemic (low blood sugar level) and interventions were done with no recheck, we would not know if the interventions were effective or not.” CNS 2 stated the protocol was to recheck the blood sugar 15 minutes after the intervention. During a review of the facility’s policy and procedure (P&P) titled, “RN Standardized Procedure: Hyper/Hypoglycemia,” dated 10/2025, the P&P indicated, “Monitor vital signs and blood glucose level 15 minutes after treatment and by clinical laboratory. Repeat every 15 minutes until blood glucose > 70 mg/dL ...” 5. During a review of Patient 16’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/11/2025, the H&P indicated, Patient 16 was admitted to the facility with diagnoses including but not limited to acute metabolic encephalopathy (brain dysfunction causing confusion, memory issues, drowsiness or coma), dysphagia (difficulty swallowing), adult failure to thrive (a syndrome of decline in older adults marked by weight loss, poor appetite, inactivity, and social withdrawal), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). The H&P also indicated Patient 16’s family reported Patient 16 had increased difficulty swallowing and pocketing food (keeping food in the mouth). Treatment plan included Patient 16 NPO (nothing by mouth) except meds (ok to give medications) pending formal swallow evaluation (to evaluate a person’s ability to swallow food) and consulting Speech Therapy (ST, professional who assesses, diagnoses, and treats communication and swallowing disorders in people in all ages). During a review of Patient 16’s physician order, dated 9/11/2025 at 11:32 a.m., the physician order indicated to keep Patient 16 NPO (nothing by mouth) except meds. During a review of Patient 16’s physician order, dated 9/11/2025 at 11:34 a.m., the physician order indicated, STAT (a medical abbreviation for immediately or without delay) swallow evaluation with reason of history of throat cancer with dysphagia. During a concurrent interview and record review on 1/8/2026 at 2:38 p.m. with Registered Nurse (RN) 3, Patient 16’s swallow evaluation, dated 9/13/2025, was reviewed. The swallow evaluation indicated Patient 16’s swallow evaluation was performed on 9/13/2025 at 11:12 a.m. RN 3 stated the swallow evaluation was completed two (2) days after the physician order (9/11/2025). During an interview on 1/8/2026 at 3:47 p.m. with the Director (DOT 7) of Rehabilitation, DOT 7 stated for patients, in general, swallow evaluation would be completed by a speech therapist (ST) within 24 hours upon receipt of order. A STAT swallow evaluation order would be completed within the same day. During an interview on 1/8/2026 at 4:20 p.m. with DOT 7, DOT 7 stated the following: there was a STAT swallow evaluation order placed on 9/11/2025 for Patient 16. However, Patient 16 was still in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) at that time and speech therapists did not see patients in the ED. There was staffing shortage the next day (9/12/2025) in the rehab department so Patient 16 was not seen by a ST. A ST finally saw Patient 16 on 9/13/2025 and completed the swallow eval (2 days after the swallow eval was ordered by the physician). This had caused a delay in getting the recommended diet for Patient 16. During an interview on 1/9/2026 at 9:03 a.m. with the Registered Nurse (RN) 10, RN 10 stated the following: nursing staff was responsible to follow up with rehab department if the swallow evaluation was not done. Nursing staff needed to follow the chain of command and escalate it to the department director to make sure the swallow evaluation was done in a timely manner so Patient 16 could eat. RN 10 stated there was no communication note found in Patient 16’s medical record regarding swallow evaluation follow-up by nursing staff and escalating to anyone’s attention. During a review of Patient 16’s nutritional intake record titled, “Care Activity - Assessment,” dated from 9/11/2025 to 9/13/2025. The nutritional intake record indicated Patient 16 was kept NPO (nothing by mouth) from 9/11/2025 at 6 p.m. to 9/12/2025 at 6 p.m. During a review of the facility’s policy and procedure titled, “Initial Evaluation/Reassessment Policy,” dated 7/2025, the P&P indicated, “An initial assessment will be initiated within one business day after receiving the order for Physical Therapy, Occupational Therapy and for Speech Therapy on each patient prior to initiation of treatment ... A written evaluation will then appear in the patient’s chart.” During a review of the facility’s policy and procedure titled, “Chain of Command,” dated 10/2025, the P&P indicated, “Registered Nurses (RN) and other associates (including non-nursing disciplines) work collaboratively with physicians to assist the patient in reaching optimal health outcomes during their hospital stay ... In situations where a conflict exists related to patient care, it is the responsibility of the RN or other associates (including non-nursing disciplines) involved to discuss the issues with the treating physician. If unable to resolve the conflict, the RN or other associates (including non-nursing disciplines) shall implement the chain of command ... 1. The RN or other associates (including non-nursing disciplines) will communicate with their immediate supervisor. 2. If the immediate supervisor is unable to resolve the issue, then (s)he will contact the department director and/or administrative house supervisor ... 4. Patient care shall not be delayed. There shall be prompt progression through the chain of command to meet patients’ needs. 5. Documentation in the medical record should reflect all notifications or attempted notifications, the individuals contacted, and the times.” 6. During a review of Patient 19’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 8/19/2025, the H&P indicated, Patient 19 was admitted to the facility for chief complaint of altered mental status (change in mental function). During a review of Patient 19’s physician orders titled, “Orders,” dated 8/19/2025, the “Orders” indicated, Patient 20 had a physician order to give clonidine (medication to lower blood pressure) 0.1 milligram (mg, a unit of measure) by mouth every six (6) hours as needed (PRN) for systolic blood pressure (SBP, top number in blood pressure reading) above 160 mmHg (millimeters of mercury, unit of measure) or diastolic blood pressure (DBP, bottom number of the blood pressure reading) above 90 mmHg. During a review of Patient 19’s, “Nurse Notes,” dated 8/19/2025, the record indicated Patient 19’s blood pressure was 180/117 mmHg at 4:59 p.m. (an ideal blood pressure for most adults is lower than 120/80 mmHg). The Nurse Notes also indicated a family member was informed of physician’s order to give Patient 19 Clonidine for SBP above 160 mmHg, and family member granted permission to give the medication. During a concurrent interview and record review on 1/6/2026 at 2:50 p.m. with Director (DOT 2) of Telemetry (a unit in the hospital where patients undergo continuous heart and vital signs monitoring), Patient 19’s “Omnicell (provides automation systems for medication management in health care system) record (medication dispensing record),” dated 8/19/2025, was reviewed. The Omnicell record indicated RN 4 had removed clonidine from the Omnicell for Patient 19 on 8/19/2025 at 4:59 p.m. DOT 2 confirmed RN 4 had removed the clonidine for Patient 19. During a review of Patient 19’s “Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient),” dated 8/19/2025, the MAR did not indicated that a Clonidine was administered to Patient 19 on 8/19/2025. During interview on 1/8/2026 at 3:57 p.m. with DOT 2, DOT 2 stated the following: Clonidine 0.1 mg should have been documented as given, refused or returned. Medications should be accounted for. If a medication was given, it should be reflected in Patient’s 19’s MAR. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Management),” dated 9/2025, the P&P indicated, “Medications are pulled and administered for one patient at a time ...Removal of medications from appropriate storage area warrants prompt administration of the medication ...If administration is delayed, the medication must be put back in its proper storage area until the medication can be administered ...Under no circumstances should the medication be kept unsecured or in inappropriate areas ...Prior to administration, the 6 R’s (Right- Right Drug, Right Dose, Right Time, Right Route, Right Patient and Right Documentation) must be verified: Right documentation...””

“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: 50594 Based on interview and record review, the facility failed to ensure nursing staff administered pain medication according to the prescribed pain scale (tool for self-reporting pain intensity) for one of 38 sampled patients (Patient 20). RN 18 gave acetaminophen (pain reliever medication to treat mild pain) 650 milligrams (mg, a unit of measure) ordered for mild pain (1-3 out of 10) to treat Patient 20’s moderate pain (4-6 out of 10), contrary to the physician’s order. This deficient practice had the potential for Patient 20 to suffer from inadequate pain relief and worsening of pain. Findings: During a review of Patient 20’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 3/7/2025, the H&P indicated Patient 20 was admitted to the facility for nausea (feeling that you need to throw up) and weakness. During a review of Patient 20’s “Medication Administration Records (MAR, a daily documentation records used by a licensed nurse to document medications and treatments given to a patient),” dated 3/7/2025, the MAR indicated acetaminophen (Tylenol) 650 milligrams (mg, a unit of measurement) by mouth every four (4) hours as needed (PRN) for mild pain (1 to 3 on the pain scale; Mild [1-3], Moderate [4-6], Severe [7-10]). During a concurrent interview and record review on 1/8/2026 at 10:02 a.m., with Program Coordinator Quality Assurance (PCQA), Patient’s 20’s MAR, dated 3/7/2025, was reviewed. The MAR indicated Patient 20 received the following: -Acetaminophen 650 mg by mouth with pain scale of a 4/10 (considered as moderate pain on the pain scale) on 3/7/2025 at 12:26 p.m. -Acetaminophen 650 mg by mouth with pain scale of a 5/10 (considered as moderate pain on the pain scale) on 3/7/2025 at 4:56 p.m. During the same interview on 1/8/2026 at 10:02 a.m. with PCQA, PCQA stated acetaminophen 650 mg which was ordered for mild pain was not appropriate for Patient 20’s pain scale of a 4 or 5 (moderate) as these pain levels (4 or 5) were considered moderate pain and not mild pain. PCQA stated the nurse should have called and clarified the order with the physician because it was not appropriate to give the acetaminophen 650 mg as it might not be effective to treat Patient 20’s pain rated as 4 or 5 on a pain scale. During an interview on 1/8/2026 at 10:51 a.m. with PCQA, PCQA confirmed RN 18 did not follow the physician’s order regarding the administration of acetaminophen on 3/7/2025 (The order for acetaminophen 650 mg was for mild pain. Patient 20 had moderate pain). During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Management),” dated 12/2022, the P&P indicated, “Prior to administration the practitioner will: a. Verify the prescriber’s order against the medication being administered ...Prior to administration, the 6 R’s (R-Right Drug, Right Dose, Right Time, Right Route, Right Patient and Right Documentation) must be verified: ...a. Right drug.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 11/2024, the P&P indicated, “10. Appropriate assessment and management of your pain, information about pain, pain relief measures ...” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 9/2025, the P&P indicated, “[facility name] respects and supports the rights of patients to safe, timely, and effective pain management ...Assess for pain using pain scale ...Numeric Pain Intensity Scale 2.4.1 None, Mild (1-3), Moderate (4-6), Severe (7-10) ...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that a documentation regarding a discussion, between a medical provider and one of 38 sampled patients (Patient 34), pertaining to the risks of leaving against medical advice (AMA, a term used when a patient chooses to leave a hospital or medical facility despite the medical advice provided by their healthcare professionals, suggesting that it is not in their best interest to do so), was completed, in accordance with the facility’s policy regarding completion of medical records and medical record contents. This deficient practice had the potential to compromise Patient 34’s right to be informed of the risks of leaving AMA when not deemed stable for discharge from the hospital. Additionally, the providers’ lack of documentation regarding Patient 34’s condition at the time Patient 34 left the hospital against medical advice could potentially compromise the safety of Patient 34 if Patient 34 was not stable when leaving the facility. Findings: During a review of Patient 34’s History and Physical (H&P, a comprehensive document that includes the patient’s medical history and the findings of a physical examination), dated 9/3/2025, the H&P indicated that Patient 34 was admitted on 9/3/2025 due to jaundice (a medical condition with yellowing of the skin or whites of the eyes, typically caused by liver disease or obstruction of the bile duct) and abdominal pain (discomfort or pain felt in the stomach area, which could be related to various underlying conditions). The H&P also indicated that the surgery team was consulted, and the recommendation was to transfer Patient 34 to a higher level of care (HLOC, a term used to refer to a medical facility or unit that provides a more intensive level of medical treatment and monitoring). During a review of case management notes from 9/4/2025 to 9/23/2025, the following was noted: -9/4/2025: Discharge plan indicated Patient 34 was to be discharged home once cleared. -9/5/2025: Patient 34 needed ERCP (Endoscopic Retrograde Cholangiopancreatography, a procedure that uses a flexible tube with a camera and X-rays to check and treat problems in the liver, gallbladder, bile ducts, and pancreas). -9/8/2025: No order for higher level of care (HLOC) needed as per physician. -9/16/2025: Patient 34 requiring inpatient hospitalization, IV antibiotics (intravenous antibiotics) and cardiac telemetry (continuous monitoring of heart activity). -9/20/2025: CM made multiple inquiries to liver transplant centers (facilities specializing in liver transplants) for HLOC transfer. Patient 34 was not accepted due to lack of insurance coverage. During a review of Patient 34’s Discharge Summary (a summary of the patient’s hospital stay, including why they were admitted, what was done for them, and instructions for after they leave), dated 9/29/2025, the record indicated that Patient 34 was admitted for several reasons, including but not limited to liver cancer (a type of cancer that starts in the liver cells), sepsis (a serious infection that spreads through the body), and cholecystitis (inflammation of the gallbladder, usually from a gallstone blocking the duct). During further review of Patient 34’s Discharge Summary, dated 9/29/2025, the record indicated the following: “ ...During the hospital course, the initial imaging (scans) showed possible cholecystitis (gallbladder inflammation). The surgery team was consulted and recommended transfer to HLOC (higher level of care) as the patient had extremely elevated bilirubin (high levels of a yellow substance in the blood, often linked to liver problems) not consistent with isolated cholecystitis. A second surgical consult was requested which repeated the same recommendations ...The GI (gastrointestinal, digestive system that breaks down food and liquids into components that the body can use for energy, growth, and tissue repair) team was consulted for further management of jaundice ...The decision was made to perform a liver biopsy (medical procedure that removes a small sample of liver tissue for microscopic examination to diagnose, stage, or monitor liver disease) on 9/24/2025, which showed ‘moderately differentiated tumor with pseudoglandular formation (tumors that looks like glandular tissue but is not truly glandular) suggestive of hepatocellular carcinoma (a type of liver cancer) ...’ The patient was managed in a telemetry unit (a unit with continuous heart monitoring), was on room air (breathing without assistance) throughout his stay, and never required oral or IV pressors (medications to raise blood pressure).” During a concurrent interview and record review on 1/6/2026, at 10:42 a.m. with Program Coordinator Quality Assurance (PCQA), Patient 34’s discharge summary, dated 9/29/2025, was reviewed. PCQA said that the note had no record. in the discharge summary, that the physician discussed the AMA (against medical advice) with Patient 34. The PCQA also verified that the note did not mention that Patient 34 left the facility against medical advice and whether Patient 34 was stable or unstable to safely leave the hospital even if it was against medical advice. During a concurrent interview and record review, on 1/6/2026, at 10:42 a.m. with Program Coordinator Quality Assurance (PCQA), Patient 34’s nursing note, dated 9/25/2025, at 4:30 p.m., was reviewed. The note indicated the following: “Patient 34 and family at bedside ...Patient 34 stated will be going AMA (against medical advice). Registered Nurse (RN) obtained consent to leave AMA ...” PCQA verified that the RN did not document if Patient 34 was seen by the physician before leaving the hospital and/or if the physician was notified of Patient 34 leaving AMA and/or if risks of leaving against medical advice were discussed with Patient 34. PCQA also confirmed that Patient 34’s record did not contain further notes regarding AMA. During an interview on 1/6/2026 at 11:33 a.m., medical doctor (MD 4) provided insights regarding Patient 34’s discharge against medical advice (AMA): “The patient left AMA because he (Patient 34) had to go back to work. I advised him to wait for the ambulance and assured him that we would provide the necessary medications, but he said he could not afford to wait anymore ... He needed to get back to his job. Although the patient (Patient 34) was alert and oriented (patient is conscious, awake, and aware of themselves and their surroundings), he was not stable enough to be discharged. He was on a telemetry floor, we managed his blood pressure, and he only used oxygen occasionally for comfort. On the day he decided to leave, he was accompanied by his wife, and I had a conversation with both at the bedside. I did not prescribe any medications or provide any discharge documents. The patient mentioned that he wanted to go to [Name of another Facility] Liver Center. Unfortunately, I did not document any of this interaction. Next time, I will make sure to take notes.” During a review of Patient 34’s AMA (against medical advice) form, signed by Patient 34 on 9/25/2025 at 4:56 p.m., the section indicating whether the patient left the hospital without seeing the physician, or after seeing the physician and being informed about the risks and consequences involved in leaving the hospital, was not marked by Patient 34 or the nurse. The form was signed by the physician on 10/6/2025, which was 11 days after Patient 34 left the facility. During an interview on 1/6/2026 at 12:07 p.m. with the charge nurse (CN 5), CN 5 said that the AMA (Against Medical Advice) form had two boxes for the nurse or the patient to check, and one of the boxes should be marked when the form was being completed. CN 5 said, “Marking the correct box would indicate whether the patient was seen by the physician or not seen by the physician prior to leaving against medical advice.” During an interview on 1/8/2026 at 11:11 a.m. with the Director of Nursing (DON), the DON said that the AMA (Against Medical Advice) form was completed between the provider and the patient, and the patient should check off the box to indicate if they were seen by the physician or not seen by the physician before leaving against medical advice. The DON said that nurses should document in the nursing progress notes or in the physician notification section (if the physician was notified that the patient wants to leave AMA). The DON also said that nursing documentation should reflect the discussion regarding risks of leaving against medical advice and should note if the patient refused to speak with the physician. During an interview on 1/9/2026 at 1:36 p.m. with the Chief Medical Officer (CMO), the CMO said, “Progress notes and discharge summaries are expected to be completed by physicians to accurately reflect what was done for the patient and for record-keeping purposes.” During a review of the facility’s Policy and Procedure (P&P) titled “Against Medical Advice (AMA), Leaving and Elopement,” dated 9/2025, the P&P indicated that, “1. The attending physician is contacted immediately by nursing personnel. 2.The RN/LVN informs the patient or their legal representative that the physician has been contacted and explains any the alternatives risks to and continued consequences of leaving, the benefits of continued hospitalization and any alternatives to continued hospitalization. 1. Documentation should include but not limited to the following: -Notification of the Attending Physician -Notification of Legal Representative/Significant Other -Notification of Security and/or Law Enforcement Officer -Patient and/or Legal Representative/Significant Other of risk and consequences of leaving AMA.” During a review of the facility’s policy and procedure (P&P) titled “Completion of Medical Records,” dated 7/2023, the P&P indicated that “... Should a patient leave the hospital against the advice of the attending physician or without proper discharge, a notation of the incident shall be made a part of the medical record, by both the attending physician and the Registered Nurse attending the patient.” During a review of the facility’s policy and procedure (P&P) titled, “Medical Record, Content of,” dated 7/2023, the P&P indicated, “A medical record is established and maintained for each individual who is evaluated and treated as an inpatient ... Documentation is to reflect the patient’s medical status in such a manner as to allow another practitioner to assume care of the patient at any time ... Procedure ... the chart must contain all pertinent and significant clinical information pertaining to the patient ... [the facility] practitioners and personnel are to document entries as soon as after the event as possible ... the entries made by physicians and non-physicians are to contain information that is meaningful and relevant to the care of the patient.””

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure its physician consultant documented consultative notes after seeing one of 38 sampled patients (Patient 13), in accordance with the facility’s policy regarding completion of medical record. This deficient practice resulted in Patient 13’s medical record not reflecting Patient 13’s condition and response to treatment on 9/17/2025. The lack of documentation can negatively impact the sharing of vital information between care providers to ensure continuity, safety, and accuracy of patient care across multidisciplinary teams. Findings: During a review of Patient 13’s “ED Physician note (ED note, medical notes completed by Emergency Department [hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician),” dated 9/17/2025, the ED note indicated, Patient 13 was brought to the facility’s emergency department (ED) from an outside OBGYN (Obstetrician-Gynecologist, physician specializing in women’s reproductive health) clinic status post cardiac arrest (heart stopped). The ED Physician Note also indicated OBGYN (MD 12) was consulted in the ED, and Patient 13 was rushed to the operating room (OR) in critical condition. During a concurrent interview and record review on 1/9/2026 at 9:26 a.m. with Registered Nurse (RN) 10, Patient 13’s medical record with physician notes, dated 9/17/2025, was reviewed. Patient 13’s medical record indicated an absence of consultation notes or any physician progress notes by MD 12. During a review of Patient 13’s “Surgical Care Record (nursing document of surgical procedure),” dated 9/17/2025, the “Surgical Care Record” indicated Patient 13 underwent an emergency procedure of Exploratory Laparotomy (a major surgery where a surgeon opens the abdomen to diagnose or treat unexplained internal problems) on 9/17/2025 with surgeon as MD 12. The “Surgical Care Record” also indicated that the procedure was canceled because Patient 13 had passed away (died). During an interview on 1/9/2026 with the Chief Medical Officer (CMO), CMO stated the following: there should be a physician note from MD 12 at least to describe what had happened with MD 12’s encounter with Patient 13. There should be adequate medical documentation to transcribe what happened to Patient 13. CMO confirmed there were no notes made by MD 12 in Patient 13’s medical record. CMO stated CMO would be talking to MD 12 to make a late entry. During a concurrent interview and record review on 1/9/2026 at 1:50 p.m. with the Chief Medical Officer (CMO), CMO stated the following: facility was aware of physician documentation issue. A memorandum was sent to all providers recently to remind them about proper documentation. During a review of the facility’s memorandum titled, “Re: Documentation Requirements for Discharge Summaries and Consultation Notes,” dated 9/5/2025, the memorandum indicated, “All consultants are required to: conduct and document an examination of the patient and a review of the patient’s medical record within 24 hours of the consultation request. Provide a written consultation note that includes: a clear assessment of the patient, a defined plan of care, based on the consultation findings, the consultant’s signature, with the completed note included in the patient’s medical record.” During a review of the facility’s Medical Staff Rules and Regulations, dated 11/2025, the Medical Staff Rules and Regulations indicated, “Performance of and Reporting of Consultations: A satisfactory consultation includes examination of the patient and the patient’s medical record ... A written opinion signed by the consultant must be included in the patient’s medical record ... When operative procedures are involved, consultations performed before surgery shall be reported before the operation, except in emergency cases. Consultation reports shall be prepared in accordance with medical record rules.” During a review of the facility’s policy and procedure (P&P) titled, “Medical Record, Content of,” dated 7/2023, the P&P indicated, “A medical record is established and maintained for each individual who is evaluated and treated as an inpatient ... Documentation is to reflect the patient’s medical status in such a manner as to allow another practitioner to assume care of the patient at any time ... Procedure ... the chart must contain all pertinent and significant clinical information pertaining to the patient ... [the facility] practitioners and personnel are to document entries as soon as after the event as possible ... the entries made by physicians and non-physicians are to contain information that is meaningful and relevant to the care of the patient.” During a review of the facility’s policy and procedure (P&P) titled, “Completion of Medical Record,” dated 7/2023, the P&P indicated, “Consultations: All patient’s records, both inpatient and outpatient must contain the results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. These results must be filed in the patient medical record within 24 hours of consultation.””

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48212 Based on interview and record review, the facility failed to ensure Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) form was completed and filed for one of 38 sampled patient’s (Patient 14) medical record after a RRT was summoned on 2/2/2024. This deficient practice resulted in Patient 14’s medical record that did not reflect Patient 14’s condition during RRT, what was done during the RRT and Patient 14’s response to RRT interventions. The lack of documentation can negatively impact the sharing of vital information between care providers to ensure continuity, safety, and accuracy of patient care across multidisciplinary teams. Findings: During a review of Patient 14’s Emergency Department (hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) Physician Documentation (ED note, medical notes completed by Emergency Department physician),” dated 2/2/2024, the ED note indicated, Patient 14 presented at facility’s ED with chief complaint of chest pain and nausea (feeling of throwing up). The ED physician note also indicated Patient 14 was admitted to the facility’s Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit for further cardiac (heart) observation (monitoring) and treatment. During a concurrent interview and record review on 1/6/2026 at 3:02p.m. with Clinical Nurse Supervisor (CNS) 1, Patient 14’s nurse notes, dated 2/2/2024, were reviewed. The nurse notes indicated, at 7:15 p.m. - “called RRT (Rapid Response Team, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), BP (blood pressure) still low and HR (heart rate) 50s (beats per minute [normal range 60 -100]).” CNS 1 stated nurse note indicated RRT was called at 7:15 p.m. and there was no completed Rapid Response Team form found in Patient 14’s medical record. During an interview on 1/6/2026 at 4:23 p.m. with the Director (DOT 6) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), DOT 6 stated the following: Rapid Response Team was an early activation in response to a patient’s change in condition to provide interventions to prevent Code Blue (hospital emergency code use to summon help when a patient’s heart stop or a patient stop breathing). A RRT form would be completed by the RRT team. The RRT form was part of a patient’s medical record. During an interview on 1/8/2026 at 11:34 a.m. with Registered Nurse (RN) 9, RN 9 stated the following: the RRT form served as a record to indicate what time the RRT was called, what time the RRT team responded, background information of patient, assessment of patient during RRT, interventions provided and patient’s response to RRT interventions. The RRT form would also record what time RRT ended and patient’s end outcome. The RRT form remained as part of patient’s medical record. RN 9 further stated without the RRT form, the healthcare team would not know what happened during the RRT. During an interview on 1/8/2026 at 3:27 p.m. with the Director of Nursing (DON), DON stated RRT form indicated details of what happened during RRT and it was part of a patient’s medical record. During a review of the facility’s Rapid Response Team form titled, “Rapid Response (Critical Assessment) Team Record,” dated 7/2011, the RRT form indicated the following elements: date, time called, location, arrival time ... primary reason for calling RRT and notify the physician using SBAR (Situation, Background, Assessment, Recommendations), interventions, patient outcome. The RRT form also required a physician signature to validate orders given during RRT. During a review of the facility’s policy and procedure (P&P) titled, “Rapid Response Team (RRT),” dated 7/2023, the P&P indicated, “It is the responsibility for the ICU Charge Nurse (or their designee), Respiratory Therapist Supervisor (or their designee) and the Administrative Nurse Supervisor to respond to a RRT call ... Procedures ... 7. The RRT will perform an intensive patient assessment and will consult with the Primary Care RN to determine patient status. 8. The RRT will call the attending physician utilizing SBAR (Situation, Background, Assessment, Recommendations) with the results of the assessment and recommendations of the Rapid Response Team members and other respondents. 9. The ICU Charge Nurse will document any orders received ... 11. The ICU Charge Nurse will complete the Rapid Response Team Record.” During a review of the facility’s policy and procedure (P&P) titled, “Medical Record, Content of,” dated 7/2023, the P&P indicated, “A medical record is established and maintained for each individual who is evaluated and treated as an inpatient ... Documentation is to reflect the patient’s medical status in such a manner as to allow another practitioner to assume care of the patient at any time ... Procedure ... the chart must contain all pertinent and significant clinical information pertaining to the patient ... Nursing notes are to contain pertinent, meaningful observation and information.””

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to: 1. Ensure two of 38 sampled patients’ (Patient 25 and Patient 33), “Discharge Summary (a record containing the patient’s condition and outcome of hospitalization, and any needs after discharge), contained the required elements such as course of hospitalization and outcome, in accordance with the facility’s Medical Staff General Rules and Regulations.” This deficient practice had the potential to compromise Patient 25’s and Patient 33’s health and recovery depriving healthcare providers of essential information necessary for continuity of care, effective communication among caregivers, and appropriate future medical treatment. 2. Ensure its physician resident (MD 13) and supervising physician (MD 14) documented accurate and appropriate information on the discharge summary (a narrative document for communicating clinical information about what happened to the patient in the hospital) for one of 38 sampled patients (Patient 13), when MD 13 documented Patient 13’s discharge condition as stable and to return to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) if signs or symptoms reoccur despite Patient 13 having died at the facility on 9/17/2025. This deficient practice resulted in Patient 13’s discharge summary not accurately reflecting Patient 13’s status and condition. This inaccurate documentation had the potential to jeopardize future patient safety of other patients affecting patient management and continuity of patient care. Findings: 1.a. During a record review of Patient 25’s “History and Physical,” dated 10/5/2025, the record indicated Patient 25 was admitted to the facility for failure to thrive. The H&P also indicated Patient 25 had a medical history of diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN, high blood pressure). During a concurrent interview and record review on 1/9/2025 at 1:55 p.m. with the Chief Medical Officer (CMO), Patient 25’s “Discharge Summary,” dated 10/7/2025, was reviewed. The CMO acknowledged that Patient 25’s “Discharge Summary” was incomplete, lacking documentation such as laboratory findings, final diagnosis, discharge medications, condition at discharge and discharge disposition, required by the medical rules and regulations established for the facility. During a review of the facility’s policy and procedure (P&P) titled, “Medical Staff General Regulations,” dated 11/6/2025, the P&P indicated, “The attending physician is responsible for documenting a discharge summary for all patients discharged from the hospital or patients who expire in the facility. The discharge summary may be handwritten or dictated. The discharge summary shall contain, at a minimum: a. Final diagnosis b. All relevant diagnoses established during the hospital stay c. Reason for admission d. Summation of hospital course including treatment and response e. Discharge medications f. Discharge instructions to patient and/or family (diet, activity, follow-up) g. Condition at discharge and discharge disposition h. Laboratory findings i. Cause of death, if known, for expired patients” 1.b. During a review of Patient 33’s History and Physical (H&P), dated 11/21/2025, the H&P indicated that Patient 33 was admitted to the facility due to weakness. The H&P also indicated that Patient 33 had a past medical history (PMH, a summary of a patient’s previous health issues, surgeries, and treatments) of end-stage renal disease (ESRD, the final phase of chronic kidney disease where the kidneys can no longer support the body’s needs), was on hemodialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and had hypertension (persistently elevated blood pressure). Patient 33 was found to be hyperkalemic (having an abnormally high level of potassium in the blood) and had missed a few dialysis sessions (a treatment that filters and purifies the blood using a machine, which is necessary when the kidneys are not functioning properly). During further review of Patient 33’s History and Physical (H&P), dated 11/21/2025, the H&P also indicated that Patient 33 required a cardiology consultation due to atrial fibrillation with rapid ventricular response (AFib with RVR, an irregular and often rapid heart rate that can lead to poor blood flow and requires prompt medical attention to manage and stabilize the heart rate). During a review of Cardiology (the medical specialty focusing on the diagnosis, treatment, and prevention of diseases related to the heart and blood vessels ) Consultation Note, dated 11/22/2025, the note indicated that the cardiologist made the following recommendations: The cardiologist recommended continuous cardiac telemetry monitoring, which uses devices to automatically transmit the patient’s heart rhythm and electrical activity to healthcare professionals for real-time observation. The plan included trending troponin levels every 2 hours for 3 cycles or until peak levels were reached. (Troponins are proteins released into the blood when the heart muscle is damaged, making them essential biomarkers for detecting heart attacks. Trending involves checking troponin at set intervals [e.g., every 2 hours for several cycles] to determine if the elevation is acute [suggesting a new cardiac event] or chronic [as seen in conditions like end-stage renal disease where clearance is impaired]). During a review of Patient 33’s Blood Result Values, dated 11/22/2025, at 3:36 p.m., the results indicated that Patient 33’s troponin level was 314 ng/L (nanograms per liter, a unit used to measure the concentration of troponin in blood; Normal levels range from 3-53 ng/L, so 314 ng/L is considered critically high. Prompt communication to the nurse ensures immediate awareness and appropriate follow-up, as elevated troponin may indicate a heart attack or other cardiac stress). This result was called to the nurse at 4:45 p.m. on 11/22/2025. During a concurrent interview and record review on 1/6/2026, at 1:36 p.m., with Nurse Practitioner (NP) and the supervising hospitalist (MD 10), Patient 33’s Discharge Summary, dated 11/25/2025, was reviewed. The Discharge Summary indicated that Patient 33’s admitting diagnosis was missing. The note detailed that the date of discharge was 11/25/2025, and Patient 33’s course of hospitalization included the following: “Weakness with hyperkalemia, AFib with RVR/aflutter, ESRD on HD, Hypertension, acute on chronic systolic HF with EF 45%, anemia... blood pressure management, hemodialysis as per renal consultation, monitoring potassium and procal (procalcitonin)levels, and rate control with cards eval... Dc (discharge) with Eliquiz and cardizem...cleared by cards(cardiology) to fu outp (outpatient)...” (Assessment included weakness associated with hyperkalemia, atrial fibrillation with rapid ventricular response and atrial flutter, end-stage renal disease on hemodialysis, hypertension ... The plan focused on blood pressure management, hemodialysis per renal consultation, monitoring potassium and procalcitonin levels, and rate control with cardiology evaluation. The patient was discharged on Eliquis [blood thinner] and Cardizem [medication to control heart rate] and cleared by cardiology for outpatient follow-up). During the same concurrent interview and record review on 1/6/2026, at 1:36 p.m., with Nurse Practitioner (NP) and the supervising hospitalist (MD 10), Patient 33’s Discharge Summary, dated 11/25/2025, was reviewed by the NP (which she [NP] had completed for Patient 33), and noted that the discharge summary could have been written with more narrative detail to better serve as a comprehensive medical record. The NP also acknowledged the use of unacceptable abbreviations. During an interview on 1/6/2026 at 1:36 p.m. with the Nurse Practitioner (NP) and the supervising hospitalist (MD), the interview focused on Patient 33’s troponin level and its absence from the discharge summary. The NP stated that Patient 33’s troponin level was 314 ng/L (nanograms per liter), and said that a level of 314 ng/L was considered critically high; however, the NP explained that in patients with end-stage renal disease (ESRD), troponin can remain elevated because the kidneys cannot effectively clear it from the blood which reduces the suspicion of an acute cardiac event (a sudden, serious problem affecting the heart that requires immediate medical attention), as the elevation may be chronic (over-time) rather than due to a heart attack. The NP said that trending troponin levels over time would have clarified whether the elevation was persistent or new, but troponin was not trended (taking serial blood tests every 3 to 6 hours to measure the rise and fall of troponin proteins released into the blood). The NP also confirmed that there was no mention of troponin results in any progress notes including the discharge summary, by the attending physician. The NP confirmed that Patient 33 was cleared by cardiology before discharge and stated that while cardiology clearance was relied upon, the primary physician remained responsible for the patient’s overall care. During a concurrent interview and record review on 1/92026 at 1:36 p.m. with the Chief Medical Officer (CMO), the CMO stated that without documentation explaining why the high troponin levels were not clinically significant or addressed, it would be unclear to others. The CMO emphasized this by saying, “How can someone reading a note that does not mention troponin at all know that it was insignificant?” During a concurrent interview and record review on 1/9/2026 at 1:55 p.m. with Chief Medical Officer (CMO), the CMO stated there were multiple criteria elements (such as final diagnosis, relevant diagnoses, reason for admission, hospital course summary, discharge medications, discharge instructions, condition at discharge, laboratory findings, and cause of death for expired patients) listed for a discharge summary, and physicians were required to follow the rules and regulations for a discharge summary documentation for the purpose of accurate record keeping. During a review of the facility’s policy and procedure (P&P) titled, “Medical Staff General Regulations,” dated 11/6/2025, the P&P indicated, “The attending physician is responsible for documenting a discharge summary for all patients discharged from the hospital or patients who expire in the facility. The discharge summary may be handwritten or dictated. The discharge summary shall contain, at a minimum: -Final diagnosis -All relevant diagnoses established during the hospital stay -Reason for admission -Summation of hospital course including treatment and response -Discharge medications -Discharge instructions to patient and/or family (diet, activity, follow-up) -Condition at discharge and discharge disposition -Laboratory findings -Cause of death, if known, for expired patients” During a review of the facility’s policy and procedure (P&P), titled “Completion of Medical Records,” dated 7/2023, the P&P indicated that “... Symbols and abbreviations may be used in the medical record from the “Approved Abbreviations List”. Final diagnoses may not be abbreviated. 2. During a review of Patient 13’s “ED Physician note (ED note, medical notes completed by Emergency Department [hospital department provides unscheduled outpatient services to patients whose condition requires immediate care] physician),” dated 9/17/2025, the ED note indicated, Patient 13 was brought to the facility’s emergency department (ED) from an outside OBGYN (Obstetrician-Gynecologist, physician specializing in women’s reproductive health) clinic status post cardiac arrest (heart stopped). The H&P also indicated OBGYN (MD 12) was consulted in the ED, and Patient 13 was rushed to the operating room (OR) in critical condition. During a review of Patient 13’s “Record of Death/Authorization for Release of Remains (death record),” dated 9/17/2025, the death record indicated, Patient 13 expired (died) on 9/17/2025 at 3:23 p.m. During a concurrent interview and record review on 1/9/2026 at 1:50 p.m. with the Chief Medical Officer (CMO), Patient 13’s “Discharge Summary (DC summary),” dated 9/17/2025, was reviewed. The DC summary indicated, “Hospital Course: Patient (Patient 13) was taken to the OR emergently in a critical condition. Patient (Patient 13) expired in OR ... condition at discharge: stable ... follow-up plan: please return to emergency room if sign or symptoms reoccur. [physician] have communicated the post discharge medical needs with the patient (Patient 13).” The DC summary also indicated the note was completed by a physician resident on 9/17/2025 and co-signed by a supervising physician on 9/18/2025. The CMO stated that the information was inaccurate as it advised Patient 13 to return to the emergency room if symptoms reoccurred, despite the patient (patient 13) having already expired. The CMO stated this error resulted from a lack of attention to detail. The CMO said the physician (MD 13) was using a template. CMO further stated the following: facility was aware of physician documentation issue. A memorandum was sent to all providers recently to remind them about proper documentation. During a review of the facility’s memorandum titled, “Re: Documentation Requirements for Discharge Summaries and Consultation Notes,” dated 9/5/2025, the memorandum indicated, “All discharge summaries must include the following elements at a minimum: Admitting Diagnosis or reason for admission, final diagnosis, all relevant diagnoses established during the hospital stay, summation of hospital course including treatment and response ...cause of death, if known, for expired patients.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46238 Based on interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met, as evidenced by: 1. The facility failed to ensure that one of 30 sampled patients (Patient 2), was informed, in a timely manner, regarding patients’ rights (refer to the fundamental entitlements and protections granted to individuals receiving healthcare services) as a hospital patient, the conditions of admission (COA, is a contract between the hospital and the patient outlining the patient’s obligations while receiving care), and provided with the standardized notice titled, “An Important Message from Medicare (IM, a notification that hospitals are required to give to all Medicare beneficiaries admitted as inpatients. It informs them about their rights as a hospital patient, including their right to appeal a hospital discharge decision),” within the required two days of admission or within 2 calendar days of discharge. This deficient practice had the potential to hinder the patient’s (Patient 2) or the patient’s representative to exercise their rights (example: the right to refuse treatment and the right to receive necessary information about their medical condition). (Refer to A-0117) 2. The facility failed to ensure that the exercise of patients’ rights (the fundamental entitlements and protections granted to individuals receiving healthcare services. These rights aim to ensure that patients receive safe, respectful, and informed care while upholding their autonomy and dignity) requirements were met, when: 2.a. The facility failed to ensure that one of 30 sampled patient’s (Patient 2) and/or Patient 2’s designated representative, received regular updates including documentation of communication from the attending physician regarding consultant findings (evaluations or recommendations provided by specialists or other healthcare providers) as well as any adjustments/modifications in Patient 2’s plan of care (a comprehensive document that outlines their health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey), in accordance with the facility’s policy regarding “Medical Rules and Regulations (R&R)” and “Patient Rights and Responsibilities.” This deficient practice had the potential to hinder a coordinated and patient-centered care due to lack of involvement of Patient 2 and/or Patient 2’s designated representative in Patient 2’s medical care and medical decision-making, which may impact Patient 2’s treatment outcome. (Refer to A-0129) 2.b. The facility failed to ensure one of 30 sampled patient’s (Patient 3), Accu-Chek (a brand of blood glucose testing system used to measure blood sugar levels), ordered to be done 4 times a day (before meals and at bedtime), was discontinued, due to lack of medical indication for continuously monitoring Patient 3’s blood sugar four times a day for over a month during Patient 3’s stay at the facility, in accordance with the facility’s policy regarding Patient Rights and “Medical Rules and Regulations (R&R).” This deficient practice had the potential to result in unnecessary discomfort, increased risk of skin irritation or infection at the blood sampling site, and increased healthcare costs for Patient 3. In addition, this deficient practice had the potential for inappropriate treatment or missed opportunities for necessary intervention, thereby compromising Patient 3’s safety. (Refer to A-0129) 3. The facility failed to ensure that one of 30 sampled patient’s (Patient 1) validation of identity, was completed, in accordance with the facility’s protocol when registering patients, performing medical procedures, and administering medications in the emergency department (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries), when Patient 1 was registered under the incorrect first name and was provided incorrect patient identifiers (a piece of information, such as wristband and labels, used to reliably and uniquely identify an individual to ensure they receive the correct care and treatment). This deficient practice had the potential to compromise Patient 1’s safety, and resulted in misidentification of Patient 1 (Patient 1 was registered under the medical record profile of Patient 1’s twin sister), prolonged stay in the Emergency Department (ED) and unnecessary repeats of venipuncture (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) which may lead to a potential psychological distress for Patient 1. (Refer to A-0142) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46238 Based on interview and record review the facility failed to ensure the Condition of Participation for Nursing Services was met, as evidenced by: 1. The facility failed to ensure one of 30 sampled patients (Patient 8), was discharged safely, when Patient 8’s discharge order was written by mistake. Nursing staff failed to clarify the order which indicated to discharge Patient 8 to a shelter via uber (a transportation and ride-sharing company), even though nursing staff noted Patient 8 would be discharged home and transported by family. In addition, Nursing staff failed to a complete a full set of vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood] with and without supplemental oxygen). The respiratory rate and oxygen saturation (without oxygen) were not assessed prior to Patient 8’s discharge, in accordance with the facility’s policy and procedure regarding Discharge of Patient. This deficient practice resulted in the unsafe discharge of Patient 8. Patient 8 passed away a few hours after discharge. (Refer to A-0395) 2. The facility failed to ensure one of 30 sampled patient’s (Patient 9) VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) Assessment was performed, in accordance with the facility’s policy and procedure regarding VTE Assessments. A full VTE assessment was not performed when Patient 9 was transferred to another unit or had a change of condition. In addition, per documentation, sequential compression devices (leg squeezers) were not removed from Patient 9’s left leg, when Patient 9 developed a blood clot to the left leg on 4/10/2025. This deficient practice had the potential for incorrect VTE risk assessments and had the potential for inappropriate interventions to be implemented for Patient 1, which could result in dislodgement of the blood clot, and possibly traveling to other organs, such as the heart or lungs, which may result in a pulmonary embolism (PE, a blockage in one of the pulmonary arteries (carry blood from the heart to the lungs] of the lungs which can cause death). (Refer to A-0395) 3. The facility failed to ensure one of 30 sampled patient’s (Patient 13) vital signs and reassessment was completed and documented every two hours, in accordance with the facility’s policy regarding “Documentation in the ED (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries) Patient Care Record” and “Standard of Nursing Care.” This deficient practice resulted in delayed or missed opportunities for appropriate medical interventions, potentially resulting in negative outcomes (example, low blood pressure) for Patient 13. (Refer to A-0395) 4. The facility failed to ensure one of 30 sampled patient’s (Patient 9) pain level was assessed, prior to administering hydrocodone/acetaminophen (or Norco, a combination medication of an opioid [a class of drugs used to reduce moderate to severe pain, and can also boost feelings of pleasure] and an over-the-counter pain reliever, used to relieve moderate to severe pain), in accordance with the facility’s policy regarding pain management. This deficient practice had the potential for Patient 9 to be medicated unnecessarily and the possibility of experiencing unnecessary side effects, such as drowsiness (feeling unusually sleep or tired), lack of energy, or even slowed or shallow breathing. (Refer to A-0395)_ 5. The facility failed to ensure one of 30 sampled patients (Patient 26), was repositioned (regularly changing a patient’s body position to relieve pressure on specific areas, especially those at risk of or affected by pressure injuries) every two hours, in accordance with the facility’s policy and procedure regarding “Skin Integrity (the overall health and condition of the skin).” This deficient practice had the potential to result in the worsening of Patient 26’s pressure injury (localized damage to the skin and/or underlying tissue, usually over a bony prominence) leading to prolonged healing and/or hospitalization. (Refer to A-0395) 6. The facility failed to ensure one of 30 sampled patient’s (Patient 26) vital signs was assessed and documented prior to discharge, in accordance with the facility’s policy regarding “Discharge of Patient.” This deficient practice had the potential of not being able to detect a change of Patient 26’s condition such as low blood pressure or low heart rate, which may compromise Patient 26’s safety upon discharge. (Refer to A-0395) 7. The facility failed to update a plan of care (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 9), when Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep veins) to the left leg, in accordance with the facility’s policy and procedure regarding plan of care. This deficient practice resulted in the lack of appropriate interventions for Patient 9, such as removal of the Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs) from the left leg, after Patient 9 was diagnosed with DVT to the left leg. This deficient practice also had the potential to result in complications such as pulmonary embolism (PE, a blockage in one of the pulmonary arteries [carry blood from the heart to the lungs] of the lungs which can cause death). (Refer to A-0396) 8. The facility failed to ensure one of 30 sampled patient’s (Patient 18) plan of care regarding infection prevention/control (a set of evidence-based practices and procedures designed to prevent the transmission of infections in healthcare settings), was developed and implemented on admission, in accordance with the facility’s policy regarding plan of care. Patient 18 had a peripherally inserted central catheter (PICC, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) on his (Patient 18) left arm. This deficient practice had the potential for Patient 18’s care needs and risk not to be addressed which may lead to complications such as infection resulting from the use of a PICC. (Refer to A-0396) 9. The facility failed to ensure one of 30 sampled patient’s (Patient 25) plan of care on infection prevention/control, was developed and implemented, in accordance with the facility’s policy regarding plan of care. Patient 25 had severe sepsis (life-threatening blood infection), urinary tract infection (UTI, bladder infection) and possible pneumonia (lung infection). This deficient practice had the potential for Patient 25’s care needs and risks not to be addressed which may lead to worsening of infection, delayed recovery, and prolonged hospitalization. (Refer to A-0396) 10. The facility failed to ensure two of 30 sampled patients’ (Patient 29 and Patient 30) plan of care on Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control), was developed and implemented, in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for Patient 29 and Patient 30’s diabetic care needs and risks to not be addressed, which may lead to complications of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). (Refer to A-0396) 11. The facility failed to ensure, for one of 30 sampled patients (Patient 25), nursing staff adhered to the facility’s policy and procedure (P&P) titled, “Active Surveillance Strategies,” when Patient 25 was not swabbed (collecting samples like a throat swab) for Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria that does not respond to antibiotics) of the nares (nose). This deficient practice had the potential for Patient 25 to receive delayed treatment and/or interventions and potentially expose other patients to the MRSA bacteria. (Refer to A-0398) 12. The facility failed to ensure one of 30 sampled patients (Patient 20), received blood pressure medication (Hydralazine Hydrochloride [HCL], medication to lower blood pressure), as ordered by the physician. This deficient practice resulted in Patient 20’s increased blood pressure level and placing the patient (Patient 20) at risk for possible stroke (when blood flow to the brain is interrupted) or aortic dissection (artery in the heart that tears due to pressure). (Refer to A-0405) 13. The facility failed to ensure one of 30 sampled patient’s (Patient 22) intravenous antibiotics (Cefepime, used to treat/prevent infection) and a medication used to control stomach bleeding (Octreotide [medication for preventing/controlling bleeding in the stomach, also known by its brand name Sandostatin]), were administered, as ordered by the physician. This deficient practice had the potential to result in worsening of infection or delay in healing from infection (from delayed administration of the Cefepime antibiotic) as well as the potential for stomach bleed (from not administering the Octreotide) for Patient 22. (refer to A-0405) 14. The facility failed to ensure one of 30 sampled patients (Patient 9), was medicated with the correct pain-relieving medication based on Patient 9’s assessed pain level, in accordance with the physician’s order, and the facility’s policy regarding medication administration. Patient 9 was assessed with moderate pain and was medicated with a medication ordered for severe pain. This deficient practice had the potential for Patient 9 to be overmedicated and possibly suffering unnecessary side effects for the elderly, such as drowsiness, dizziness, urinary retention (the inability to completely empty the bladder), delirium (a temporary state of confusion or disorientation), or respiratory depression (a condition where breathing becomes abnormally slow and shallow). (Refer to A-0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Medical Record Services was met, as evidenced by: 1. The facility failed to ensure a discharge summary (a document that provides a concise overview of a patient’s hospital stay, including diagnoses, treatments, and follow-up instructions, ensuring a smooth transition of care to other healthcare providers and the patient) was promptly completed, within 10 days of discharge, as per the facility’s policy and procedure regarding Medical Records, for one of 30 sampled patients (Patient 8). This deficient practice resulted in Patient 8’s discharge summary being completed 15 days after discharge, which can negatively affect patient safety and continuity of care. (Refer to A-0438) 2. The facility failed to ensure documentation in the medical record was accurate, for one of 30 sampled patients (Patient 9), when Patient 9’s VTE (Venous Thromboembolism, blood cloth forms in a vein, usually deep in the legs) Assessment inaccurately indicated medicinal prophylaxis (medication to prevent a condition) to prevent blood clot formation, had been ordered for Patient 9 on 4/7/2025. This deficient practice resulted in an inaccurate description of interventions to prevent blood clot formation for Patient 9 and had the potential for not implementing additional interventions to prevent blood clots. (Refer to A-0438) 3. The facility failed to ensure one of 30 sampled patient’s (Patient 12), nursing documentation accurately reflected Patient 12’s Peripherally Inserted Central Catheter (PICC, long, thin tube that goes through the vein to the heart to deliver medication, fluids) assessment (evaluation) being completed in the “Infectious Disease Bundle (set of questions related to invasive tubes necessary for patient care),” in accordance with the facility’s policy regarding nursing documentation. This deficient practice had the potential for Patient 12 to not receive the appropriate evaluation and care. (Refer to A-0467) 4. The facility failed to ensure that for one of 30 sampled patients (Patient 2), the attending physician communicated and documented the outcome of the hospitalization, including follow-up care and provisions for post-hospital care (after hospital care) such as any upcoming appointments, patient care needs, durable medical equipment (DMEs such as wheelchair), and plans for ongoing care by providers like home health services, in accordance with the facility’s policy regarding “Medical Rules and Regulations (R&R).” This deficient practice resulted in unmet care needs for Patient 2, when Patient 2 was discharged with no wheelchair and no means for mobility to follow-up on necessary appointments, thus potentially compromising Patient 2’s safety and increasing risk of readmission and complications. (Refer to A-0468) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 2) was informed, in a timely manner, regarding patients’ rights (refer to the fundamental entitlements and protections granted to individuals receiving healthcare services) as a hospital patient, the conditions of admission (COA, is a contract between the hospital and the patient outlining the patient’s obligations while receiving care), and provided with the standardized notice titled, “An Important Message from Medicare (IM, a notification that hospitals are required to give to all Medicare beneficiaries admitted as inpatients. It informs them about their rights as a hospital patient, including their right to appeal a hospital discharge decision),” within the required two days of admission or within 2 calendar days of discharge. This deficient practice had the potential to hinder the patient’s (Patient 2) or the patient’s representative, the exercise of their rights (example: the right to refuse treatment and the right to receive necessary information about their medical condition). Findings: During an interview on 8/7/2025 at 1:03 p.m. with Patient 2’s family member (FM), the FM stated that during Patient 2’s admission at the facility, Patient 2 did not receive a copy of “An Important Message from Medicare (IM, a notification that hospitals are required to give to all Medicare beneficiaries admitted as inpatients. It informs them about their rights as a hospital patient, including their right to appeal a hospital discharge decision),” during Patient 2’s stay in the facility. The FM stated that the facility never attempted to contact the designated representative regarding the condition of admission (COA, is a contract between the hospital and the patient outlining the patient’s obligations while receiving care) or the “Important Message from Medicare.” The FM said that the facility first attempted to discharge Patient 2 on 7/8/2025, but the rights to appeal the discharge were never provided and/or explained to Patient 2 and/or FM. The FM also said that the FM never received a copy of the Important Message from Medicare (IM), and the patient’s rights (refer to the fundamental entitlements and protections granted to individuals receiving healthcare services) notice, was never provided to FM or Patient 2. During a review of Patient 2’s History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 7/6/2025, the H&P indicated that Patient 2 was admitted to the facility on 7/6/2025 due to abdominal pain and nausea (an urge to throw up). During a concurrent interview and record review on 8/7/2025 at 3:07 p.m. with the administration supervisor (ADS 2), Patient 2’s electronic medical record (EMR, a digital collection of a patient’s medical history, diagnoses, medications, immunizations, and other health information that is stored and accessed electronically) for the admission from 7/6/2025 through 7/18/2025, was reviewed. The EMR titled, “Patients’ rights as a hospital patient, the conditions of admission (COA), and a notice titled “An Important Message from Medicare (IM),” were reviewed. The COA and IM indicated that on 7/6/2025, Patient 2 was provided with the COA and IM, but was unable to sign. The ADS 2 said that a follow-up from registration was required since the patient (Patient 2) was not able to sign on the first attempt. During the same interview on 8/7/2025 at 3:07 p.m. with the administration supervisor (ADS 2), the ADS 2 said, “The registration staff should keep trying to present the COA and the IM to the patients and obtain the signature as proof that the patient was provided with the information. When a patient is unable to sign, clinical documentation should demonstrate why the patient is unable to sign the COA and IM. The next of kin should be contacted when the patient is not capable of making decisions.” The ADS 2 then reviewed clinical documentation made by the registration staff and said that there was no documentation to indicate the registration staff’s attempt to contact the next of kin for Patient 2. The ADS 2 said, “I can see documentation that the patient (Patient 2) was ‘weak’ when the attempt to present the information (the COA, the Patient Rights, and the IM), to Patient 2, was made on 7/6/2025. She (the registration staff member) also did not upload the ‘Follow-up log,’ which should be kept for patients unable to sign their COA and IM, and the log should indicate documented reason why signatures for the COA and IM were not obtained. Based on this record (Follow-up log), the registration staff member attempted to obtain Patient 2’s signature on 7/7/2025 and 7/8/2025, but the reason why the patient was not able to sign was not indicated in the log.” The ADS 2 then confirmed that Patient 2 signed the COA and IM on 7/9/2025 (3 days after admission and 1 day after the first “cancelled” order for discharge on 7/8/2025). During a review of the facility’s policy and procedure (P&P) titled, “Admitting,” dated 7/2023, the P&P indicated, “The Conditions of Admission (COA) contains twenty topic items with detailed legal and informational elements ... The completion of this legal and binding document is essential. The patient or patient’s representative agrees that by signing this document that they understand the terms and conditions and acknowledges his/her agreement by signing the document in the presence of Registration Representative. By signing the COA document the patient or the patient’s legal representative certifies that they have read and received a copy of this document ...If patient is unable to sign: the registration representative must indicate the reason ...An Important Message from Medicare ... is a mandated form that reviews the patients’ rights as a Medicare or Senior recipients while in-patient and provides contact resources for the patients if needed. The Form provides Medicare Discharge Rights for the patients about their discharge rights from the facility ...” During a review of the Federal Regulations 42 CFR 489.27(a) and 42 CFR 405.1205(c), the Federal Regulations indicated “each Medicare beneficiary who is an inpatient (or his/her representative) must be provided the standardized notice, ‘An Important Message from Medicare’ (IM), within 2 days of admission...” and “requires that hospitals present a copy of the signed IM in advance of the patient’s discharge, but not more than two calendar days before the patient’s discharge.””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interview and record review the facility failed to ensure that the exercise of patients’ rights (the fundamental entitlements and protections granted to individuals receiving healthcare services. These rights aim to ensure that patients receive safe, respectful, and informed care while upholding their autonomy and dignity) requirements were met, when: 1. The facility failed to ensure that one of 30 sampled patients (Patient 2) and/or Patient 2’s designated representative, received regular updates including documentation of communication from the attending physician regarding consultant findings (evaluations or recommendations provided by specialists or other healthcare providers) as well as any adjustments/modifications in Patient 2’s plan of care (a comprehensive document that outlines their health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey ), in accordance with the facility’s policy regarding “Medical Rules and Regulations (R&R)” and “Patient Rights and Responsibilities.” This deficient practice had the potential to hinder a coordinated and patient-centered care due to lack of involvement of Patient 2 and/or Patient 2’s designated representative in Patient 2’s medical care and medical decision-making, which may impact Patient 2’s treatment outcome. 2. The facility failed to ensure one of 30 sampled patient’s (Patient 3), Accu-Chek (a brand of blood glucose testing system used to measure blood sugar levels), ordered to be done 4 times a day (before meals and at bedtime) was discontinued, due to lack of medical indication for continuously monitoring Patient 3’s blood sugar four times a day for over a month during Patient 3’s stay at the facility, in accordance with the facility’s policy regarding Patient Rights and “Medical Rules and Regulations (R&R).” This deficient practice had the potential to result in unnecessary discomfort, increased risk of skin irritation or infection at the blood sampling site, and increased healthcare costs for Patient 3. In addition, this deficient practice had the potential for inappropriate treatment or missed opportunities for necessary intervention, thereby compromising Patient 3’s safety. Findings: 1. During a review of Patient 2’s History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 7/6/2025, the H&P indicated that Patient 2 was admitted to the facility on 7/6/2026 due to abdominal pain and nausea (urge to throw up). During an interview on 8/7/2025 at 1:03 p.m. with Patient 2’s family member (FM), the FM stated that during Patient 2’s admission at the facility, the attending physician rarely communicated the plan of care (a comprehensive document that outlines their health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey) with the family. The FM also reported that the facility attempted to discharge Patient 2 multiple times without having the attending physician speak with the family prior to placing the discharge order. Additionally, the FM said that the physician never communicated with the family that Patient 2 could not walk and required a wheelchair. FM 1 said that after Patient 2 was discharged home via ambulance, Patient 2 had no means of mobility (ability to move freely) or transportation to attend appointments, as the facility discharged Patient 2 without arranging for a wheelchair at home. During an interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ stated that when Patient 2 was admitted to the facility on 7/5/2025, Patient 2 was able to walk with a walker. However, based on the physical therapy (PT) evaluation, dated 7/14/2025 (completed after Patient 2 underwent surgical hernia [a condition where an internal organ or tissue bulges through a weak spot in the surrounding muscle or tissue] repair), Patient 2 could no longer walk and was significantly below functional baseline (Patient 2’s usual level of independence and mobility), thus would require a wheelchair. DDQ also said that the PT Evaluation indicated that there was no recommended discharge DME (Durable Medical Equipment, medical equipment that is primarily and customarily used to serve a medical purpose, is durable enough to withstand repeated use, and is generally only useful to a patient due to illness or injury and in the home environment. Examples include wheelchairs) need, because Patient 2 confirmed ownership of a wheelchair. However, the PT Evaluation also indicated that Patient 2 “was a poor historian and confused, and wheelchair ownership may need to be confirmed with the son (which was not done).” The DDQ also said that the physician (MD 2) did not order a wheelchair (DME) for Patient 2 prior to discharge. During further interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said the following regarding case management (a collaborative process focused on coordinating patient care to ensure efficient, effective, and safe transitions through the healthcare system) and discharge planning (a coordinated process of preparing patients to leave the hospital and transition to the next level of care, whether that’s home, a rehabilitation facility, or another setting) for Patient 2, “The case management (CM) team responsible for the patient’s (Patient 2) insurance group was involved and participated in rounds (a structured process where medical professionals visit patients to assess their condition, review their care plan, and address any needs) with the physician; all relevant medical records for Patient 2 were faxed to the medical insurance group CM. The CM team from the insurance group was responsible for following up on the DME needs for patient (Patient 2).” During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ explained that the facility was not contracted with the medical group that insured Patient 2, and the CM team from that group did not share the information about communications or decision made between the case management team and the physician. “For instance, after entering an order for home health services post-discharge and communicating this to the insurance group, the facility’s case management has no way of knowing if the home health services were arranged or set-up for the patient (Patient 2).” During an interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said, “I review physical therapy recommendations before discharge. For example, if a patient needs a walker, I place an order for discharge planning department, and then they identify the need for a durable medical equipment (DME). The discharge planning team will communicate this need to the contracted insurance case management (CM) to arrange for the DME, but they (referring to the contracted insurance CM) do need to have an order for a walker to arrange for it.” During an interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said the following regarding communication requirements with patients and families: “I communicate with patients and families daily. I discuss the plan of care, goals of care, and prognosis (the predicted future course and outcome of a disease or medical condition) ... I document to the best of my ability, and documenting the communication in a patient’s medical record is a medical record-keeping requirement.” MD 2 also said that during Patient 2’s admission, MD 2 documented communication with Patient 2’s son in the progress notes. During a review of Patient 2’s Attending physician progress notes, dated 7/6/2025 through 7/18/2025, the progress notes indicated that on: -7/6/2025- there was no documentation of discussing an admission plan or plan of care with Patient 2 or Patient 2’s family. -7/7/2025- there was no documentation indicating that Patient 2 and/or family were updated regarding their (Patient 2) plan of care. -7/8/2025-the note indicated that Patient 2 was going to be discharged back to home on 7/8/2025 -7/9/2025-there was documentation indicating that the plan of care was discussed with Patient 2’s son at the bedside -7/10/2025- the note indicated that Patient 2 was pending being evaluated by general surgeon; no documentation was found in the note regarding the plan of care and the plan for surgery having been discussed with Patient 2 and/or their family. -7/11/2025- the note indicated that Patient 2 was scheduled for “hernia repair today,” but no documentation of the plan of care and consultation evaluation results discussed with Patient 2 and/or their family was found recorded in the 7/11/2025 progress note. -7/18/2025-Discharge Summary-no documentation of what diet Patient 2 should follow at home, no documentation of DME needs at home, and no documentation of Home Health arrangements being discussed with Patient 2 and/or their family having been recorded in the Discharge Summary dated 7/18/2025. -The Attending physician progress notes, dated 7/6/2025 through 7/18/2025, were reviewed on 8/7/2025 at 10:30 a.m., with the stroke (when blood flow to the brain is interrupted) coordinator (SC) and the Director of Data Quality (DDQ) and the information indicated in the physician progress notes were verified by the SC and DDQ. During an interview on 8/8/2025 at 2:52 p.m. with the Chief Medical Officer (CMO), the CMO made a statement regarding documentation and discussion of the plan of care with patients and families: “Communication-every physician is mandated to communicate with the family regarding admission, discharge, and whenever there is a change in the patient’s condition, a need for a procedure, or tests and/or outcomes. The expectation is for the physicians to communicate and document these interactions in the patients’ medical records.” During a review of the facility’s “Medical Rules and Regulations (R&R),” dated 10/2024, the Medical R&R indicated, “1.8 Duties of Attending physicians: 1.8-4:Communication with the family regarding the findings of consultants and alterations to the plan of care is the duty of the Attending physician ...1.8.-6: Coordinating the management of the patient with nursing ... 1.8-7: reassessing the patient at regular intervals ....1.8-8: Working closely with case management staff to assure that the record contains sufficient information to support coverage and resource use decisions ...1.8-10: Working with discharge planning to assure a smooth transition of the patient to the appropriate after care setting ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 1/2025, the P&P indicated, “Patients have the right to 2. Have effective communication for critical information in a manner you understand ... information from your physician about your diagnosis, prognosis, treatment or consent for treatment, discharge planning ...5. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care ...” 2. During a review of Patient 3’s History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 10/13/2024, the H&P indicated that Patient 3 was admitted to the facility on 10/13/2024 due to altered mental status (AMS, a change in a person’s level of consciousness [a person’s state of awareness and responsiveness to their surroundings), awareness, and cognitive function [the mental processes involved in acquiring, processing, and using information]). During a review of Patient 3’s nursing narrative notes , dated 11/7/2024, the nursing narrative notes indicated that on 11/7/2024 at 1:30 p.m., Patient 3’s blood sugar level was 230 milligram per deciliter (mg/dL, measuring unit, normal range for blood glucose level is 70-99 mg/dl fasting [not eating and drinking anything, except water, for a period of time], and below 140 mg/dL non-fasting), with a documented order to give Patient 3 a total of 10 units (U, measuring unit for insulin) of insulin (a hormone produced by the pancreas that regulates blood sugar levels) intravenously (IV, give directly into the vein).The nursing narrative notes further indicated that the nurse contacted the resident physician (Resident Physician 1) regarding the inability to administer IV insulin due to the level of care (the intensity and type of medical services provided to a patient based on the complexity and severity of their condition). During further review of Patient 3’s nursing narrative notes , dated 11/7/2025, the nursing narrative notes indicated that on 11/7/2024 at 2:07 p.m., the registered nurse documented that the physician who ordered the insulin did not call back, and an order to discontinue blood sugar checks was obtained from a different resident physician (Resident Physician 2) to stop all blood sugar testing (called Accu-Chek, brand name of blood glucose [sugar] meters used to monitor blood sugar levels) altogether because Patient 3 was not diabetic (a condition characterized by high blood sugar levels due to the body’s inability to produce or use insulin effectively). During an interview on 8/8/2025 at 11:24 a.m. with the clinical educator (CE), the CE stated the following regarding nurses’ expectations when clarifying orders that may seem medically unnecessary, “ It would be prudent for the nurses to ask why they are checking blood sugars in patients with no history of diabetes and when there is no sliding scale (a protocol that outlines insulin doses to be administered based on specific blood sugar levels) ordered to address the blood sugars that are out of range.” During a concurrent interview and record review on 8/8/2025 at 1:30 p.m. with the Clinical Nurse Supervisor (CNS 5), Patient 3’s electronic medical record (EMR, a digital collection of a patient’s medical history, diagnoses, medications, immunizations, and other health information that is stored and accessed electronically) for the visit dated 10/13/2024-through 12/6/2025, was reviewed. The CNS 5 confirmed that Patient 3 had no documented diagnosis of diabetes. The CNS 5 also confirmed that Patient 3 had no order for insulin sliding scale. The CNS 5 said the physician placed an order for blood sugar checks - (before meals and at bedtime, 4 times a day) on 10/13/2024. The CNS 5 said that the order for the Accu-Chek did not include a rationale (a reason or justification) for monitoring the patient’s (Patient 3’s) blood sugar. The CNS 5 also verified that Patient 3’s Accu-Chek order was discontinued on 11/7/2024. During an interview on 8/8/2025 at 12:11 p.m. with the physician (MD 3), MD 3 stated that he (MD 3) did not know why the blood sugar checks were ordered by one of the resident physicians. MD 3 said, “ Accu-Chek was probably ordered because patient (Patient 3) came in as a stroke patient (an individual who has experienced a cerebrovascular accident [CVA], commonly known as a stroke, where blood flow to the brain is disrupted, leading to potential brain damage and loss of function),” but MD 3 could not explain why an insulin sliding scale was not ordered. During an interview on 8/8/2025 at 2:52 p.m. with the Chief Medical Officer (CMO), the CMO stated that the facility had been aware of this case (referring to the unnecessary ordering of glucose checks for Patient 3). The CMO further clarified that this medical case (Patient 3’s stay from 10/13/2024 through 12/6/2024 ) had undergone peer review (a process where healthcare professionals review and evaluate each other’s clinical decisions and practices to ensure quality and adherence to standards). The peer review confirmed that blood sugar checks on Patient 3 should have been discontinued since they were never medically required. The CMO stated that the physician should have never ordered the glucose checks, and additionally, the CMO said that nurses-patient advocates, should have raised concerns and questioned the order with the physician, but they did not. During an interview on 8/8/2025 at 2:32 p.m. with the Program Director for internal Medicine-Residency Program (MD 4) and the Chief medical Officer (CMO), MD 4 said that MD 3 was the supervising physician for the resident physicians overseeing care for Patient 3. MD 4 said that the duty of a supervising physician was to know their patients well to ensure that the care delivered to the patients was appropriate and not compromised. MD 4 also said that attending supervising physicians must be familiar with all orders made by resident physicians during their rounds. The CMO emphasized that supervising physicians were expected to know their patients, and it was unacceptable for a supervising physician to have no idea why the Accu-Chek was ordered in the first place and/or insulin sliding scale was not. During a review of Patient 3’s History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 10/13/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of a person’s previous medical conditions, illnesses, surgeries, hospitalizations, and treatments) of hypertension (elevated blood pressure), pacemaker (a small, battery-powered electronic device that helps regulate a slow heart rate [bradycardia] by sending electrical impulses to the heart), blindness in the right eye and dementia (a broad term describing a decline in mental abilities, including memory, thinking, and reasoning, severe enough to interfere with daily life). The H&P also indicated that Patient 3’s sugar level was 108 mg/dL (milligram per deciliter, a unit of measure) and hemoglobin A1C (HgA1C, a blood test that reflects a person’s average blood sugar levels over the past 2-3 months) was pending to rule out diabetes; Accu-Chek was ordered; if positive for diabetes, add insulin. During a review of Patient 3’s medical record titled, “Laboratory Results,” dated 10/13/2024, the MR indicated that Hemoglobin A1C resulted on 10/13/2024 and was 5.3 % (Below 5.7% is healthy). During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Care,” dated 7/2023, the P&P indicated, “Standard I: A. Assessment: This is the process of identifying and collecting information concerning the health status of assigned patients on the unit: assessment is to be complete, continuous, and systematic ... 2. Standard II: A. Assuming responsibility and accountability for ensuring that a stated level of quality is maintained as it relates to individual patents on specific units.” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 1/2025, the P&P indicated, “Considerate and respectful care, and to be made comfortable ...” During a review of the facility’s policy and procedure (P&P) titled, “Internal Medicine Residency Program,” dated 4/2025, the P&P indicated, “ The Policy applies to the residents in the Internal Medicine Residency Program and the supervising faculty at the [name] Medical Center ...It is the policy of [Name} medical center to ensure that residents are appropriately supervised by the teaching staff ...Supervising Attending Physician is ultimately responsible for the care of the patient ...” During a review of the facility’s “Medical Rules and Regulations (R&R),” dated 10/2024, the Medical R&R indicated, “The attending physician is the MD or DO who is responsible for the care of the principal diagnosis, that clinical condition which is the main reason the patient was hospitalized ...Duties of the Attending Physician include, but not limited to: Coordinating the management of the patient with nursing ...Reassessing the patient at regular intervals ...””

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that one of 30 sampled patient’s (Patient 1) validation of identity, was completed, in accordance with the facility’s protocol when registering patients, performing medical procedures, and administering medications in the emergency department (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries), when Patient 1 was registered under the incorrect first name and was provided incorrect patient identifiers (a piece of information, such as wristband and labels, used to reliably and uniquely identify an individual to ensure they receive the correct care and treatment). This deficient practice had the potential to compromise Patient 1’s safety, and resulted in misidentification of Patient 1 (Patient 1 was registered under the medical record profile of Patient 1’s twin sister), prolonged stay in the Emergency Department (ED) and unnecessary repeats of venipuncture (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) which may lead to a potential psychological distress for Patient 1. Findings: During a review of Patient 1’s Emergency Department Physician Documentation, dated 7/16/2025, the ED Physician Documentation indicated that Patient 1 was seen in the emergency department (ED, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries) on 7/16/2025 for low back and pelvic (The bones between the lower abdomen and upper thighs that connect the spine to the legs) pain after a Motor Vehicle collision (MVC, any incident where a vehicle [or vehicles] comes into contact with another vehicle, a pedestrian, an animal, or a stationary object) one (1) hour before the arrival in the ED. The ED Physician Documentation also indicated Patient 1 was 16 weeks pregnant and wanted to check the health of the baby after being in an accident. During a concurrent interview and record review on 8/6/2025, at 10:48 a.m. with the STEMI Coordinator (MIC, a healthcare professional, often a registered nurse, who is responsible for the organization, development, planning, management, and evaluation of a hospital’s ST-segment elevation myocardial infarction [STEMI, a severe type of heart attack where a major artery supplying blood to the heart is completely blocked, causing significant damage to the heart muscle] program), Patient 1’s electronic medical record (EMR) titled, “Emergency Department Visit,” dated 7/16/2025, was reviewed. The EMR indicated that Patient 1 completed registration in the emergency department (ED) on 7/15/2025 at 9:15 p.m. The registration form titled, “Medical Screening Patient Information Sheet,” dated 7/15/2025, indicated that Patient 1’s first name was different from the name on the label created for Patient 1 by the registration staff. The MIC confirmed that Patient 1’s first name, did not match the first name recorded on the label. During an interview on 8/6/2025 at 11:18 a.m. with the Administration Supervisor (AS 1), the AS 1 stated, “When a patient first arrives at the emergency department, they are provided with the intake forms (a document used to collect essential information from a patient upon their arrival), which are later reviewed by registration staff and patient’s identity is verified by the patient either verbalizing their name and date of birth and/or providing their physical identification card (ID card) and/or driver’s license (DL). Once the personal information has been validated, the medical record for the visit is typically created. The registration staff creates a digital encounter visit profile (electronic medical record) and prints labels for the patient (adhesive tags printed with important information, used to accurately identify the patient and ensure correct matching records, samples, medications, and wristbands). The registration personnel then creates a wristband and forwards it to the printer in the triage area (the process of quickly assessing patients in an emergency to determine the severity of their condition and prioritize their care), which is printed by the triage nurse for patient identification purposes.” During an interview on 8/6/2025 at 11:20 a.m. with the emergency department registered nurse (RN) 15, RN 15 said the following regarding validation of patients’ identity in triage (and emergency department): “We verify the patient’s identity against their wristband. We ask the patient their first and last name, as well as their date of birth and verify the obtained information against what is recorded on the wristband and digital medical records. If the information does not match or is incorrect, we contact registration staff to re-do the labels and the wristband. Once the patient is moved inside the emergency department from triage area, anyone who meets the patient, prior to performing any procedures or administering medication, must ensure they are identifying the right patient by verifying the information against the wristband and confirming verbally with the patient their name and date of birth. We can then scan the barcode printed on the label to administer medication, for example. I am not sure phlebotomists (healthcare personnel who specializes in drawing blood from patients) do it, but when nurses draw blood, they have to make sure this is the correct patient before they complete any procedure or administer a treatment or medications.” During further review of Patient 1’s “Emergency Department Physician Documentation,” dated 7/16/2025, the ED Physician Documentation indicated that Patient 1 was originally registered under the twin sister’s name. The initial physician’s orders (venipuncture [medical procedure to withdraw a blood sample from a vein for laboratory testing], Tylenol [acetaminophen, medication used for pain], and pelvic ultrasound [a non-invasive medical imaging test that uses high-frequency sound waves to create pictures of the organs and structures within the pelvic area]), were placed under the wrong account (an account that was created under the twin’s sister name for the visit on 7/15/2025) before the patient (Patient 1) realized that her (Patient 1) name was incorrect on the wristband (a band worn by patients, typically around their wrist, to facilitate quick and accurate patient identification). The ED Physician Documentation also indicated that Patient 1 was later re-registered under the correct name and medical account, but the phlebotomy department (the department responsible for the practice of drawing blood from a patient, typically for diagnostic testing, medical research, or blood donation) refused to process the blood draw that had been previously collected under the incorrect name, as a result, Patient 1’s blood draw had to be repeated. During a concurrent interview and record review on 8/6/2025 at 11:20 a.m. with STEMI Coordinator (MIC), Patient 1’s twin sister’s electronic medical record (EMR) titled, “ED Summary Report,” dated 7/15/2025, was reviewed. The MIC reviewed the EMR titled, “ED Summary Report,” and verified that there was a documentation under the incorrect EMR (Patient 1’s twin sister’s EMR) indicating that Patient 1 received 650 milligrams (mg, measuring unit) Tylenol (medication for mild pain), had venipuncture, urinalysis (a laboratory test that involves examining a patient’s urine to assess its physical properties, chemical composition, and microscopic components), and pelvic ultrasound all completed while registered under Patient 1’s twin sister’s medical profile. During a review of the facility’s policy and procedure (P&P) titled, “Patient Identification,” dated 7/2023, the P&P indicated that “at least two identifiers are used when preparing to collect specimens and when processing specimens. The use of any two of the following .... Is considered acceptable when validating a patient’s identity: -Patient name -Patient account number -Patient medical record number -Patient date of birth Before drawing blood specimen, ask the patient to state his or her name and spell it, if in doubt. Verify by checking armband, comparing two identifiers with the information on the collection document (labels) ...Do not assume that the armband is correct if patient states his name is different, go verify with nurse ...” During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration,” dated 6/2024, the P&P indicated, “4. Prior to administration, the 6 R’s must be verified: a. Right drug -Verify that the medication selected for administration is the correct one based on the medication order and product label by reading the medication label at least 3 times i. When selecting the medication ii. Just prior to administration iii. Just after administration b. Right dose c. Right time (30-60 min before or after scheduled administration time) d. Right route e. Right patient (using 2 identifiers, not including room number) f. Right documentation ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36206 Based on interview and record review the facility failed to: 1. Ensure one of 30 sampled patients (Patient 8) was discharged safely, when Patient 8’s discharge order was written by mistake. Nursing staff failed to clarify the order which indicated to discharge Patient 8 to a shelter via uber (a transportation and ride-sharing company), even though nursing staff noted Patient 8 would be discharged home and transported by family. In addition, Nursing staff failed to a complete a full set of vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood] with and without supplemental oxygen). The respiratory rate and oxygen saturation (without oxygen) were not assessed prior to Patient 8’s discharge, in accordance with the facility’s policy and procedure regarding Discharge of Patient. This deficient practice resulted in the unsafe discharge of Patient 8. Patient 8 passed away a few hours after discharge. 2. Ensure one of 30 sampled patient’s (Patient 9) VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) Assessment was performed, in accordance with the facility’s policy and procedure regarding VTE Assessments. A full VTE assessment was not performed when Patient 9 was transferred to another unit or had a change of condition. In addition, per documentation, sequential compression devices (leg squeezers) were not removed from Patient 9’s left leg, when Patient 9 developed a blood clot to the left leg on 4/10/2025. This deficient practice had the potential for incorrect VTE risk assessments and had the potential for inappropriate interventions to be implemented for Patient 1, which could result in dislodgement of the blood clot, and possibly traveling to other organs, such as the heart or lungs, which may result in a pulmonary embolism (PE, a blockage in one of the pulmonary arteries [carry blood from the heart to the lungs] of the lungs which can cause death). 3. Ensure one of 30 sampled patient’s (Patient 13) vital signs and reassessment was completed and documented every two hours, in accordance with the facility’s policy regarding “Documentation in the ED (Emergency Department, a hospital department that provides 24/7 unscheduled medical care to patients who require immediate attention for acute illnesses or injuries) Patient Care Record” and “Standard of Nursing Care.” This deficient practice resulted in delayed or missed opportunities for appropriate medical interventions, potentially resulting in negative outcomes (example, low blood pressure) for Patient 13. 4. Ensure one of 30 sampled patient’s (Patient 9) pain level was assessed, prior to administering hydrocodone/acetaminophen (or Norco, a combination medication of an opioid [a class of drugs used to reduce moderate to severe pain, and can also boost feelings of pleasure] and an over-the-counter pain reliever, used to relieve moderate to severe pain), in accordance with the facility’s policy regarding pain management. This deficient practice had the potential for Patient 9 to be medicated unnecessarily and the possibility of experiencing unnecessary side effects, such as drowsiness (feeling unusually sleep or tired), lack of energy, or even slowed or shallow breathing. 5. Ensure one of 30 sampled patients (Patient 26), was repositioned (regularly changing a patient’s body position to relieve pressure on specific areas, especially those at risk of or affected by pressure injuries [localized damage to the skin and/or underlying tissue, usually over a bony prominence]) every two hours, in accordance with the facility’s policy and procedure regarding “Skin Integrity (the overall health and condition of the skin).” This deficient practice had the potential to result in the worsening of Patient 26’s pressure injury leading to prolonged healing and/or hospitalization. 6. Ensure one of 30 sampled patient’s (Patient 26) vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood]), was assessed and documented prior to discharge, in accordance with the facility’s policy regarding “Discharge of Patient.” This deficient practice had the potential of not being able to detect a change of Patient 26’s condition such as low blood pressure or low heart rate which may compromise Patient 26’s safety upon discharge. On 8/07/2025 at 10:38 a.m., the survey team called an immediate Jeopardy (a situation in which the facility’s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment or death to a patient) in the presence of the Director of Quality Improvement (DQI), Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO). Patient 8 was admitted to the facility for shortness of breath (being unable to breath normally) and swelling to both legs, on 6/3/2025. The facility failed to ensure Patient 8 was discharged safely, when Patient 8’s discharge order was written by mistake on 6/5/2025, indicating to discharge patient (Patient 8) to a shelter via uber (a transportation network company that provides a platform for users to request rides), with home medications. Patient 8’s discharge order was not clarified by Registered Nurse (RN 1), who documented that Patient 8 would be discharged home, not a shelter, and transportation would be provided by a family member, not by uber. Earlier, on the day of discharge on 6/5/2025, Patient 8’s nursing assessment indicated Patient 8 was noted with bilateral (both) wheezing (a high-pitched whistling sound produced during breathing, caused by narrowed airways) to the upper chest, short of breath, had difficulty breathing, was receiving 3 - 4 Liters of supplemental oxygen, had a distended abdomen, and pitting edema (a type of swelling [edema] where a pit or indentation remains in the skin after pressure is applied and then released) to the bilateral lower extremities. RN 1 also failed to take a full set of vital signs (blood pressure, heart rate, respiratory rate, Temperature, Oxygen saturation [a measure of how much oxygen is in the blood]) prior to discharging Patient 8. Patient 8’s heart rate was 107 (elevated, normal is 60 - 100), the respiratory rate (the number of breaths a person takes per minute, typically measured at rest) was not assessed. The oxygen saturation was 95 %, while Patient 8 was receiving 3 L/min of supplemental oxygen. The oxygen saturation level was not assessed after Patient 8’s supplemental oxygen was discontinued by RN 1. RN 1 did not clarify with the provider if Patient 8 should be discharged with or without oxygen. Patient 8 was discharged home, with family, without oxygen on 6/5/2025 at 3:32 p.m. Patient 8’s discharge summary indicated Patient 8 needed further treatment and unfortunately had been discharged in error. A nurse’s note dated 6/5/2025 at 8:23 p.m. indicated Patient 8 passed away at home (after being discharged in error). On 8/08/2025 at 11:51 a.m., the IJ was removed in the presence of the DQI, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The acceptable IJ Removal Plan included the following: Clarification of any discharge orders by the provider that does not correlate with patient condition or discharge disposition. Discharge assessment with a full set of vital signs and assessment of patient’s oxygen needs. Facility Discharge policy to include assessment of patient’s oxygen needs; if patient is on oxygen at the time of discharge, ensure there is accommodation in place for home oxygen and clarify with the discharging provider. Modifications of the electronic medical record to include the Discharge Patient Assessment module to include “Respiratory Rate, oxygen saturation on room air, and Delivery Method, and applicable need for home oxygen. The charge nurse will notify the Nursing Director of all pending discharges. The Nursing Director will review all discharge orders and discharge assessments to ensure all elements of discharge are met, prior to discharging patients. All units are documenting the verification with initial, in the Safe Discharge Monitoring Tool. In addition, education and re-education on clarification of any discharge order that does not correlate with patient condition or discharge disposition, Safe Discharge progress, Discharge of Patient policy revision, notify provider if vital signs are out of range at discharge, if patients are on oxygen at time of discharge, ensure there are either arrangements made for home oxygen or notify provider for further instructions. Findings: 1. During a concurrent interview and record review on 8/6/2025 at 9:56 a.m. with Registered Nurse (RN) 1, RN 1 stated the following: RN 1 assumed care for Patient 8 on 6/5/2025 at 10:46 a.m. Patient 8 was admitted on 6/3/2025 for shortness of breath (being unable to breathe normally) and leg swelling. RN 1 confirmed that Patient 8 was not receiving oxygen at home, at the time of admission. Patient 8 required supplemental oxygen during his (Patient 8) hospitalization. RN 1 received a physician’s order on 6/5/2025 at 2:02 p.m., to discharge Patient 8 to a shelter, via uber (a transportation and ride-sharing company), and continue home medications. RN 1 did not question the order, to discharge to a shelter via uber. RN 1 only verified that Patient 8 was not homeless and would not be discharged to a shelter, instead Patient 8 would be discharged home with a family member (FM 1), who was present at the bedside. RN 1 checked Patient 8’s vital signs (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation [a measure of how much oxygen is in the blood] with and without supplemental oxygen) prior to discharge. The heart rate was 107 (elevated, normal 60-100), the respiratory rate (the number of breaths a person takes per minute) was not checked, prior to discharge. The oxygen saturation level was 95 % while Patient 8 was still receiving oxygen at 3 liters. RN 1 discontinued Patient 8’s oxygen and discharged Patient 8 home with FM 1. During the same interview on 8/6/2025 at 9:56 a.m. with Registered Nurse (RN) 1, RN 1 stated Patient 8’s oxygen saturation level was not assessed, after the supplemental oxygen was discontinued. RN 1 observed Patient 8 and determined Patient 8 was not in respiratory distress (a condition where a person has difficulty breathing, often characterized by rapid, shallow, or labored breathing) after discontinuing the oxygen, then RN 1 discharged Patient 8 home with FM 1 at 3:32 p.m. RN 1 did not contact the physician to question the discharge order or to question whether or not Patient 8 should be discharged without oxygen. RN 1 stated that on 6/5/2025 at 4 p.m., she (RN 1) received a call from Physician (MD) 5, who informed her (RN 1) that Patient 8’s discharge order was written in error and to notify Patient 8 and family to return to the hospital. RN 1 called Patient 8 and left a voice mail to return to the hospital. RN 1 stated that later that day, on 6/5/2025 at 8:23 p.m., MD 5 informed RN 1 that MD 5 spoke to Patient 8’s family member (FM 2), who stated that Patient 8 passed away. During an interview on 8/6/2025 at 11:16 a.m. with the Director of Telemetry (DT 1), the DT 1 stated the following: A full set of vital signs were required upon discharge to determine if it was safe to discharge a patient. DT 1 verified that the Respiratory Rate was not documented upon discharge, and Patient 8’s oxygen saturation was not checked when Patient 8’s supplemental oxygen was discontinued. In addition, DT 1 stated that Patient 8’s discharge order, to discharge to a shelter via uber, should have been questioned since it did not match what was observed with Patient 8, who had family at bedside to take Patient 8 home. During an interview on 8/6/2025 at 1:14 p.m. with MD 5, MD 5 stated the following: Patient 8 was admitted due to shortness of breath and edema (swelling of body tissues due to an excessive buildup of fluid) to both legs. Patient 8 appeared to be in heart failure (heart does not pump blood as well as it should). Patient 8 required supplemental oxygen while hospitalized, and there was no previous history of Patient 8 receiving oxygen at home. Patient 8’s plan included further workup per cardiology (a branch of medicine that deals with disease of the heart) and nephrology (a branch of medicine specializing in treating kidney conditions) recommendations. During the same interview on 8/6/2025 at 1:14 p.m. with MD 5, MD 5 stated that on 6/5/2025, he (MD 5) had another patient who was to be discharged to a shelter. MD 5 meant to place an order for another patient to be discharged to a shelter but instead MD 5 placed a discharge order for Patient 8, in error. A little later that day, while MD 5 checked Patient 8’s notes, MD 5 realized that Patient 8 had been discharged by mistake and immediately called RN 1 to notify Patient 8 to return to the hospital. MD 5 also called FM 1, who was crying at the time. FM 1 informed MD 5 that Patient 8 passed away at home. MD 5 stated nursing staff should advocate for patients. Nursing staff could have questioned the discharge order and should have checked Patient 8’s oxygenation status without oxygen and informed him (MD 5) of the results. If oxygen saturation was less than 92 % on room air, MD 5 could have ordered an ABG (Arterial Blood Gas, measures the level of oxygen and carbon dioxide in the blood) to determine if Patient 8 needed oxygen at home, and that may have resulted in MD 5 realizing that Patient 8’s discharge order was a mistake. During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/3/2025, the H&P indicated the following: Patient 8 was admitted to the facility on 6/3/2/2025 for shortness of breath and leg swelling. Patient 8 had a past medical history of Atrial fibrillation/flutter (irregular and rapid heart rate/heart’s upper chambers beat too quickly), Hypertension (high blood pressure), Diabetes mellitus (high blood sugar), urinary retention (difficulty urinating and completely emptying the bladder), and COPD (chronic obstructive pulmonary disease, a group of lung disease that block air flow and make it difficult to breathe) exacerbation (increase in severity of illness). Patient 8 was admitted to the Telemetry ward (a specialized hospital area dedicated to continuous, remote monitoring of patients’ vital signs, primarily focusing on cardiac [heart] activity) and consult with Cardiology and Nephrology (additional work ups (blood draw, diagnostic tests) were ordered but were not carried out due to Patient 8 being discharged inadvertently). During a review of Patient 8’s Initial Nursing Assessment, dated 6/3/2025, the Initial Nursing Assessment indicated Patient 8 did not reside in a temporary living situation or shelter. During a review of Patient 8’s Telemetry Nurse’s Flow Sheet, dated 6/5/2025 at 8 a.m., the Flow Sheet indicated the following: Patient 8 had shortness of breath/difficulty breathing/ Labored respirations (difficulty/increased effort in breathing). Receiving oxygen via nasal cannula (a medical device used to deliver supplemental oxygen) at 4 L/min (Liters per minute, a unit of measure). Bilateral (both) wheezing (a high-pitched whistling sound produced during breathing, caused by narrowed airways) to the upper lungs ...Bilateral legs 4+ pitting edema (a type of swelling [edema] where a pit or indentation remains in the skin after pressure is applied and then released) ... Unsteady gait (an abnormal walking pattern characterized by a lack of balance or coordination). Distended abdomen (a noticeable increase in the size of the abdomen). During a review of Patient 8’s nurse’s note, dated 6/5/2025 at 8:30 a.m., the nurse’s notes indicated the following: Patient 8 noted with “wheezing bilaterally in upper chest. On 3 liters of oxygen ...Abdomen distended. Patient 1 noted with 4+ pitting edema bilaterally ...” During a review of Patient 8’s nurse’s note, dated 6/5/2025 at 10:45 p.m., the nurse’s note indicated the following: Patient 8 “is on 3 liters of oxygen. Declined using oxygen at home. Nurse (RN 1) received report, Patient 8 has lower extremity pitting edema ...Abdomen was distended).” During a review of Patient 8’s Discharge Order, dated 6/5/2025 at 2:05 p.m., the Discharge order indicated to discharge to shelter via Uber, continue home medications. During a review of Patient 8’s Patient Visit Summary, dated 6/5/2025 at 2:35 p.m., Patient Visit Summary indicated the following: Pulse rate: 107 (high, normal is 60 - 100), blood pressure 113/86 (normal 120/80), Oxygen saturation was 95 % (within normal limits), there was no documentation indicating if Patient 8 was receiving oxygen at that time of measuring. Respiratory rate was not assessed. During a review of Patient 8’s nurse’s note, dated 6/5/2025 at 3:32 p.m., the nurse’s note indicated Patient 8’s daughter (FM 1) was in patient’s room when the discharge order news was relayed to Patient 1. FM 1 drove Patient 8 home. During a review of Patient 8’s nurse’s note, dated 6/5/2025 at 8:23 p.m., the nurse’s note indicated MD 5 called back. MD 5 stated he (MD 5) spoke to Patient 8’s family member (FM 2). MD 2 reported that Patient 8 passed away at home (soon after discharge from the facility). During a review of Patient 8’s Discharge Summary, dated 6/20/2025, the Discharge Summary indicated the following: Patient 8 was admitted on 6/3/2025 and discharged on 6/5/2025. Patient 8 was in need of diuresing (elimination of urine and excess body fluid) due to his (Patient 8) dependent edema (swelling that occurs in the lower parts of the body due to the effects of gravity) and pleural effusions (buildup of fluid between the tissues that line the lungs and the chest) noted. Patient 8 needed further evaluation. Unfortunately, Patient 8 was discharged from the hospital in error. Upon realizing this, a call was immediately made to the patient (Patient 8) and family to instruct Patient 8 to return to the hospital immediately or go to the nearest hospital available for medical attention. During a review of the facility’s Policy and Procedure (P&P) titled, “Discharge of Patient,” dated 10/2023, the P&P indicated the following: The nurse caring for patient is responsible to document the following. Condition of patient: Discharge vital signs. During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Care,” dated 7/2023, the P&P indicated, “Standard I: A. Assessment: This is the process of identifying and collecting information concerning the health status of assigned patients on the unit: assessment is to be complete, continuous, and systematic ... 2. Standard II: A. Assuming responsibility and accountability for ensuring that a stated level of quality is maintained as it relates to individual patents on specific units.” 2. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS 5), Patient 9’s medical record, was reviewed. CNS 5 stated the following: VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) Risk assessments should be done every shift, and could be documented with no change, if indicated. A complete VTE Assessment should also be documented when a patient was transferred to another unit or when the patient had a change of condition. Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). Patient 9’s VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) assessment, dated 4/7/2025, indicated Patient 9 had a VTE risk score of 10 (highest risk of developing a blood clot). During the same concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, the VTE assessment also indicated that Intermittent Pneumatic Compression Devices (IPC device, used to help prevent blood clots in the deep veins of the legs) had been applied to both legs of Patient 9. CNS 5 stated that Patient 9 was transferred from the Medical Intensive Care Unit (a specialized unit that provides intensive 24-hour care for patients with severe, life-threatening medical conditions) to the Telemetry unit (a floor dedicated to patients who require continuous cardiac [heart] monitoring) on 4/9/2025. A full VTE assessment, indicating that Patient 9 had been transferred to another unit, should have been done, but was not. During the same interview on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 stated that on 4/10/2025, Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep vein of the leg) to the left leg. CNS 5 stated a full VTE assessment should have been done, for Patient 9’s change of condition (development of DVT) but, was not. CNS 5 verified that VTE Risk Shift Assessments indicated “No Change of Condition,” from 4/9/2025 through 4/14/2025, and this was incorrect because Patient 9 had been transferred to another unit, and also developed a DVT, which was a change of condition. CNS 5 stated full VTE assessments should have been done, and this would have triggered for possible medicinal prophylaxis (actions taken to prevent disease, illness, or injury), or the IPC device to be removed from the left leg. CNS 5 verified that per VTE assessments, which indicated “No Change of Condition,” the IPC device had not been removed from the left leg. CNS 5 stated IPC device was contraindicated in left leg because of the risk of dislodging the blood clot and possibly traveling to the other organs, such as the lungs. During a review of Patient 9’s “VTE Risk Shift Assessment,” dated 4/7/2025 at 11:30 a.m., the VTE Assessment indicated the following: - Score patient at: Admission -VTE Risk Factors: Age 60-74, patient immobile/anticipate >72 hours, COPD (chronic obstructive pulmonary disease, a group of lung disease that block air flow and make it difficult to breathe), Obesity (BMI [Body Mass Index- a measure of body fat based on height and weight. A BMI between 18.5 and 24.9 is generally considered healthy, while a BMI of 30 or higher indicates obesity] > 30, Admitted to critical care (specialized medical care for patients with life-threatening illnesses or injuries). -VTE Risk Score: 10 (score of 10 or greater is generally considered high risk for venous thromboembolism) -VTE Risk Level: (highest risk of developing a blood clot) -Mechanical Device Applied: Yes -Mechanical Device Applied: Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs) -Medicinal Prophylaxis Ordered: Yes (incorrect, verified by CNS 5) -VTE Assessment Results: No Action Needed. During a review of Patient 9’s “VTE Risk Shift Assessment,” dated 4/8/2025 at 8 a.m., the assessment indicated the following: - Score patient at: s/p (status post [after]) Surgical Procedure -VTE Risk Factors: Age 60-74, Obesity (BMI [Body Mass Index- a measure of body fat based on height and weight] > 300, Admitted to critical care. -VTE Risk Score: 9 -VTE Risk Level: (highest risk of developing a blood clot) -Mechanical Device Applied: Yes -Mechanical Device Applied: Intermittent Pneumatic Compression Device -Medicinal Prophylaxis Ordered: No -Reason For No Medicinal Prophylaxis: Complication medical care -Medicinal Contraindication Reason: S/P Laminectomy -VTE Assessment Results: No Action Needed. During a review of Patient 9’s VTE Risk Shift Assessment, dated 4/9/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed. During a review of Patient 9’s VTE Risk Shift Assessment, dated 4/10/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed. During a review of Patient 9’s VTE Risk Shift Assessment, dated 4/11/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed. During a review of Patient 9’s VTE Risk Shift Assessment, dated 4/12/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed. During a review of Patient 9’s VTE Risk Shift Assessment, dated 4/13/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed. During a review of Patient 9’s VTE Risk Shift Assessment, dated 4/14/2025 at 8 a.m. and at 8 p.m., the assessment indicated the following: Score patient at: No change of condition. VTE Risk Level: No Change of condition. VTE Assessment Results: No Action Needed. During a review of Patient 9’s nurse’s notes, dated 4/9/2025 at 6:45 p.m., the nurse’s notes indicated Patient 9 was transferred from the Medical Intensive Care Unit (a specialized unit that provides intensive 24-hour care for patients with severe, life-threatening medical conditions) to the Telemetry unit (a floor dedicated to patients who require continuous cardiac [heart] monitoring). During a review of Patient 9’s nurse’s notes, dated 4/10/2025 10:43 p.m., the nurse’s notes indicated the following: MD (physician) Communication. Called MD to inform him regarding Patient 9’s ultrasound (medical imaging that uses high-frequency sound waves to create pictures of the inside of the body) results. Patient 9 was positive for deep vein thrombosis (DVT, blood clot forms in a deep vein) on the left leg. During a review of Patient 9’s nurse’s notes, dated 4/10/2025 11:07 p.m., the nurse’s notes indicated the following: Nurse reported the result of Patient 9’s ultrasound and that Patient 9 was positive for DVT on the left leg; doctor said to await image results to be posted and inform the morning doctor team. During a review of the facility’s policy and procedure (P&P) titled, “Venous Thromboembolism Risk Assessment and Prophylaxis (VTE),” dated 7/2023, the P&P indicated the following: It is the policy of the Hospital that “all adults (age >18 years) will be assessed for venous thromboembolism (VTE) risk upon admission to the hospital, at key transitions in care, and that appropriate interventions will be used to prevent VTE ...Key Transitions in care include transfers to/from intensive care settings, changes of service, post-operatively or post-interventional procedure ...Upon inpatient admission, all hospitalized patients must be assessed for level of VTE risk and/or contraindications for VTE prophylaxis using the EMR-Approved VTE Risk Assessment Tool ...All contraindications to VTE prophylaxis will be documented in the medical record ...Repeat VTE risk assessment will occur with any change of condition and key transitions. If a patient refuses prophylaxis ...The prescriber should always be contacted when a patient is unable or unwilling to take a prescribed medication or mechanical device so that alternative interventions can be considered.” 3. During a review of Patient 13’s “Admission/Registration” record, undated, the record indicated that Patient 13 was admitted into the emergency department (ED) on 03/21/2025 at 2:50 p.m., with complaints of nausea (feeling an urge to vomit) as the reason for her (Patient 13) visit. During a concurrent interview and record review on 8/05/2025 at 10:47 a.m. with the Clinical Nurse Supervisor (CNS) 2, Patient 13’s medical record titled, “Notes” dated 03/21/2025 2:55 p.m. - 03/21/2025 9:57 p.m., were reviewed. Patient 13’s medical record indicated that patient (Patient 13) was seen in the emergency department on 03/21/2025 and was triaged (a system used to rapidly assess and prioritize patients arriving at the emergency room based on the severity of their condition) at 2:55 p.m. Patient 13 was then sent to the ED navigator nurse (a nurse who guides, and facilitate communication and coordinates care within the ED) at 2:58 p.m. Patient 13’s medical record indicated that call-out (to summon) to Patient 13 was made at 8:00 p.m., 8:30 p.m., and 8:50 p.m. It was then documented that Patient 13 “left without being seen (LWBS, patients who leave the ED before being evaluated by a physician)” at 8:00 p.m. During the same interview on 8/05/2025 at 10:47 a.m. with the Clinical Nurse Supervisor (CNS) 2, CNS 2 stated that Patient 13 was sent to the waiting room by the nurse navigator until she (Patient 13) can be seen by the ED provider. The last patient vital signs were taken at 2:55 p.m., it was only established that the patient had left the hospital at 8:00 p.m. CNS 2 said that the ED staff should have checked on the patient (Patient 13) and reassessed her (Patient 13) vital signs earlier, prior to establishing Patient 13 as a LWBS patient at 8:00 p.m. CNS 2 added that ED staff should have reassessed Patient 13’s vital signs every 2 hours (starting upon patient’s arrival up to when a patient leaves), according to policy and procedure (Patient 13’s vital signs was only assessed and documented once during Patient 13’s ED stay). During a review of the facility’s Policy and Procedure (P&P) titled, “Documentation in the ED Patient Care Record,” with last reviewed date of 09/2023, the P&P indicated the following: “TRIAGE ASSESSMENT: An initial triage assessment by qualified personnel will be completed and documented for all patients checked into the Emergency Department. Documentation of re-assessment shall be done on all triaged patients in the waiting room every 2 hours or sooner as clinically indicated. The following information shall be entered in the patients Emergency Department Patient Care Record in the EHR. All areas must be completed, if not applicable, the NA (Not Applicable) box has to be checked.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Care,” dated 7/2023, the P&P indicated, “Standard I: A. Assessment: This is the process of identifying and collecting information concerning the health status of assigned patients on the unit: assessment is to be complete, continuous, and systematic ... 2. Standard II: A. Assuming responsibility and accountability for ensuring that a stated level of quality is maintained as it relates to individual patents on specific units.” 4. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS 5), Patient 9’s medical record, was reviewed. CNS 5 stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). During the same interview on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 said that on 4/12/2025 at 3:14 a.m., Patient 9 received hydrocodone/acetaminophen (or Norco, a combination medication of an opioid [a class of drugs used to reduce moderate to severe pain, and can also boost feelings of pleasure] and an over-the-counter pain reliever- acetaminophen, used to relieve moderate to severe pain) 10/325 mg (milligram, a unit of measure), 1 tablet. CNS 5 verified Patient 9’s pain level was not assessed prior to receiving hydrocodone/acetaminophen. CNS 5 stated that the pain level of Patient 9 should have been assessed by verbally asking the patient or by using the FLACC scale (a behavioral observation tool used to assess pain in children and non-verbal patients who cannot communicate their pain), if Patient 9 was not able to verbalize the pain. CNS 5 stated medicating patients without assessing the pain level could result in the unnecessary administration of pain medications. During a review of Patient 9’s Medication Orders, dated 4/7/2025, the orders indicated to give Hydrocodone/Acetaminophen (Norco) 10/325, 1 tablet, every 6 hours, by mouth, for moderate pain (4 - 6/10). During a review of Patient 9’s Medication Administration Record (MAR), dated 4/12/2025 at 3:14 a.m., the MAR indicated Patient 9 received 1 tablet of Norco. The pain scale/score indicated “Unable to Scale.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 7/2023, the P&P indicated the following: A comprehensive pain assessment is conducted as appropriate to the patient’s condition and the score of care, treatment, and services ...Behavioral and physiological indicators are important indices for assessment of pain in patients unable to self-report ...Assess pain using a pain scale ...before ... each pain management intervention ...Pain intensity will be assessed using one of the following pain scales ...FLACC Behavior Scale (a behavioral observation tool used to assess pain in children and non-verbal patients who cannot communicate their pain), Pain Faces Scale (a tool used to help people, especially children describe the intensity of their pain), and Numerical Pain Intensity Scale (tool used to assess pain, 0 = no pain, 1 - 3 = mild pain, 4-6 =severe pain, 10 = worse possible pain). 5. During a review of Patient 26’s History & Physical,” dated 2/7/2025, the H&P indicated Patient 26 was admitted to the facility for being unresponsive (not reacting or responding to stimuli). Patient 26’s medical history included lupus (body’s immune[fights infection] system attacks healthy tissues and organs), hypertension (HTN, high blood pressure), obesity (overweight), and left below the knee amputation (BKA, limb below the knee was removed). During a review of Patient 26’s “Wound Care Nurse Consultation” record, dated 2/13/2025, the record indicated Patient 26 had an unstageable (full thickness tissue loss) pressure injury (localized damage to the skin caused by constant pressure) on the sacrogluteal (tail bone and buttocks area) that was present on admission (2/7/2025). The note further indicated it was recommended to turn and reposition (regularly changing a patient’s body position to relieve pressure on specific areas, especially those at risk of or affected by pressure injuries) Patient 26 every two hours. During a review of Patient 26’s “Wound Care Nurse Consultation” record, dated 4/4/2025, the record indicated Patient 26 still had an unstageable pressure injury. The note further indicated it was recommended to turn and reposition Patient 26 every two hours. During a concurrent interview and record review on 8/6/2025 at 9:45 a.m. with the Stroke Coordinator (SC), Patient 26’s “Turn and Reposition” record, dated 2/10/2025 and 4/5/2025, were reviewed. The “Turn and Reposition” record indicated the following: -On 2/10/2025 at 2:00 a.m. and 4:00 a.m., Patient 26 was positioned to supine (lying on their back). Patient 26 remained in that position for four hours. Patient 26 was next repositioned to their left side at 6:00 a.m. -On 4/5/2025 at 6:00 a.m. and 8:00 a.m., Patient 26 was positioned on their right side. Patient 26 remained in that position for four hours. Patient 26 was next repositioned at 10:00 a.m. to their left side. -On 4/5/2025 at 4:00 p.m., 6:00 p.m., and 8:00 p.m., Patient 26 was positioned on their left side. Patient 26 remained in that position for six hours. Patient 26 was next repositioned at 10:00 p.m. to their right side. During an interview on 8/7/2025 at 4:15 p.m. with the ST-Segment Elevation myocardial infarction (STEMI, heart attack) Coordinator (MIC), the MIC stated it was important to turn patients to prevent wounds and make sure there were no other issues. MIC stated if there was no order to turn the patient, it was expected for the nurses to turn the patients every two hours. MIC stated there were reposition signs that the nurses can look at, and turning was part of the interventions and general care of the patient. During a concurrent interview and record review on 8/8/2025 at 12:02 p.m. with the Director of Critical Care (DCC), DCC stated nurses were expected to turn the patients every two hours unless there was a contraindication, such as being hemodynamically (body fluid volume) unstable. DCC acknowledged the nurses’ notes on 2/10/2025 and 4/5/2025 did not indicate Patient 26 was unstable at that time to be turned. During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity,” dated 10/2024, the P&P indicated, “Reposition patient at least every 2 hours based on patient’s condition and comorbidities. Clarify and document any limitations per physician or any patient refusal.” 6. During a concurrent interview and record review on 8/7/2025 at 3:57 p.m. with the ST-Segment Elevation Coordinator (STEMI) Coordinator (MIC), MIC verified Patient 26 did not have vital signs assessed and documented upon discharge on 4/17/2025 at 7:00 p.m. Patient 26’s last set of vital signs was taken at 4:00 p.m., three hours prior to discharge. MIC stated it was expected for Patient 26 to have vital signs assessed upon discharge. During a concurrent interview and record review on 8/7/2025 at 4:15 p.m. with the MIC, the MIC stated vital signs were important to be taken prior to discharge to make sure the patient was stable (a patient’s condition that is not changing significantly) for discharge. MIC also stated if the patient was not stable the nurse would need to notify the physician, possibly extend the patient’s hospital stay, and perform interventions as ordered. During a review of the facility’s policy and procedure (P&P) titled, “Discharge of Patient,” dated 10/2023, the P&P indicated, “The discharge of the patient from the hospital should ensure continuity of care in the transition from hospital to home or from hospital to another facility ...The nurse caring for patient is responsible to document the following: Condition of patient to include: Discharge vital signs.””

“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: 50515 Based on interview and record review, the facility failed to: 1. Update a plan of care (a documented strategy that outlines patient care goals, interventions, and evaluations to address specific health issues and provides a means of communication among health care providers) for one of 30 sampled patients (Patient 9), when Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep veins) to the left leg), in accordance with the facility’s policy and procedure regarding plan of care. This deficient practice resulted in the lack of appropriate interventions for Patient 9, such as removal of the Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs) from the left leg, after Patient 9 was diagnosed with DVT to the left leg. This deficient practice also had the potential to result in complications such as pulmonary embolism (PE, a blockage in one of the pulmonary arteries [carry blood from the heart to the lungs] of the lungs which can cause death). 2. Ensure one of 30 sampled patient’s (Patient 18) plan of care regarding infection prevention/control (a set of evidence-based practices and procedures designed to prevent the transmission of infections in healthcare settings), was developed and implemented on admission, in accordance with the facility’s policy regarding plan of care. Patient 18 had a peripherally inserted central catheter (PICC, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) on his (Patient 18) left arm. This deficient practice had the potential for Patient 18’s care needs and risks not to be addressed which may lead to complications such as infection resulting from the use of a PICC. 3. Ensure one of 30 sampled patient’s (Patient 25) plan of care on infection prevention/control, was developed and implemented, in accordance with the facility’s policy regarding plan of care. Patient 25 had severe sepsis (life-threatening blood infection), urinary tract infection (UTI, bladder infection) and possible pneumonia (lung infection). This deficient practice had the potential for Patient 25’s care needs and risks not to be addressed which may lead to worsening of infection, delayed recovery, and prolonged hospitalization. 4. Ensure two of 30 sampled patients’ (Patient 29 and Patient 30) plan of care on Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control) was developed and implemented, in accordance with the facility’s policy regarding plan of care. This deficient practice had the potential for Patient 29 and Patient 30’s diabetic care needs and risks to not be addressed which may lead to complications of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Findings: 1. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 reviewed Patient 9’s medical record and stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). Patient 9’s VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) assessment, dated 4/7/2025, indicated Patient 9 had a VTE risk score of 10 (highest risk of developing a blood clot). The VTE assessment also indicated that Intermittent Pneumatic Compression Devices (IPC device, used to help prevent blood clots in the deep veins of the legs) had been applied to both legs. During the same interview on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, CNS 5 stated that on 4/10/2025, Patient 9 developed deep vein thrombosis (DVT, a blood clot to the deep vein of the leg) to the left leg. CNS 5 verified that VTE Risk Shift Assessments indicated “No Change of Condition,” from 4/9/2025 through 4/14/2025, and this was incorrect because Patient 9 developed a DVT, which was a change of condition. CNS 5 verified that Patient 9’s plan of care titled, “High Risk for VTE/DVT,” was not updated to include appropriate interventions, such as removing the IPC device from the left leg. CNS 5 verified that per VTE assessments, indicating “No Change of Condition,” implied that the IPC device was still placed on Patient 9’s left leg and had not been removed. CNS 5 stated IPC device was contraindicated to be used on left leg because of the risk of dislodging the blood clot and possibly traveling to the other organs, such as the lungs. During a review of Patient 9’s “VTE Risk Shift Assessment,” dated 4/7/2025 at 11:30 a.m., the VTE Assessment indicated the following: - Score patient at: Admission -VTE Risk Factors: Age 60-74, patient immobile/anticipate >72 hours, COPD (chronic obstructive pulmonary disease, a group of lung disease that block air flow and make it difficult to breathe), Obesity (BMI [Body Mass Index- a measure of body fat based on height and weight. A BMI between 18.5 and 24.9 is generally considered healthy, while a BMI of 30 or higher indicates obesity > 300), Admitted to critical care (specialized medical care for patients with life-threatening illnesses or injuries). -VTE Risk Score: 10 -VTE Risk Level: (highest risk of developing a blood clot) -Mechanical Device Applied: Yes -Mechanical Device Applied: Intermittent Pneumatic Compression Device (IPC device, used to help prevent blood clots in the deep veins of the legs) -Medicinal Prophylaxis Ordered: Yes (incorrect, verified by CNS 5) -VTE Assessment Results: No Action Needed. During a review of Patient 9’s nurse’s notes, dated 4/10/2025 10:43 p.m., the nurse’s notes indicated the following: MD (physician) Communication. Called MD to inform him regarding Patient 9’s ultrasound (medical imaging that uses high-frequency sound waves to create pictures of the inside of the body) results. Patient 9 was positive for deep vein thrombosis (DVT, blood clot forms in a deep vein) on the left leg. During a review of Patient 9’s nurse’s notes, dated 4/10/2025 11:07 p.m., the nurse’s notes indicated the following: Nurse reported the result of Patient 9’s ultrasound that Patient 9 was positive for DVT on the left leg; doctor said to await image results to be posted and inform morning doctor team. During a review of Patient 9’s Plan of Care titled, “High Risk VTE (Venous Thromboembolism- It’s a condition where blood clots form in the veins, most commonly in the deep veins of the legs [Deep Vein Thrombosis or DVT] or in the lungs )/DVT,” initiated on 4/8/2025, the Plan of Care indicated the following: Goal: Remain free of VTE/DVT. Interventions included: Administer anticoagulant (a medication that reduces or prevents blood clotting) per MD order, Sequential Compression Device (SCD, leg squeezers, used to improve circulation and prevent blood clots), out of bed to chair, monitor for signs and symptoms of thrombophlebitis (a condition in which a blood clot in a vein causes inflammation and pain), and perform range of monitor exercises (movements performed to maintain or improve the flexibility and movement of joints and muscles). During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care: Patient, Interdisciplinary,” dated 7/2023, the P&P indicated the following: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Identify the problem: problems are identified through analysis and assessment data. The problem can be actual or potential and should reflect consideration of the patients’ physical ...needs. Choose the interventions: Interventions reflect the course of action that will be taken to move the patient towards the expected outcomes that have been established. They shall be consistent with established standards of care. The interventions should be specific; they are guidelines by which subsequent care providers will render care to the patient ...Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon change in patient’s condition. 2. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem,” dated 08/01/2025, the H&P indicated that Patient 18 suddenly experienced the onset of excruciating (intensely painful) right flank pain (pain felt on the right side of the body, between the upper abdomen and back, specifically below the ribs and above the hip bone). The H&P indicated Patient 18 denied any fever. Patient 18’s family was concerned and called the paramedics. During further review of Patient 18’s H&P, dated 8/01/2025, the H&P indicated Patient 18 was brought into the emergency room for evaluation. Computed Tomography (CT, a medical imaging procedure that uses X-rays to create detailed, cross-sectional images of the body) scan was obtained, and it showed evidence of a right mid ureteral stone (a stone located in the urethra, the tube that carries urine from the bladder to the outside of the body) with hydronephrosis (the swelling of one or both kidneys due to a buildup of urine) of the right kidney. The patient (Patient 18) treatment plan included antibiotic therapy (the administration of antibiotics to treat infections). During a review of Patient 18’s “Diagnostic Imaging Report,” dated 08/04/2025, the record indicated successful placement of a PICC (peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart) line to Patient 18’s left arm. The PICC was indicated for intravenous (IV, refers to the administration of fluids or medication directly into a patients vein) access for intravenous therapy. During a concurrent interview and record review on 08/05/2025 at 3:05 p.m. with the Clinical Nurse Specialist (CNS 2), Patient 18’s medical record titled, “Plan of Care,” undated, indicated that a plan of care for infection prevention and control was not initiated. CNS 2 said that the nurse should have initiated a plan of care for Infection Prevention/Control (IPC). A plan of care on IPC was needed because the patient (Patient 18) would be on IV antibiotics, also there could be a risk for infection due to Patient18’s PICC line insertion site. During a review of the Policy and Procedure (P&P) titled “Plan of Care,” with last reviewed date of 04/2023, the P&P indicated the following: PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient’s care. Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient’s condition. Nursing notes shall reflect the interventions, and the patient’s response to nursing care provided. This documentation may be in the narrative notes or on a checklist. 3. During a review of Patient 25’s “History and Physical (H&P),” dated 3/23/2025, the H&P indicated Patient 25 was admitted to the facility for generalized weakness and slurred (not clear) speech. Patient 25 had a medical history of hypertension (HTN, high blood pressure), dementia (a progressive state of decline in mental abilities), and stroke (loss of blood flow to the brain) with the inability to move the right side of the body. During a concurrent interview and record review on 8/5/2025 at 1:22 p.m. with the Clinical Nurse Supervisor (CNS) 1, Patient 25’s “Infectious Disease Note,” dated 3/24/2025, was reviewed. The Infectious Disease Note indicated Patient 25 had severe sepsis (life-threatening blood infection), urinary tract infection (UTI, bladder infection) and possible pneumonia (lung infection). During a concurrent interview and record review on 8/5/2025 at 2:27 p.m. with CNS 1, Patient 25’s “Care Activity-Plan of Care (POC),” undated, was reviewed. The plan of care indicated Patient 25 did not have a POC related to infection other than “Urinary Tract Infection (UTI, bladder infection).” CNS 1 stated there was an “Infection Prevention/Control” POC that should have been applied to the patient (in order to address the condition of sepsis and possible pneumonia). During an interview on 8/5/2025 at 2:33 p.m. with CNS 1, CNS 1 stated that the purpose of a plan of care was to have guidance for the patient’s care. CNS 1 stated it was important to determine what interventions worked or did not work for the patient, and the outcomes were based on the POC. CNS 1 stated anytime a problem was identified, a POC should be added. CNS 1 also stated the POC should be started as soon as the nurse does their assessment and within 24 hours of admission. During a review of the Policy and Procedure (P&P) titled “Plan of Care,” with last reviewed date of 04/2023, the P&P indicated the following: PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient’s care. Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient’s condition. Nursing notes shall reflect the interventions, and the patient’s response to nursing care provided. This documentation may be in the narrative notes or on a checklist. 4.a. During a review of Patient 29’s “History and Physical (H&P),” dated 8/2/2025, the H&P indicated Patient 29 was admitted to the facility for chest pain. Patient 29 had a medical history of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Gastro esophageal reflux disease (GERD, chronic digestive disease where the contents of the stomach refluxes [backs up] and irritates the esophagus), and hyperlipidemia (HLD, high amount of fat in the blood). During an interview on 8/5/2025 at 2:33 p.m. with the Clinical Nurse Supervisor (CNS) 1, CNS 1 stated the purpose of a plan of care (POC), was to have guidance on the patient’s care. CNS 1 stated it was important to have a plan of care to see what interventions worked or did not work for the patient, and the outcomes were based on the POC. CNS 1 stated, anytime a problem was identified, a POC should be added. CNS 1 also stated the care plan should be started as soon as the nurse does their assessment and within 24 hours of admission. During a concurrent interview and record review on 8/6/2025 at 3:10 p.m. with the Stroke Coordinator (SC), Patient 29’s “Electronic Medical Record (EMR, a digital version of paper chart),” undated, was reviewed. The EMR indicated Patient 29 had orders for blood sugar checks, insulin (injectable medication used to control blood sugar) sliding scale (determines the amount to be given based on blood sugar values) and was on a diabetic diet. During a concurrent interview and record review on 8/6/2025 at 3:20 p.m. with the SC and the ST-segment elevation myocardial infarction (STEMI, heart attack) coordinator (MIC), Patient 29’s “Care Activity-Plan of Care,” undated, was reviewed. The SC acknowledged Patient 29 did not have a POC for diabetes, and stated it was important for the patient to have one. The MIC was also asked if it was expected for a patient with diabetes to have a POC. The MIC stated it was expected because the patient’s blood sugar was being managed. During a review of the Policy and Procedure (P&P) titled “Plan of Care,” with last reviewed date of 04/2023, the P&P indicated the following: PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient’s care. Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient’s condition. Nursing notes shall reflect the interventions, and the patient’s response to nursing care provided. This documentation may be in the narrative notes or on a checklist. 4.b. During a review of Patient 30’s “History and Physical (H&P),” dated 8/2/2025, the H&P indicated Patient 30 was admitted to the facility for distended (swollen) abdomen and frequent paracentesis (a procedure that involves inserting a needle or catheter into the abdomen to remove fluid). The H&P also indicated Patient 30 had a medical history of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), cirrhosis (liver disease), and breast cancer (cells grow out of control and affects how other normal cells work). During an interview on 8/5/2025 at 2:33 p.m. with CNS 1, CNS 1 stated the purpose of a plan of care (POC) was to have guidance on the patient’s care. CNS 1 stated it was important to have a POC to see what interventions worked or did not work for the patient (Patient 30), and the outcomes were based on the POC. CNS 1 stated, anytime a problem was identified, a POC should be added. CNS 1 also stated the POC should be started as soon as the nurse does their assessment and within 24 hours of admission. During a concurrent interview and record review on 8/6/2025 at 3:30 p.m. with the Stroke Coordinator (SC), Patient 30’s “Electronic Medical Record (EMR),” undated, was reviewed. The EMR indicated Patient 30 had orders for blood sugar checks, insulin (injectable medication used to control blood sugar) sliding scale (determines the amount to be given based on blood sugar values), and was on a diabetic diet. During the same concurrent interview and record review on 8/6/2025 at 3:30 p.m. with the SC, Patient 30’s “Care Activity-Plan of Care,” undated, was reviewed. The SC acknowledged Patient 30 did not have a Diabetes Mellitus POC and should have had one. During a review of the Policy and Procedure (P&P) titled “Plan of Care,” with last reviewed date of 04/2023, the P&P indicated the following: PURPOSE STATEMENT: To ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs. POLICY STATEMENT: The Plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission. In addition to input from nursing, the Plan of Care should contain entries by other departments/disciplines involved in the care of the patients. This plan is discussed with, and developed as a result of, coordination with the patient and/or family and significant others and other disciplines involved in the patient’s care. Documentation: Nursing documentation will reflect that the Plan of Care has been reviewed and/or updated every shift and upon changes in patient’s condition. Nursing notes shall reflect the interventions, and the patient’s response to nursing care provided. This documentation may be in the narrative notes or on a checklist.”

“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: 50516 Based on interview and record review, the facility failed to ensure, for one of 30 sampled patients (Patient 25), nursing staff adhered to the facility’s policy and procedure (P&P) titled, “Active Surveillance Strategies,” when Patient 25 was not swabbed (collecting samples (like a throat swab) for Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria that does not respond to antibiotics) of the nares (nose). This deficient practice had the potential for Patient 25 to receive delayed treatment and/or interventions and potentially expose other patients to the MRSA bacteria. Findings: During a review of Patient 25’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 4/7/2025, the H&P indicated Patient 25 was admitted to the facility because the skilled nursing facility (SNF, facility for individuals with a need for lower level nursing care) was unable to accommodate Patient 25. Patient 25’s medical history included hypertension (HTN, high blood pressure), sepsis (life-threatening bloodstream infection), urinary tract infection (UTI, bladder infection), stroke (loss of blood flow to the brain) and was unable to move the right side of their body. During a concurrent interview and record review on 8/5/2025 at 2:56 p.m. with the Clinical Nurse Supervisor (CNS) 1, Patient 25’s medical record, was reviewed. CNS 1 stated patients needed to be swabbed for MRSA if they were readmitted to the facility within 30 days. CNS 1 stated Patient 25 should have been swabbed for MRSA (Methicillin-Resistant Staphylococcus Aureus, a bacteria that does not respond to antibiotics) on the day she (Patient 25) was readmitted (4/6/2025). During a concurrent interview and record review on 8/5/2025 at 3:03 p.m. with CNS 1, Patient 25’s “Specimen Inquiry,” dated 4/11/2025, was reviewed. The record indicated Patient 25 had an order placed for MRSA nares (nose) to be collected. CNS 1 verified the order was not carried out until 4/9/2025, two days after the order was placed. During a review of the facility’s policy and procedure (P&P) titled, “Active Surveillance Strategies,” dated 4/2024, the P&P indicated, “Each patient admitted to (name of the facility) shall be tested for MRSA in the following cases, within 24 hours of admission with a nares swab for MRSA: Patient with a history of hospitalization within the prior 30 days.””

“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: 50515 Based on interview and record review, the facility failed to: 1. Ensure one of 30 sampled patients (Patient 20), received blood pressure medication (Hydralazine Hydrochloride [HCL], medication to lower blood pressure), as ordered by the physician. This deficient practice resulted in Patient 20’s increased blood pressure level and placing the patient (Patient 20) at risk for possible stroke (when blood flow to the brain is interrupted) or aortic dissection (artery in the heart that tears due to pressure). 2. Ensure one of 30 sampled patient’s (Patient 22) intravenous antibiotics (Cefepime, used to treat/prevent infection) and a medication used to control stomach bleeding (Octreotide [medication for preventing/controlling bleeding in the stomach, also known by its brand name Sandostatin]), were administered, as ordered by the physician. This deficient practice had the potential to result in worsening of infection or delay in healing from infection (from delayed administration of the Cefepime antibiotic) as well as the potential for stomach bleed (from not administering the Octreotide) for Patient 22. 3. Ensure one of 30 sampled patients (Patient 9), was medicated with the correct pain-relieving medication based on Patient 9’s assessed pain level, in accordance with the physician’s order, and the facility’s policy regarding medication administration. Patient 9 was assessed with moderate pain and was medicated with a medication ordered for severe pain. This deficient practice had the potential for Patient 9 to be overmedicated and possibly suffering unnecessary side effects for the elderly, such as drowsiness (feeling unusually sleep or tired), dizziness, urinary retention (the inability to completely empty the bladder), delirium (a temporary state of confusion or disorientation), or respiratory depression (a condition where breathing becomes abnormally slow and shallow). Findings: 1. During a review of Patient 20’s “History and Physical Exam (H&P, a full, complete assessment of a patient’s medical history and current condition),” dated 3/6/2025, the H&P indicated, Patient 20 was admitted for left leg fracture (broken bone) and thoracic aortic aneurysm (TAA- balloon-like bulge in aorta [artery in heart] due to weakened and stretching walls). During a review of Patient 20’s “Hydralazine Medication Order,” dated 3/11/2025, the medication order indicated an order for Hydralazine Hydrochloride (HCL, medication used to lower blood pressure; also known as Apresoline-brand name of medication) 25 milligrams (mg, a unit of measure) 1 tablet oral (by mouth) every 8 hours, hold for systolic blood pressure (the top number in a blood pressure reading and represents the pressure in the arteries when the heart contracts and pumps blood out) less than 110 mmHg (Millimeters of Mercury, a unit of pressure). During a concurrent interview and record review on 8/6/2025 at 9:57 a.m. with the House supervisor (HS), Patient 20’s “Medication Administration” record, dated 3/11/2025 through 3/14/2025, was reviewed. The medication administration record indicated that on 3/13/2025 at 10:00 p.m., Hydralazine was not given to Patient 20 as ordered. The HS stated Patient 20 was transferred from one unit to another unit, however, it (referring to the Hydralazine) should have been administered by either the sending nurse or the receiving nurse before or after the transfer. During a review of Patient 20’s “Nurse Notes,” dated 3/13/2025 at 10:21 p.m. and at 11:45 p.m., the receiving nurse documented receiving Patient 20 at 10:21p.m. with a blood pressure of 139/74. At 11:45 p.m., the receiving nurse documented Patient 20 did not receive hydralazine medication from transferring nurse or from receiving nurse. During a review of Patient 20’s “Vital Signs,” record dated 3/13/2025 through 3/14/2025, the record indicated the following: -On 3/13/2025 at 9:00 p.m. blood pressure 134/71 -On 3/13/2025 at 10:21p.m., blood pressure 130/65 -on 3/14/2025 at 12:00 a.m., blood pressure 148/76 During an Interview on 8/6/2025 at 10:25 a.m. with HS, the HS stated, the blood pressure medication should have been given before Patient 20 was transferred or administered to Patient 20 once arrived at the receiving unit by receiving nurse. HS further stated Patient 20’s blood pressure was possibly high (at 12 a.m. on 3/14/2025) due to missing the 10:00 p.m. dose of Hydralazine (on 3/13/2025). During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications,” revised 5/2024, the P&P indicated, “the administration of each dose of medication shall be accurately recorded in the patient’s electronic medication administration record (eMAR) via barcode scanning during administration. Scheduled doses which are omitted shall be documented with the reasons as to why the dose were omitted.” 2. During a review of Patient 22’s “History and Physical Exam (H&P, a full, complete assessment of a patient’s medical history and current condition),” dated 6/27/2025, the H&P indicated, Patient 22 was admitted to the facility for altered mental status (change in person’s consciousness [a person’s state of awareness and responsiveness to their surroundings], awareness and cognitive function [the mental processes involved in acquiring, processing, and using information]) after being found unresponsive (not reacting or responding to stimuli) and possible sepsis (a serious blood infection). The H&P also indicated Patient 22 had a history of liver cirrhosis (damage to the liver disrupting its ability to function including the risk of bleeding). 2.a. During a review of Patient 22’s “Medication Orders,” dated 7/2/2025, the Medication Orders indicated a physician order for Cefepime (antibiotic medication used to treat infection) 1 gram (gm-unit of measurement) every 12 hours intravenously (IV-through the vein). During a concurrent interview and record review on 8/6/2025 at 2:59 p.m. with the house supervisor (HS), Patient 22’s “Medication Administration” record, dated 7/2/2025 through 7/3/2025 for Cefepime, was reviewed. The Medication Administration record indicated the following: -On 7/2/2025 at 10:56 p.m., Patient 22 received Cefepime. Next scheduled dose was on 7/3/2025 at 10:56 a.m. There was no documentation that Patient 22 received the next Cefepime dose on 7/3/2025 at 10:56 a.m. This finding was verified with the House Supervisor. -On 7/3/2025 at 2:02 p.m. Patient 22 received Cefepime. Total delay of three hours and 6 minutes from the scheduled dose (10:56 a.m.). During the same interview on 8/6/2025 at 2:59 p.m. with the house supervisor (HS), the HS stated, “I am unable to determine the reason for Cefepime not given as scheduled.” During an interview on 8/6/2025 at 3:35 p.m. with HS, the HS stated, the expectation was for nurses to administer antibiotics as scheduled, its implication had to do with effectiveness of medication for the patient. During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications” revised 5/2024, the P&P indicated, “the administration of each dose of medication shall be accurately recorded in the patient’s electronic medication administration record (eMAR) via barcode scanning during administration. Scheduled doses which are omitted shall be documented with the reasons as to why the dose were omitted. The appropriate times for medication administration may be established by the pharmacy and therapeutic committee. The committee may determine guidelines for the correct and appropriate times of administration of medication in response to the prescribers’ orders.” 2.b. During a review of Patient 22’s “Medication Orders,” dated 6/30/2025, the Medication Orders record indicated a physician order for Octreotide (medication for preventing/controlling bleeding in the stomach, also known by its brand name Sandostatin) 1000 microgram (mcg-unit of measurement) 5 milliliter (ml-unit of measuring fluid) per hour, continuously (without interruption) intravenously (IV-through the vein). During a concurrent interview and record review on 8/6/2025 at 3:25 p.m. with the house supervisor (HS), Patient 22’s “Medication Administration” record, dated 6/30/2025 through 7/13/2025, for Octreotide, was reviewed. The Medication Administration record indicated the following: -On 7/2/2025, no documentation of Octreotide administration. -On 7/8/2025, no documentation of Octreotide administration. -On 7/9/2025, no documentation of Octreotide administration. -On 7/11/2025, no documentation of Octreotide administration. -The HS stated that medication should be given as ordered to ensure 24-hour coverage was effective. During a review of Patient 22’s “Physician Progress Note,” dated 7/3/2025, the progress note indicated that the physician made the primary nurse aware that the continuous IV medication (Octreotide) was off and the order should have remained active. The progress note further indicated the physician requested for medication (Octreotide) to be continued as ordered. During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications” revised 5/2024, the P&P indicated, “the administration of each dose of medication shall be accurately recorded in the patient’s electronic medication administration record (eMAR) via barcode scanning during administration. Scheduled doses which are omitted shall be documented with the reasons as to why the dose were omitted. The appropriate times for medication administration may be established by the pharmacy and therapeutic committee. The committee may determine guidelines for the correct and appropriate times of administration of medication in response to the prescribers’ orders.” 3. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with Clinical Nurse Supervisor (CNS) 5, CNS 5 reviewed Patient 9’s medical record and stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). During a review of Patient 9’s Medication Orders, dated 4/7/2025, the orders indicated to give Morphine Sulfate 4 mg IV (in the vein) every three (3) hours as needed for severe pain (7-10). During a review of Patient 9’s Medication Administration Record (MAR), dated 4/11/2025 at 9:12 p.m., the MAR indicated Patient 9 received 4 mg of Morphine for a pain level of 6/10 on FLACC scale. During the same concurrent interview and Medication Administration record review on 8/7/2025 at 1:50 p.m. with Clinical Nurse Supervisor (CNS) 5, CNS 5 said that on 4/11/2025 at 9:12 p.m., Patient 9 received 4 milligrams (mg, a unit of measure) of Morphine (a powerful opiate pain reliever used to treat moderate to severe pain) for a pain level of 6/10 (moderate pain) using the FLACC scale (a behavioral observation tool used to assess pain in children and non-verbal patients who cannot communicate their pain). CNS 5 also verified that Morphine was ordered for severe pain (7/10). CNS 5 confirmed that Norco (prescription painkiller that combines hydrocodone, an opioid analgesic, and acetaminophen, a non-opioid analgesic) was prescribed for moderate pain (4 - 6/10). CNS 5 stated Patient 9 was overmedicated (since Patient 9 received Morphine which was indicated for severe pain; Patient 9 only had moderate pain of 6/10 and should have received Norco and not Morphine) and did not receive the correct medication as ordered by the physician. During a review of the facility’s policy and procedure (P&P) titled, “Medication Administration (Management),” dated 1/2023, the P&P indicated the following: “4. Prior to administration, the 6 R’s must be verified. 4.a., Right drug - verify that the medication selected for administration is the correct one based on the medication order ...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility failed to: 1. Ensure a discharge summary (a document that provides a concise overview of a patient’s hospital stay, including diagnoses, treatments, and follow-up instructions, ensuring a smooth transition of care to other healthcare providers and the patient) was promptly completed, within 10 days of discharge, as per the facility’s policy and procedure regarding Medical Records, for one of 30 sampled patients (Patient 8). This deficient practice resulted in Patient 8’s discharge summary being completed 15 days after discharge, which can negatively affect patient safety and continuity of care. 2. Ensure documentation in the medical record was accurate, for one of 30 sampled patients (Patient 9), when Patient 9’s VTE (Venous Thromboembolism, blood cloth forms in a vein, usually deep in the legs) Assessment inaccurately indicated medicinal prophylaxis (medication to prevent a condition) to prevent blood clot formation, had been ordered for Patient 9 on 4/7/2025. This deficient practice resulted in an inaccurate description of interventions to prevent blood clot formation for Patient 9 and had the potential for not implementing additional interventions to prevent blood clots. Findings: 1. During a concurrent interview and record review on 8/7/2025 at 12:28 p.m. with the Director of Medical Records (DMR), the DMR stated that the discharge summary (a document that provides a concise overview of a patient’s hospital stay, including diagnoses, treatments, and follow-up instructions, ensuring a smooth transition of care to other healthcare providers and the patient) should be completed within 10 days after patients were discharged. The DMR verified that Patient 8 was discharged on 6/5/2025 and the discharge summary was completed on 6/20/2025, fifteen (15) days after discharge. During a review of Patient 8’s History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 6/3/2025, the H&P indicated the following: Patient 8 was admitted to the facility on 6/3/2025 for shortness of breath (being unable to breathe normally) and leg swelling. During a review of Patient 8’s Discharge Order, dated 6/5/2025 at 2:05 p.m., the Discharge order indicated to discharge to shelter via Uber (a transportation network company that provides a platform for users to request rides), continue home medications. During a review of Patient 8’s nurse’s note, dated 6/5/2025 at 3:32 p.m., the nurse’s note indicated Patient 8’s daughter (FM 1) was in patient’s (Patient 8) room when the discharge order news was relayed to Patient 8. FM 1 drove Patient 8 home. During a review of Patient 8’s Discharge Summary, dated 6/20/2025, the Discharge Summary indicated the following: Patient 8 was admitted on 6/3/2025 and discharged on 6/5/2025. Patient 8 was in need of diuresing (elimination of urine and excess body fluid) due to his dependent edema (swelling that occurs in the lower parts of the body due to the effects of gravity) and pleural effusions (buildup of fluid between the tissues that line the lungs and the chest) noted. Patient 8 needed further evaluation. Unfortunately, Patient 8 was discharged from the hospital in error. Upon realizing this, a call was immediately made to the patient and family to instruct Patient 8 to return to the hospital immediately or go to the nearest hospital available for medical attention. During a review of the facility’s policy and procedure (P&P) titled, “Medical Record, Content Of,” dated 7/12/2023, the P&P indicated the following: Documentation is to reflect the patient’s medical status in such a manner as to allow another practitioner to assume care of the patient at any time. Discharge Summary / Transfer Summary / Death Summary: All inpatient medical records, regardless of length of stay, must have a discharge summary/death summary or transfer summary completed within 10 days after the patient’s discharge, death, or transfer. During a review of the facility’s policy and procedure (P&P) titled, “Medical Record, Content Of,” dated 7/12/2023, the P&P indicated the following: Documentation is to reflect the patient’s medical status in such a manner as to allow another practitioner to assume care of the patient at any time. It is the responsibility of the medical staff and other hospital care providers to document timely and accurately all treatment and care provided, all diagnosis reached and the outcomes of these processes in accordance with relevant laws, regulations, and accreditation standards. 2. During a concurrent interview and record review on 8/7/2025 at 1:50 p.m. with the Clinical Nurse Supervisor (CNS) 5, Patient 9’s medical record, was reviewed. CNS 5 stated the following: Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone [small bone that makes up the spine] to relieve pressure on the spinal cord [a major communication pathway, carrying signals between the brain and the rest of the body] or nerves). During the same interview on 8/7/2025 at 1:50 p.m. with the CNS 5, CNS 5 stated Patient 9’s VTE (Venous Thromboembolism, blood clot forms in a vein, usually deep in the legs) assessment indicated Patient 9 was at high risk of developing a blood clot. The VTE assessment also indicated that SCD (leg squeezers) had been applied and medicinal prophylaxis (medication to prevent blood clot formation) had been ordered. CNS 5 verified that no medication to prevent blood clots had been ordered on 4/7/2025 for Patient 9 and the documentation was inaccurate. CNS 5 stated Patient 9 just had surgery and medications to prevent blood clots should be avoided at this time. During a review of Patient’s History and Physical (H&P), dated 4/7/2025, the H&P indicated Patient 9 was admitted on 4/7/2025 after undergoing a laminectomy (a surgical procedure that involves removing a portion of the vertebral bone to relieve pressure on the spinal cord or nerves). During a review of Patient 9’s “VTE Assessment,” dated 4/7/2025 at 6:25 a.m., the VTE Assessment indicated a score of 10 (high risk of develop blood clot). SCD (Sequential Compression Device, leg squeezers, used to improve circulation and prevent blood clots) applied. Medicinal prophylaxis (preventative treatment) ordered: Yes. CNS 5 verified that no medicinal prophylaxis was ordered, and the documentation was incorrect. During a review of Patient 9’s Physician’s Orders, dated 4/7/2025, there was no medicinal prophylaxis ordered for Patient 9. This was verified by CNS 5. During a review of the facility’s policy and procedure (P&P) titled, “Medical Record, Content Of,” dated 7/12/2023, the P&P indicated the following: Documentation is to reflect the patient’s medical status in such a manner as to allow another practitioner to assume care of the patient at any time. It is the responsibility of the medical staff and other hospital care providers to document timely and accurately all treatment and care provided, all diagnosis reached and the outcomes of these processes in accordance with relevant laws, regulations, and accreditation standards.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 50516 Based on interview and record review, the facility failed to ensure one of 30 sampled patient’s (Patient 12), nursing documentation accurately reflected Patient 12’s Peripherally Inserted Central Catheter (PICC, long, thin tube that goes through the vein to the heart to deliver medication, fluids) assessment (evaluation) being completed in the “Infectious Disease Bundle (set of questions related to invasive tubes necessary for patient care),” in accordance with the facility’s policy regarding nursing documentation. This deficient practice had the potential for Patient 12 to not receive the appropriate evaluation and medical care. Findings: During a review of Patient 12’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/29/2025, the H&P indicated Patient 12 was admitted to the facility for being less responsive (a reduction in a person’s ability to react to stimuli, whether verbal, physical, or environmental), had a left side facial droop (sagging), and was leaning towards the left side. Patient 12’s medical history included Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), hyperlipidemia (HLD, high concentration of fat in the blood), Atrial Fibrillation (irregular heartbeat) and stroke (loss of blood flow to the brain). During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with the Clinical Nurse Supervisor (CNS) 1, Patient 12’s order for “Peripherally Inserted Central Catheter (PICC, long, thin tube that goes through the vein to the heart to deliver medication, fluids) Line Insertion,” dated 7/30/2025, was reviewed. Patient 12 needed the PICC line for poor intravenous (IV, into the vein) access and for fluids (hydration) and antibiotics (medication used to fight infection). During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with CNS 1, Patient 12’s “IV or Invasive Line Bundle,” dated 7/30/2025, was reviewed. The record indicated Patient 12 had a PICC and was assessed (evaluated) on 7/30/2025 starting at 12:30 p.m. The record further indicated Patient 12 had the PICC on 7/31/2025 and 8/1/2025 and was assessed every four hours. During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with CNS 1, Patient 12’s “Infectious Disease Bundle (set of questions related to tubes or IVs that go into the patient and can cause infection),” dated 7/30/2025 to 8/1/2025, was reviewed. The record indicated “No” was marked under the question “Does patient have central line?” After marking “No,” the next set of questions were about a Foley Catheter (tube that goes into the bladder to drain urine). The record indicated the following: -On 7/30/2025 at 9:00 p.m., “No” was marked under the question “Does patient have central line?” No further questions related to a central line were present. -On 7/31/2025 at 9:30 a.m. and at 9:00 p.m., “No” was marked under the question “Does patient have central line?” No further questions related to a central line were present. -On 8/1/2025 at 9:00 a.m., “No” was marked under the question “Does patient have central line?” No further questions related to a central line were present. -On 8/1/2025 at 9:00 p.m., the record indicated “Yes” was marked under “Does the patient have central line.” Additional questions related to the central line were included such as, “Is central line still needed; Aseptic (clean) technique used for insertion, dressing changes; insertion site covered with transparent, semi-permeable dressing (special tape that covers the insertion site); scrubbed access port (where fluids and medication is put into) with antiseptic (cleaning agent) before each use.” CNS 1 acknowledged Patient 12’s “Infectious Disease Bundle” was not documented accurately. During a concurrent interview and record review on 8/7/2025 at 3:00 p.m. with CNS 1, CNS 1 stated nurses needed to document under the “Infectious Disease Bundle” to ensure interventions (tasks) were carried out. CNS 1 also stated it was important to document correctly for the nurses to not miss anything, and the expectation was that everything should be completed. During a review of the facility’s policy and procedure (P&P) titled, “Nursing Documentation,” dated 1/2025, the P&P indicated, “The Licensed Nurse (RN/LVN) will document the nursing care provided using the nursing process ...Documentation will include implementation of physician orders & nursing actions, clinical observations & outcomes.””

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 46238 Based on interview and record review the facility failed to ensure that for one of 30 sampled patients (Patient 2), the attending physician communicated and documented the outcome of the hospitalization, including follow-up care and provisions for post-hospital care (after hospital care) such as any upcoming appointments, patient care needs, durable medical equipment (DMEs such as wheelchair), and plans for ongoing care by providers like home health services, in accordance with the facility’s policy regarding “Medical Rules and Regulations (R&R).” This deficient practice resulted in unmet care needs for Patient 2, when Patient 2 was discharged with no wheelchair and no means for mobility to follow-up on necessary appointments, thus potentially compromising Patient 2’s safety and increasing risk of readmission and complications. Findings: During an interview on 8/7/2025 at 1:03 p.m. with Patient 2’s family member (FM), the FM stated that during Patient 2’s admission at the facility, the attending physician rarely communicated the plan of care (a comprehensive document that outlines a patient’s health conditions, treatment plans, and care goals, serving as a roadmap for their healthcare journey) with the family. The FM also reported that the facility attempted to discharge Patient 2 multiple times without having the attending physician speak with the family prior to placing the discharge order. Additionally, the FM said that the physician never communicated with the family that Patient 2 could not walk and required a wheelchair. FM 1 said that after Patient 2 was discharged home via ambulance, Patient 2 had no means of mobility or transportation to attend appointments, as the facility discharged Patient 2 without arranging for a wheelchair at home. During a review of Patient 2’s History and Physical (H&P, a comprehensive assessment of a patient’s health status), dated 7/6/2025, the H&P indicated that Patient 2 was admitted to the facility on 7/6/2026 due to abdominal pain and nausea (the urge to throw up). During an interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ stated that when Patient 2 was admitted to the facility on 7/5/2025, Patient 2 was able to walk with a walker. However, based on the physical therapy (PT) evaluation, dated 7/14/2025 (completed after Patient 2 underwent surgical hernia [a condition where an internal organ or tissue bulges through a weak spot in the surrounding muscle or tissue] repair), Patient 2 could no longer walk and was significantly below functional baseline (Patient 2’s usual level of independence and mobility). During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said that the PT Evaluation indicated that there was no recommended discharge DME (Durable Medical Equipment) need, because Patient 2 confirmed ownership of a wheelchair. However, the PT Evaluation also indicated that Patient 2 “was a poor historian and confused, and wheelchair ownership may need to be confirmed with the son,” (which was not done). The DDQ also said that the physician (MD 2) did not order a wheelchair (DME) for Patient 2 prior to discharge. During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said the following regarding case management (a collaborative process focused on coordinating patient care to ensure efficient, effective, and safe transitions through the healthcare system) and discharge planning (a coordinated process of preparing patients to leave the hospital and transition to the next level of care, whether that’s home, a rehabilitation facility, or another setting) for Patient 2, “The case management (CM) team responsible for the patient’s (Patient 2) insurance group was involved and participated in rounds (a structured process where medical professionals visit patients to assess their condition, review their care plan, and address any needs) with the physician; all relevant medical records for Patient 2 were faxed to the medical insurance group CM. During the same interview on 8/7/2025 at 2:07 p.m. with the Director of Data Quality (DDQ), the DDQ said the CM team from the insurance group was responsible for following up on the DME needs for Patient 2. The DDQ explained that the facility was not contracted with the medical group that insured Patient 2, and the CM team from that group did not share the information about communications or decision made between the case management team and the physician. “For instance, after entering an order for home health services post-discharge and communicating this to the insurance group, the facility’s case management had no way of knowing if the home health services were arranged or set-up for the patient (Patient 2).” During an interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said, “I review physical therapy recommendations before discharge. For example, if a patient needs a walker, I place an order for discharge planning department, and then they identify the need for a durable medical equipment (DME). The discharge planning team will communicate this need to the contracted insurance case management (CM) to arrange for the DME, but they (referring to the contracted insurance CM) do need to have an order for a walker to arrange for it.” During the same interview on 8/8/2025 at 2:56 p.m. with the attending physician (MD 2), the MD 2 said the following regarding communication requirements with patients and families: “I communicate with patients and families daily. I discuss the plan of care, goals of care, and prognosis ... I document to the best of my ability, and documenting the communication in a patient’s medical record is a medical record-keeping requirement.” MD 2 also said that during Patient 2’s admission, MD 2 documented communication with Patient 2’s son in the progress notes. During a review of Patient 2’s Attending physician progress notes, dated 7/6/2025 through 7/18/2025, the notes indicated that on: 7/18/2025-Discharge Summary-there was no documentation of what diet Patient 2 should follow at home, no documentation of DME needs at home, and no documentation of Home Health arrangements being discussed with Patient 2 and/or their family, recorded in the Discharge Summary dated 7/18/2025. During a record review on 8/7/2025 at 10:30 a.m. with the stroke coordinator (SC) and the Director of Data Quality (DDQ), the Attending physician progress notes, dated 7/6/2025 through 7/18/2025, were reviewed. The SC and the DDQ verified the lack of documentation in Patient 2’s discharge summary dated 7/18/2025. During a review of the facility’s “Medical Rules and Regulations (R&R),” dated 10/2024, the Medical R&R indicated, “1.8 Duties of Attending physicians: 1.8-4:Communication with the family regarding the findings of consultants and alterations to the plan of care is the duty of the Attending physician ...1.8.-6: Coordinating the management of the patient with nursing ... 1.8-7: reassessing the patient at regular intervals ....1.8-8: Working closely with case management staff to assure that the record contains sufficient information to support coverage and resource use decisions ...1.8-10: Working with discharge planning to assure a smooth transition of the patient to the appropriate after care setting ...2.1: A medical record will be created and maintained for the purpose of providing continuity of care for the patient ... and healthcare providers .... serving as a method of communication between healthcare providers serving the patient ...providing detailed and organized information for use in case management, quality assessment, and performance improvement...2.6-2: The Attending physician is responsible for documenting a discharge summary for all patients discharged from the hospital....the discharge summary shall contain, at a minimum: discharge instructions to patient and/or family (diet, activity, follow-up)...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 1/2025, the P&P indicated, “Patients have the right to 2. Have effective communication for critical information in a manner you understand ... information from your physician about your diagnosis, prognosis, treatment or consent for treatment, discharge planning ...5. Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. The right to effective communication and to participate in the development and implementation of the plan of care ...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50515 Based on observation, interview, and record review, the facility failed to ensure staff compliance with the facility policies to prevent and control the transmission of infection within the facility, for two of 30 sampled patients (Patient 22 and Patient 28), in accordance with the facility’s policies regarding infection prevention and control when: 1. Patient 22’s intravenous (IV, administered through the vein) tubing (known as “piggyback,” a flexible tube that administers medication) was not labeled with a date for change of IV tubing and the IV tubing was looped around itself connected to its distal port. This deficient practice had the potential for Patient 22 being exposed to infections such as phlebitis (infection of the veins) and/or bloodstream infection caused by prolonged use of IV tubing and/or improperly capped IV ports. 2. Patient 28’s purewick (external device that uses suction to remove urine) was not kept off the floor, in accordance with basic infection control measures. This deficient practice had the potential for germs to travel up the tubing from the floor into the bladder (a muscular, hollow organ that serves as a reservoir for urine), potentially leading to infection. Findings: 1. During a review of Patient 22’s “History and Physical Exam (H&P, a full, complete assessment of a patient’s medical history and current condition),” dated 6/27/2025, the H&P indicated, Patient 22 was admitted to facility for altered mental status (change in person’s consciousness [a person’s state of awareness and responsiveness to their surroundings], awareness and cognitive function [the mental processes involved in acquiring, processing, and using information]) after being found unresponsive (not reacting or responding to stimuli). During a concurrent observation and interview on 8/5/2025 at 11:42 a.m., with Patient 22’s Primary Nurse (RN) 3 and the Charge Nurse (CN) 3, on the medical floor unit, in Patient 22’s room, there was an unlabeled, with no date of change IV piggyback (a flexible tube that administers medication) hanging, looped on itself with the entry port (section that attaches to patient) attached to the distal port (port normally capped if unused or connected to another IV line). The CN 3 stated it was not acceptable for the tubing to be connected or looped to itself through the distal port, it was not sanitary. The CN 3 further stated, the facility had caps with alcohol used to cover and protect the IV tubing or IV lines for purposes of infection prevention. During an interview on 8/5/2025 at 11:45 a.m. with the CN 3, the CN 3 demonstrated the light and dark “Disinfecting Caps for Needle- free Valves” which were used to cover the IV ports and prevent infection. The CN 3 stated these caps were provided and made available to nurses and they hang from the IV pole for easy access when needed. During an interview on 8/7/2025 at 3:25 p.m. with the Clinical Educator (CE) and the Director of Nursing (DN), CE stated nurses were expected to label IV tubing with date of next tubing change and initials, as well as to cap every unused open port with the disinfectant caps provided by facility. The DN stated that the expectation for nurses was to cap every port for prevention of infection, and it would not be acceptable for nurses to loop IV tubing on itself as this (the use of disinfectant caps for IV ports) was a standard nursing practice. The CE and DN both stated dating the IV tubing and capping the IV port were part of educational in-services provided to nurses upon hire. During a review of the facility’s policy and procedures (P&P) titled, “Infection control Policy and procedures Manual,” revised 4/2024, the P&P indicated, “Tubing change label all lines and pumps with the IV medications and solutions that are infusing. The policy and procedures tables for line flushing, blood withdrawal, cap change and line removal must be strictly adhered to.” 2. During a review of Patient 28’s “History and Physical (H&P),” dated 7/31/2025, the H&P indicated Patient 28 was admitted to the facility for shortness of breath (being unable to breathe normally). Patient 28 had a medical history of Atrial Fibrillation (irregular heartbeat), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and renal (kidney) disease. During a concurrent observation and interview on 8/5/2025 at 11:20 a.m., with Registered Nurse (RN) 4, in Patient 28’s room, Patient 28’s Purewick (external device that sucks up urine) tubing (plastic tube that connects to the patient), was observed on the floor. RN 4 confirmed Patient 28 had a purewick and the tubing was on the floor. RN 4 stated the tubing should not be on the floor and RN 4 moved the tubing off the floor. During an interview on 8/7/2025 at 4:15 p.m. with the ST-Segment Elevation Myocardial Infarction (STEMI, heart attack [blood vessels to the heart are blocked and not receiving enough oxygen]) Coordinator (MIC), the MIC stated patient tubing should not be on the floor. MIC stated it was an infection control issue because the tubing was touching the dirty floor, and bacteria could get into the patient from the tubing. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention/Control,” dated 4/2025, the P&P indicated, “The scope of the Infection Prevention and Control program for (name of the facility) includes the prevention, surveillance, and control of infection ...The purpose of the infection prevention and control program is to provide a safe and healthful environment for all who enter this facility.””

“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: 50515 Based on interviews and record review, the facility failed to ensure that a physician order for Neutropenic Precaution (isolation guidelines designed to protect patients with weak immunity) was implemented in a timely manner, for one of 30 sampled patients (Patient 19), who was immunocompromised (having a weakened immune system reducing ability to fight infections). This deficient practice had the potential for Patient 19 being exposed to hospital acquired infections potentially leading to serious illness and/or death. Findings: During a review of Patient 19’s “History and Physical Exam (H&P, a full, complete assessment of a patient’s medical history and current condition),” dated 2/7/2025, the H&P indicated, Patient 19 was admitted for generalized weakness with a medical history of Myeloid leukemia (aggressive form of blood cancer). Patient 19’s admitting white blood cell (WBC-cells that fight infection. Normal count ranging from 4.5 to 11) count was 1.0. During an interview on 8/5/2025 at 1:36 p.m. with the House supervisor (HS), the HS stated nurses knew to implement Neutropenic Precautions (isolation guidelines designed to protect patients with weak immunity) by reading the physician plan of care, and nurses were expected to put a sign up letting other staff/visitors know that patient was on Neutropenic Precautions which meant wearing a mask, gloves and gown when entering patient room and discouraging visitors to visit when sick. During an interview on 8/5/2025 at 2:16 p.m. with the Clinical Supervisor (CNS) 1, CNS 1 added, nurses could implement Neutropenic Precautions and follow up with a physician order for Neutropenic Precaution. During a concurrent interview and record review on 8/5/2025 at 2:18 p.m. with the House Supervisor (HS), Patient 19’s “Orders,” dated 2/7/2025, was reviewed. The record indicated, a physician order/instruction was given on 2/7/2025 at 4: 13 p.m., to place Patient 19 on Neutropenic Precautions/isolation. During the same concurrent interview and record review on 8/5/2025 at 2:18 p.m., Patient 19’s “Care Activity-Assessment,” dated 2/7/2025 to 2/8/2025, were reviewed. The record indicated the following: -On 2/7/2025 at 8:00 p.m., Nurse documented Patient 19 was not on Neutropenic Precautions/isolation. -On 2/8/2025 at 8:00 a.m., Nurse documented Patient 19 was placed on Neutropenic precautions/isolation. A total of 15 hours and 47 minutes after the physician order was given. -The HS stated, “I don’t know why nurse documented no isolation,” but the documented implementation of the Neutropenic Precaution was late. During a review of the facility’s policy and procedure (P&P) titled, “Infection Prevention/Control Policy and Procedure Manual,” revised 2/2025, the P&P indicated, “Neutropenic/Reverse Isolation Precautions- Place allogeneic hematopoietic stem cell transplant (HSCT)patients in a protective Environment as described in “Guidelines to Prevent Opportunistic Infections in HSCT patients,” the Guidelines for Environmental infection Control in Health care Facilities,” and the “Guidelines for Preventing Health-Care Associated Pneumonia, 2003” to reduce exposure to environmental fungi. When Neutropenic precautions are put into place: perform scrupulous hand hygiene and assist the patient to do the same, Do not allow roommates, visitors or staff with infections into room, no flowers or potted plants in the room, keep sinks and bathrooms fixtures dry, restrict uncooked fruits which cannot be unpeeled, uncooked vegetables(especially salads) and uncooked meats and fish from the diet. Document the type of isolation used in the medical record...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to complete a medical screening examination (MSE, the initial exam performed by a physician when a patient presents to an emergency department to request care) to determine if an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity - like severe pain, a pregnant woman in labor, and a mental health disturbance) existed for one of twenty sampled patients (Patient 19), when Patient 19 presented to the Emergency Department (ED, provides immediate medical care to patients with acute, life-threatening illness and injuries) complaining of chest pain and an EKG was not performed within 10 minutes of ED arrival. This deficient practice resulted in Patient 19 not having a medical screening examination (MSE) to determine whether an emergency medical condition existed, such as a myocardial infarction (heart attack, blockage of blood flow to the heart muscle) or other cardiovascular related problems, upon arrival to the ED complaining of chest pain. Findings: During a review of Patient 19’s “Face Sheet,” dated 3/17/2025, the Face Sheet indicated Patient 19 walked in to the Emergency Department at 12:40 a.m. for chest pain with neck pain. During a review of Patient 19’s “Conditions of Admission (COA),” dated 3/17/2025, the COA indicated form was signed by Patient 19 on 3/17/2025 at 12:40 a.m. During a review of Patient 19’s “View Existing Collection Notes,” dated 3/17/2025 and timed at 12:50 a.m., the Notes indicated Patient 19 was eligible for public health insurance. During concurrent observation and interview on 7/8/2025 at 01:34 p.m. with the Triage Nurse (TRN) from the Emergency Department, the TRN stated that patients enter the Emergency Department and present to the Check-In window with the Triage nurse, who documents in a “Walk-In Triage Log” patients’ arrival time, name, complaint, oxygen level, heart rate, respiration rate, allergies, pain level, notes, and nurse initials, then the triage nurse sends the patients to the registration desk to register with the admitting department. TRN stated after patients register, the patient’s name will appear in the triage’s nurse computer and the triage nurse will call the patient to place the identification wristband on the patient and complete the triage process, which includes assigning a priority level, a full vital signs (VS, temperature, blood pressure, heart rate/minute, oxygen level, respiratory rate, and pain), EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) for patients who complaint of chest pain, and a past medical history is collected by an Emergency Medical Technician, located right next door to the triage nurse at the Check-In window. During a concurrent interview and record review on 7/10/2025 at 10:37 a.m. with the Registered Nurse of Emergency Department (RNED) 1, RNED 1 stated Patient 19 presented to the ED on 3/17/2025 at 12:40 a.m. for chest pain with neck pain. Patient 19 registered at the Registration window. RNED 1 also stated Patient 19 was called in the waiting room by Registered Nurse of Emergency Department (RNED) 2 at 01:13 a.m., 01:35 a.m., and 01:44 a.m. with no response. RNED 1 stated Patient 19 waited for 33 minutes to be called for triage (a preliminary assessment in order to determine the urgency of a patient’s need for treatment and nature of treatment required) and verified an EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) had not been completed prior to Patient 19’s registration. RNED 1 stated that there were no records of interventions or treatment such as, EKG, triage, or MSE, being done for the Patient 19 because Patient 19 left without been seen. During a concurrent interview on 7/10/2025 at 11:22 a.m. with the Emergency Department Clinical Supervisor (EDCS), EDCS stated patients presenting to the ED with complaint of chest pain will be provided with EKG (a non-invasive test that records the electrical activity of the heart) immediately. A physician interprets the EKG to determine a patients’ priority level. In addition, standard orders are placed, and patients are placed in a room immediately. EDCS stated Patient 19’s EKG was not performed for Patient 19 upon arrival to the ED. In addition, Patient 19 was not triaged, nor did Patient 19 receive a medical screening exam. During a concurrent interview and record review on 7/10/2025 at 1:45 p.m. with the Medical Director of the Emergency Department (MDED), the MDED stated that standardized procedures for patients presenting to the ED with complaints of chest pain will require an immediate EKG and interpretation by a physician to help determine whether an emergency medical condition exists. Patients are immediately expediated for STEMI (a severe type of heart attack characterized by a complete blockage of a major coronary artery) order set and blood work. MDED stated the failure to complete the standardized procedures for Patient 19 had the potential for myocardial infarction (MI, heart attack) and/or cardiac catheterization (a procedure where a thin, flexible tube [catheter] is inserted into a blood vessel and guided to the heart to diagnose and treat certain heart conditions). During a review of the facility’s policy and procedure (P&P) titled, “RN Standardized Procedures: Emergency Department,” dated 3/2025, the P&P indicated the following. Patients presenting to the emergency department (ED) receive timely high-quality care. Therefore, a Registered Nurse (RN) in the ED may begin evaluation and care of patients using standardized procedures that are withing their scope of practice. Section 7. Procedure 7.2 The Emergency Department Standardized Procedure for specific patient conditions indicated Patients presenting with symptom (s) and or complaint (s) with Chest pain and are greater than or 40 years old or known cardiac history; the standardized procedure order sets to include: Labs, including, Troponin (indicate heart muscle damage). Nursing orders include to activate a facility STEMI order set, Cardiac Monitor, Start IV (Saline Lock). Cardiology, a 12-lead EKG, to show to MD immediately. Imaging includes a Chest x-ray. During a review of the facility’s policy and procedure (P&P) titled, “Medical Screening Examination” dated 9/2023, the P&P indicated “to provide a medical screening examination with the facility’s capability by an Emergency Physician for all individuals presenting to the Emergency Department without regard for their ability to pay. To determine the existence of an emergency medical condition. To provide medical screening, examination, emergency services and care as indicated to stabilize the medical condition of the patient ...if it is determined that the individual has an emergency medical condition, the Emergency Department will provide the individual, within the capabilities of the Hospital, with such further medical examination and treatment, as required, to stabilize the medical condition ...5. Without Delay: The Emergency Department will not delay the provision of a medical screening examination, further medical examination and stabilizing treatment, or appropriate transfer of an individual with an emergency medical condition in order to inquire about the individual’s method of payment or insurance status.” During a review of the facility’s policy and procedure (P&P) titled, “Chest Pain,” dated 9/2023, the P&P indicated “it is the policy of [facility’s name] to attempt to reduce the morbidity and mortality associated with patients presenting to the Emergency Department with chest pain or other cardiovascular related problems. Qualified personnel accomplish this through rapid assessment, intervention and treatment of these symptoms without delay for financial or any other reason. Patients presenting to the Emergency Department with symptoms/signs suggestive of acute coronary syndrome or cardiac event will be immediately triaged and will receive an EKG within 10 minutes of arrival to the emergency department (ED) ...The RN will order an EKG if EKG shows signs of STEMI/NSTEMI, acute ischemia, then patient is to be placed in bed immediately. ED physician initiates Code STEMI as indicated by the EKG.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to complete a medical screening examination (MSE, the initial exam performed by a physician when a patient presents to an emergency department to request care) to determine if an emergency medical condition (EMC, a medical condition manifesting itself by acute symptoms of sufficient severity - like severe pain, a pregnant woman in labor, and a mental health disturbance) existed for one of twenty sampled patients (Patient 19), when Patient 19 presented to the Emergency Department (ED, provides immediate medical care to patients with acute, life-threatening illness and injuries) complaining of chest pain and an EKG was not performed within 10 minutes of ED arrival. This deficient practice resulted in Patient 19 not having a medical screening examination (MSE) to determine whether an emergency medical condition existed, such as a myocardial infarction (heart attack, blockage of blood flow to the heart muscle) or other cardiovascular related problems, upon arrival to the ED complaining of chest pain. Findings: During a review of Patient 19’s “Face Sheet,” dated 3/17/2025, the Face Sheet indicated Patient 19 walked in to the Emergency Department at 12:40 a.m. for chest pain with neck pain. During a review of Patient 19’s “Conditions of Admission (COA),” dated 3/17/2025, the COA indicated form was signed by Patient 19 on 3/17/2025 at 12:40 a.m. During a review of Patient 19’s “View Existing Collection Notes,” dated 3/17/2025 and timed at 12:50 a.m., the Notes indicated Patient 19 was eligible for public health insurance. During concurrent observation and interview on 7/8/2025 at 01:34 p.m. with the Triage Nurse (TRN) from the Emergency Department, the TRN stated that patients enter the Emergency Department and present to the Check-In window with the Triage nurse, who documents in a “Walk-In Triage Log” patients’ arrival time, name, complaint, oxygen level, heart rate, respiration rate, allergies, pain level, notes, and nurse initials, then the triage nurse sends the patients to the registration desk to register with the admitting department. TRN stated after patients register, the patient’s name will appear in the triage’s nurse computer and the triage nurse will call the patient to place the identification wristband on the patient and complete the triage process, which includes assigning a priority level, a full vital signs (VS, temperature, blood pressure, heart rate/minute, oxygen level, respiratory rate, and pain), EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) for patients who complaint of chest pain, and a past medical history is collected by an Emergency Medical Technician, located right next door to the triage nurse at the Check-In window. During a concurrent interview and record review on 7/10/2025 at 10:37 a.m. with the Registered Nurse of Emergency Department (RNED) 1, RNED 1 stated Patient 19 presented to the ED on 3/17/2025 at 12:40 a.m. for chest pain with neck pain. Patient 19 registered at the Registration window. RNED 1 also stated Patient 19 was called in the waiting room by Registered Nurse of Emergency Department (RNED) 2 at 01:13 a.m., 01:35 a.m., and 01:44 a.m. with no response. RNED 1 stated Patient 19 waited for 33 minutes to be called for triage (a preliminary assessment in order to determine the urgency of a patient’s need for treatment and nature of treatment required) and verified an EKG (electrocardiogram, a non-invasive test that records the electrical activity of the heart) had not been completed prior to Patient 19’s registration. RNED 1 stated that there were no records of interventions or treatment such as, EKG, triage, or MSE, being done for the Patient 19 because Patient 19 left without been seen. During a concurrent interview on 7/10/2025 at 11:22 a.m. with the Emergency Department Clinical Supervisor (EDCS), EDCS stated patients presenting to the ED with complaint of chest pain will be provided with EKG (a non-invasive test that records the electrical activity of the heart) immediately. A physician interprets the EKG to determine a patients’ priority level. In addition, standard orders are placed, and patients are placed in a room immediately. EDCS stated Patient 19’s EKG was not performed for Patient 19 upon arrival to the ED. In addition, Patient 19 was not triaged, nor did Patient 19 receive a medical screening exam. During a concurrent interview and record review on 7/10/2025 at 1:45 p.m. with the Medical Director of the Emergency Department (MDED), the MDED stated that standardized procedures for patients presenting to the ED with complaints of chest pain will require an immediate EKG and interpretation by a physician to help determine whether an emergency medical condition exists. Patients are immediately expediated for STEMI (a severe type of heart attack characterized by a complete blockage of a major coronary artery) order set and blood work. MDED stated the failure to complete the standardized procedures for Patient 19 had the potential for myocardial infarction (MI, heart attack) and/or cardiac catheterization (a procedure where a thin, flexible tube [catheter] is inserted into a blood vessel and guided to the heart to diagnose and treat certain heart conditions). During a review of the facility’s policy and procedure (P&P) titled, “RN Standardized Procedures: Emergency Department,” dated 3/2025, the P&P indicated the following. Patients presenting to the emergency department (ED) receive timely high-quality care. Therefore, a Registered Nurse (RN) in the ED may begin evaluation and care of patients using standardized procedures that are withing their scope of practice. Section 7. Procedure 7.2 The Emergency Department Standardized Procedure for specific patient conditions indicated Patients presenting with symptom (s) and or complaint (s) with Chest pain and are greater than or 40 years old or known cardiac history; the standardized procedure order sets to include: Labs, including, Troponin (indicate heart muscle damage). Nursing orders include to activate a facility STEMI order set, Cardiac Monitor, Start IV (Saline Lock). Cardiology, a 12-lead EKG, to show to MD immediately. Imaging includes a Chest x-ray. During a review of the facility’s policy and procedure (P&P) titled, “Medical Screening Examination” dated 9/2023, the P&P indicated “to provide a medical screening examination with the facility’s capability by an Emergency Physician for all individuals presenting to the Emergency Department without regard for their ability to pay. To determine the existence of an emergency medical condition. To provide medical screening, examination, emergency services and care as indicated to stabilize the medical condition of the patient ...if it is determined that the individual has an emergency medical condition, the Emergency Department will provide the individual, within the capabilities of the Hospital, with such further medical examination and treatment, as required, to stabilize the medical condition ...5. Without Delay: The Emergency Department will not delay the provision of a medical screening examination, further medical examination and stabilizing treatment, or appropriate transfer of an individual with an emergency medical condition in order to inquire about the individual’s method of payment or insurance status.” During a review of the facility’s policy and procedure (P&P) titled, “Chest Pain,” dated 9/2023, the P&P indicated “it is the policy of [facility’s name] to attempt to reduce the morbidity and mortality associated with patients presenting to the Emergency Department with chest pain or other cardiovascular related problems. Qualified personnel accomplish this through rapid assessment, intervention and treatment of these symptoms without delay for financial or any other reason. Patients presenting to the Emergency Department with symptoms/signs suggestive of acute coronary syndrome or cardiac event will be immediately triaged and will receive an EKG within 10 minutes of arrival to the emergency department (ED) ...The RN will order an EKG if EKG shows signs of STEMI/NSTEMI, acute ischemia, then patient is to be placed in bed immediately. ED physician initiates Code STEMI as indicated by the EKG.””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36206 Based on interview and record review. The facility failed to: 1. Complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for one of 22 sampled patients (Patient 8). This deficient practice resulted in Patient 8 not receiving an MSE and evaluation for EMC (Emergency medical Condition), which had the potential for patient harm. Patient 8 left the facility without being seen (LWBS). (Refer to A-2406) 2. Carry out physician’s orders for two of 22 sampled patients (Patients 1 and 9) who presented to the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment. This deficient practice resulted in the facility failing to provide further medical examination and stabilizing treatment to Patients 1 and 9, and had the potential to result in harm. (Refer to A-2407) Findings: 1. During a concurrent interview and record review on 3/6/2025 at 3:40 p.m. with the Performance Improvement Coordinator (PIC), Patient 8’s Emergency Department Summary, dated 9/1/2024, was reviewed. The Emergency Department Summary indicated Patient 8 arrived in the Emergency Department (ED) on 9/1/2024 at 12:21 a.m. with a chief complaint of “headache, fainted and hit back of head on the floor at concert, swelling and scalp abrasion, had cocktail drink and marijuana at concert.” Patient 8 was Triaged (Acuity Level) on 9/1/2024 at 12:32 am, as Emergency Severity Index (ESI) level-3 (Urgent) (“Requires 2 or more resources and VS may or may not be in Danger Zone”). Vital Signs were- Temperature: 98.2 F (normal 97F to 99F); Pulse 94 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure148/93 (normal BP 120/80); Pulse oximetry 99% on room air (RA);1/10 Pain assessment. Electrocardiogram (EKG, measures heart’s electrical activity) was ordered at 12:47 a.m. indicating “ST elevation probably normal repolarization pattern.” RN (Registered Nurse) attempted first call for Patient 8 at 3:00 a.m., for MSE recorded at 3:05 a.m. Patient 8 left without being seen (LWBS). PIC verified Patient 8 did not have an MSE, no neurologic exam, no head injury exam, or cleansing of Patient 8’s head abrasion, no lab and no image orders. During a review of the facility’s policy and procedure (P&P) titled, “Medical Screening Exam,” dated 10/20/2023, the P&P indicated “to provide a medical screening exam to all the individuals presenting to the emergency department to determine if an emergency medical condition exists and to provide medical screening examination emergency services and care as indicated to stabilize the medical condition.” During a review of the facility’s policy and procedure (P&P) titled, “RN standardized procedures Emergency Department,” dated 7/20/2024, the P&P under section: presenting symptoms Syncope, indicated implementation of standardized procedures in the emergency department evaluation for Syncope included: lab blood draw for CBC (complete blood count); Basic Metabolic Panel. Nursing orders include cardiac monitor, pulse oximeter Monitor; oxygen to keep saturation above 90%; checking Patient’s blood sugar level and EKG. 2.a. During a concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), DED stated the following: Patient 1 presented to the ED on 1/17/2025 at 11:30 p.m. for shortness of breath and throat swelling. Patient 1 was evaluated by the Physician (MD 1) at 11:59 p.m. The DED reviewed Patient 1’s medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac (Toradol, a nonsteroidal anti-inflammatory drug, reduces inflammations and relieves moderate to severe pain), Dexamethasone (treats inflammation [swelling]), Diphenhydramine (Benadryl, treats allergies), Normal Saline (a solution of salt and water similar to that found in the body) had been ordered and had not been administered to Patient 1. There was no documentation indicating the reason the medications had not been given. During the same concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), Patient 1’s medical record was reviewed. Patient 1’s medical record indicated MD 1 ordered Cardiac (heart) monitoring and Oximetry (a non-invasive method to measure a person’s blood oxygen saturation, or the percentage of red blood cells carrying oxygen, providing a quick assessment of how well the lungs are functioning) on 1/18/2025 at 12:09 a.m. for Patient 1. The DED verified there was no documentation indicating as to whether the cardiac monitoring or oximetry orders were carried out and it should have been documented. MD 1 also ordered a CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) scan on 1/18/2025 at 12:19 a.m., which was not completed. DED stated Patient 1 left against medical advice (AMA, a situation where a patient leaves a healthcare facility before their doctor recommends) on 1/18/2025 at 4:15 am. The DED verified that none of the physician’s orders were carried out or completed during the time Patient 1 was in the ED, for approximately 4 hours. During a concurrent interview and record review on 3/6/2025 at 9:59 a.m. with the Manager of Pharmacy (MOP), the MOP stated the following: One-time medications orders in the Emergency Department automatically cancel themselves one minute after the medication is ordered by the physician. The medication then appears as “active” in the medication administration record (MAR) and the medication is highlighted in red until the medication is acknowledged and administered by a nurse. MOP stated that medications ordered in the ED are immediately available to nurses to avoid any delay in administering the medication. Medications ordered in the ED should be given as soon as possible. The MOP reviewed Patient 1’s medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac, Diphenhydramine, Dexamethasone, and Normal Saline had been ordered by the physician. The MAR indicated that the medications were not acknowledged by a nurse and the medications were not administered to Patient 1. The MOP stated that the medications for Patient 1 were meant to treat Patient 1 symptoms, including throat swelling. During a review of Patient 1’s “Triage (a preliminary assessment in order to determine the urgency of a patient’s need for treatment and nature of treatment required)” note, dated 1/17/2025 at 11:34 p.m., the triage note indicated the following: Patient 1 complained of throat pain and SOB (shortness of breath) one (1) hour ago ... Patient 1 started with hoarse voice and suddenly could not speak ...Priority level: 3 (Urgent, conditions prompt attention but can wait a short period for assessment and treatment) During a review of Patient 1’s “ED Physician Documentation,” dated 1/18/2025 at 12:17 a.m., the ED Physician Documentation indicated the following: “Chief complaint: Shortness of breath (SOB). Stated Complaint: Throat swelling. Patient (1) ...with history of asthma (a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breath) presents ...for evaluation of throat pain and swelling and difficulty speaking after returning from vacation...” During a review of Patient 1’s “Physician Note,” dated 1/18/2025 at 12:09 a.m., the noted indicated “Patient okay to get CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) with contrast (a dye or substance that helps show abnormal areas inside the body) without labs.” During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m., the Physician’s order indicated the following: Ketorolac 15 milligrams (MG, a unit of measurement) IV (in the vein) Once (one time). During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m., the Physician’s Order indicated the following. Dexamethasone 10 mg IV Once. During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m. indicated the following: Diphenhydramine 50 mg IV Once. During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m., the Physician’s Order indicated the following: Sodium Chloride (IV fluid) 1000 milliliters (ml, a unit of measurement) one time. During a review of Patient 1’s “Medical Administration Record,” dated 1/18/2025, the Medical Administration Record indicated the following: -Ketorolac (Toradol) 15 milligrams (MG) IV (in the vein) Once (one time). Current status was active (pending administration to patient) and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication was administered by a nurse. -Dexamethasone 10 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse. -Diphenhydramine (Benadryl, relieves allergies) 50 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse. - Sodium Chloride (IV fluid) 1000 milliliters (ml) one time. Current status was active and was highlighted in red. There was no documentation indicating that order was acknowledged or carried out. During a review of Patient 1’s “Orders,” dated 1/18/2025 at 12:09 a.m., the Orders indicated for a Rapid Group A Strep Test (a diagnostic test used to detect the presence of Group A streptococcus bacteria [a common bacteria found on the skin or throat]). There was no documentation indicating that the test had been completed, nor were there any test results in the medical record. This was verified by DED in an interview. During a review of Patient 1’s “Orders,” dated 1/18/2025, the Orders indicated the following was ordered for Patient 1: -Oximetry (a medical procedure that measures the oxygen saturation of the blood) Continuous: Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview. - Cardiac Monitor (a device that records the heart’s electrical activity): Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview. -IV Saline Lock (a capped-off intravenous [in the vein] catheter that is flushed with saline to prevent blood from clotting and maintain access for further medication or fluid administration), Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview. During a review of Patient 1’s “Summary Report,” dated 1/18/2025, the report indicated “left ama (against medical advice) without signing paperwork.” During a review of the facility’s policy and procedure (P&P) titled, “Medical Screening Examination,” dated 10/2023, the P&P indicated the following: The hospital will provide a medical screening examination ...to any individual who comes to the Emergency Department seeking an examination or medical treatment ...to determine if the individual has an emergency medical condition ...If is determined that the individual has an emergency medical condition, the Emergency department will provide the individual, within the capacities of the Hospital, with such further medical examination and treatment, as required to stabilize the medical condition. 2.b. During a concurrent interview and record review, on 3/7/2025 at 10:45 a.m. with the Stroke Coordinator (SC), Patient 9’s Emergency Department Summary record, dated 9/15/2024, was reviewed. The Emergency Department Summary indicated Patient 9 arrived in ED on 9/15/2024 at 7:28 p.m. with chief complaint “Chest pain, sudden onset, left sided Chest pain, hurts when moves.” Patient 9’s Triage (Acuity Level) on 9/15/2024 at 7:34 p.m. was Emergency Severity Index (ESI) level-3 (urgent). Vital Signs: Temperature: 98.5 F (normal 97 Fahrenheit- a unit of measurement to 99F); Pulse 69 (normal is 60 to 100); Respiration rate (RR):19 breaths per minute (normal RR 12 to 20); Blood Pressure (BP)1161/97 (normal is BP 120/80) Pulse oximetry 98% on room air (RA), 4/10 Pain assessment. During a review of Patient 9’s physician orders dated 9/15/2024 at 9 p.m., the physician orders indicated STAT (emergent) physician orders :Nitroglycerin (medicine used to treat chest pain), aspirin 81 milligrams (mg, a unit of measurement); IV saline; continuous cardiac monitor; continuous pulse oximetry; oxygen cannula; undress and gown patient; electrocardiogram; notification of admission to telemetry ; complete blood count; basic metabolic panel; D- dimer (a protein that is released when blood clots break down); B type natriuretic peptide (a hormone released by the heart in response to increased stress); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged), Chest X-ray. During further review of Patient 9’s medical record, the Lab (laboratory) results included a Critical Value Troponin (found in heart muscle and usually elevated when heart muscle is damaged) level which was elevated= 54 (normal 3 to 34). At 9:10 p.m., lab attempted twice to notify a registered nurse (RN) of critical Troponin result but with no response. D-Dimer (a protein that is released when blood clots break down) was elevated 18.37 (normal<0.50). B type natriuretic peptide was181 (normal o to 100). Follow-up Troponin level drawn at 10:51 p.m. showed a Troponin level of 51 (normal 3 to 34), reported to RN at 12:22 a.m. on 9/16/2024. The EKG result indicated: incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart). During a review of Patient 9’s physician orders dated 9/16/2024 at 1 a.m., the Stat orders included Enoxaparin (injectable blood thinner that prevents and treats blood clots), Ultrasound (US) Venous lower extremity (US of leg veins for blood clots); Lung perfusion studies (to evaluate for blood clots in the lung). During a review of Patient 9’s physician orders dated 9/16/2024 at 1:49 a.m., the record indicated to Request Admit from ED. During a review of Patient 9’s ED Physician Documentation, dated 9/15/2024, the record indicated Patient 9 had elevated Troponin and D -dimer and Patient 9 needed evaluation and treatment for Pulmonary embolus. Same document indicated Patient 9’s EKG included incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart), inverted T wave (could be heart attack) and no ST elevation (elevation indicated heart artery blockage). Patient 9’s diagnosis included; acute coronary syndrome (Chest pain that can lead to heart attack); NSTEMI (heart attack with damage to heart without ST elevation); rule out pulmonary embolus (artery in the lung is blocked by a blood clot), and acute kidney injury (AKI, kidneys suddenly lose their ability to function). Plan indicated to admit Patient 9 to telemetry (a specialized ward where patients receive continuous cardiac [heart] monitoring) unit and facility Hospitalist notified. The same document indicated that findings and plan was explained to Patient 9 and that Patient 9 was provided aftercare instructions and instructions to return for worsening symptoms. The record also indicated that Patient 9 had to follow-up with PMD and indicated Patient 9’s condition improved. Patient 9’s ED Physician Documentation was signed 9/16/ 2024 at 1:27 p.m. During a concurrent interview and record review on 3/7/2025 at 11:10 a.m. with the Director of Emergency Department (DED), Patient 9’s Emergency Department Summary, dated 9/15/2024, was reviewed. DED was asked if Patient 9 was on continuous cardiac monitor and continuous oximetry, DED stated there was no documentation Patient 9 was on continuous cardiac monitor or continuous pulse oximetry. DED was asked would the continuous Cardiac monitor and continuous oximetry alarm make noise if Patient 9 was disconnected, DED stated yes and verified there was no documentation by RN of Patient 9 being disconnected from the cardiac monitor. DED was also asked if Patient 9 received medications ordered STAT by physician including Aspirin, Morphine Sulphate, Nitroglycerin, and Lovenox. DED stated Aspirin was ordered at 9 p.m. and given at 10:14 p.m. and Nitroglycerin was given by a licensed vocational nurse (LVN) at 10:27 p.m. DED confirmed that Morphine, Lovenox, and Normal Saline IVF were not given as per physician orders. During the same concurrent interview and record review on 3/7/2025 at 11:25 a.m. with the Director of Emergency Department (DED), the DED stated Patient 9 left sometime after 10 p.m., not sure when Patient 9 left. Patient 9’s Emergency Department Summary, documented by an LVN, under section Notes, indicated “Patient (Patient 9) not found in ED common areas” on 9/16/2024 at 12 midnight. DED also confirmed there was no Discharge orders written by MD. During a review of Patient 9’s “ED Physician Documentation,” dated 9/16/2024 at 2:38 a.m., the documentation indicated Patient 9 could not be found and might have eloped. Physician tried to telephone Patient 9 twice, left voicemail that cardiac enzymes were elevated and could have blood clot in lungs both of which were life threatening and to return to ED. During a review of the facility’s policy and procedure (P&P) titled, “RN standardized procedures emergency department,” dated 7/20/2024, the P&P indicated “RN is responsible for a patient for whom a standardized procedure has been implemented including: showing EKG to the physician notifying the physician of any abnormal lab or radiology result , any change in patient condition abnormal vital signs or any other concern regarding the patient... the RN is responsible to ensure physician orders are received ... and implemented in a timely manner.” During a review of a facility’s policy and procedure titled, “Medical Screening Exam,” dated 10/20/2023, under section: stabilizing treatment, the P&P indicated “if it is determined that an individual has an emergency medical condition the emergency department will provide the individual with the capabilities of the hospital such further medical examination and treatment as required to stabilize the medical condition.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 31993 Based on interview and record review, the facility did not complete a Medical Screen Examination (MSE - screening used to determine whether a patient has an emergent medical condition) and treatment for one of 22 sampled patients (Patient 8). This deficient practice resulted in Patient 8 not receiving an MSE and evaluation for EMC (Emergency medical Condition), which had the potential for patient harm. Patient 8 left the facility without being seen (LWBS). Findings: During a concurrent interview and record review, on 3/6/2025 at 3:40 p.m. with the Performance Improvement Coordinator (PIC), Patient 8’s Emergency Department Summary, dated 9/1/2024, was reviewed. The Emergency Department Summary indicated Patient 8 arrived in the Emergency Department (ED) on 9/1/2024 at 12:21 a.m. with a chief complaint of “headache, fainted and hit back of head on the floor at concert, swelling and scalp abrasion, had cocktail drink and marijuana at concert.” Patient 8 was Triaged (Acuity Level) on 9/1/2024 at 12:32 am, as Emergency Severity Index (ESI) level-3 (Urgent) (“Requires 2 or more resources and VS may or may not be in Danger Zone”). Vital Signs were- Temperature: 98.2 F (normal 97F to 99F); Pulse 94 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure148/93 (normal BP 120/80); Pulse oximetry 99% on room air (RA);1/10 Pain assessment. Electrocardiogram (EKG, measures heart’s electrical activity) was ordered at 12:47 a.m. with indication of “ST elevation probably normal repolarization pattern.” RN call attempted first call for Patient 8 at 3:00 a.m., for MSE recorded at 3:05 a.m. Patient 8 left without being seen (LWBS). PIC verified Patient 8 did not have an MSE, no neurologic exam, no head injury exam or cleansing of Patient 8’s head abrasion, no lab and no image orders. During a review of the facility’s policy and procedure (P&P) titled, “Medical Screening Exam,” dated 10/20/2023, the P&P indicated “to provide a medical screening exam to all the individuals presenting to the emergency department to determine if an emergency medical condition exists and to provide medical screening examination emergency services and care as indicated to stabilize the medical condition.” During a review of the facility’s policy and procedure (P&P) titled, “RN standardized procedures Emergency Department,” dated 7/20/2024, the P&P under section: presenting symptoms Syncope, indicated implementation of standardized procedures in the emergency department evaluation for Syncope included: lab blood draw for CBC (complete blood count); Basic Metabolic Panel. Nursing orders include cardiac monitor, pulse oximeter Monitor; oxygen to keep saturation above 90%; checking Patient’s blood sugar level and EKG.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 36206 Based on interview and record review the facility failed to carry out physician’s orders for two of 22 sampled patients (Patients 1 and 9) who presented to the Emergency Department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment. This deficient practice resulted in the facility failing to provide further medical examination and stabilizing treatment to Patients 1 and 9 and had the potential to result in harm. Findings: 1. During a concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), DED stated the following: Patient 1 presented to the ED on 1/17/2025 at 11:30 p.m. for shortness of breath and throat swelling. Patient 1 was evaluated by the Physician (MD 1) at 11:59 p.m. The DED reviewed Patient 1’s medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac (Toradol, a nonsteroidal anti-inflammatory drug, reduces inflammations and relieves moderate to severe pain), Dexamethasone (treats inflammation [swelling]), Diphenhydramine (Benadryl, treats allergies), Normal Saline (a solution of salt and water similar to that found in the body) had been ordered and had not been administered to Patient 1. There was no documentation indicating the reason the medications had not been given. During the same concurrent interview and record review on 3/5/2025 at 3:19 p.m. with the Director of Emergency Department (DED), Patient 1’s medical record was reviewed. Patient 1’s medical record indicated MD 1 ordered Cardiac (heart) monitoring and Oximetry (a non-invasive method to measure a person’s blood oxygen saturation, or the percentage of red blood cells carrying oxygen, providing a quick assessment of how well the lungs are functioning) on 1/18/2025 at 12:09 a.m. for Patient 1. The DED verified there was no documentation indicating as to whether the cardiac monitoring or oximetry orders were carried out and it should have been documented. MD 1 also ordered a CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) scan on 1/18/2025 at 12:19 a.m., which was not completed. DED stated Patient 1 left against medical advice (AMA, a situation where a patient leaves a healthcare facility before their doctor recommends) on 1/18/2025 at 4:15 am. The DED verified that none of the physician’s orders were carried out or completed during the time Patient 1 was in the ED, for approximately 4 hours. During a concurrent interview and record review on 3/6/2025 at 9:59 a.m. with the Manager of Pharmacy (MOP), the MOP stated the following: One-time medications orders in the Emergency Department automatically cancel themselves one minute after the medication is ordered by the physician. The medication then appears as “active” in the medication administration record (MAR) and the medication is highlighted in red until the medication is acknowledged and administered by a nurse. MOP stated that medications ordered in the ED are immediately available to nurses to avoid any delay in administering the medication. Medications ordered in the ED should be given as soon as possible. The MOP reviewed Patient 1’s medication orders dated 1/18/2025 at 12:15 a.m. and stated that Ketorolac, Diphenhydramine, Dexamethasone, and Normal Saline had been ordered by the physician. The MAR indicated that the medications were not acknowledged by a nurse and the medications were not administered to Patient 1. The MOP stated that the medications for Patient 1 were meant to treat Patient 1 symptoms, including throat swelling. During a review of Patient 1’s “Triage (a preliminary assessment in order to determine the urgency of a patient’s need for treatment and nature of treatment required)” note, dated 1/17/2025 at 11:34 p.m., the triage note indicated the following: Patient 1 complained of throat pain and SOB (shortness of breath) one (1) hour ago ... Patient 1 started with hoarse voice and suddenly could not speak ...Priority level: 3 (Urgent, conditions prompt attention but can wait a short period for assessment and treatment). During a review of Patient 1’s “ED Physician Documentation,” dated 1/18/2025 at 12:17 a.m., the ED Physician Documentation indicated the following: “Chief complaint: Shortness of breath (SOB). Stated Complaint: Throat swelling. Patient (1) ...with history of asthma (a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breath) presents ...for evaluation of throat pain and swelling and difficulty speaking after returning from vacation...” During a review of Patient 1’s “Physician Note,” dated 1/18/2025 at 12:09 a.m., the noted indicated “Patient okay to get CT (computed tomography, a medical imaging procedure that uses x-rays to create a detailed cross-sectional images of the body) with contrast (a dye or substance that helps show abnormal areas inside the body) without labs.” During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m., the Physician’s order indicated the following: Ketorolac 15 milligrams (MG, a unit of measurement) IV (in the vein) Once (one time) . During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m., the Physician’s Order indicated the following. Dexamethasone 10 mg IV Once. During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m. indicated the following: Diphenhydramine 50 mg IV Once. During a review of Patient 1’s “Physician’s Order,” dated 1/18/2025 at 12:15 a.m., the Physician’s Order indicated the following: Sodium Chloride (IV fluid) 1000 milliliters (ml, a unit of measurement) one time. During a review of Patient 1’s “Medical Administration Record,” dated 1/18/2025, the Medical Administration Record indicated the following: -Ketorolac (Toradol) 15 milligrams (MG) IV (in the vein) Once (one time). Current status was active (pending administration to patient) and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication was administered by a nurse. -Dexamethasone 10 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse. -Diphenhydramine (Benadryl, relieves allergies) 50 mg IV Once. Current status was active and was highlighted in red. There was no documentation indicating that the medication order had been acknowledged or that the medication had been administered by a nurse. - Sodium Chloride (IV fluid) 1000 milliliters (ml) one time. Current status was active and was highlighted in red. There was no documentation indicating that order was acknowledged or carried out. During a review of Patient 1’s “Orders,” dated 1/18/2025 at 12:09 a.m., the Orders indicated for a Rapid Group A Strep Test (a diagnostic test used to detect the presence of Group A streptococcus bacteria [a common bacteria found on the skin or throat]). There was no documentation indicating that the test had been completed, nor were there any test results in the medical record. This was verified by DED in an interview. During a review of Patient 1’s “Orders,” dated 1/18/2025, the Orders indicated the following was ordered for Patient 1: -Oximetry (a medical procedure that measures the oxygen saturation of the blood) Continuous: Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview. - Cardiac Monitor (a device that records the heart’s electrical activity): Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview. -IV Saline Lock (a capped-off intravenous [in the vein] catheter that is flushed with saline to prevent blood from clotting and maintain access for further medication or fluid administration), Status - Active. There was no documentation indicating the order had been completed. This was verified by DED in an interview. During a review of Patient 1’s “Summary Report,” dated 1/18/2025, the report indicated “left ama (against medical advice) without signing paperwork.” During a review of the facility’s policy and procedure (P&P) titled, “Medical Screening Examination,” dated 10/2023, the P&P indicated the following: The hospital will provide a medical screening examination ...to any individual who comes to the Emergency Department seeking an examination or medical treatment ...to determine if the individual has an emergency medical condition ...If is determined that the individual has an emergency medical condition, the Emergency department will provide the individual, within the capacities of the Hospital, with such further medical examination and treatment, as required to stabilize the medical condition. 2. During a concurrent interview and record review, on 3/7/2025 at 10:45 a.m. with Stroke Coordinator (SC), Patient 9’s Emergency Department Summary record, dated 9/15/2024, was reviewed. The Emergency Department Summary indicated Patient 9 arrived in ED on 9/15/2024 at 7:28 p.m. with chief complaint “Chest pain, sudden onset, left sided Chest pain, hurts when moves.” Patient 9’s Triage (Acuity Level) on 9/15/2024 at 7:34 p.m. was Emergency Severity Index (ESI) level-3 (urgent). Vital Signs: Temperature: 98.5 F (normal 97 Fahrenheit- a unit of measurement to 99F); Pulse 69 (normal is 60 to 100); Respiration rate (RR):19 breaths per minute (normal RR 12 to 20); Blood Pressure (BP)1161/97 (normal is BP 120/80) Pulse oximetry 98% on room air (RA), 4/10 Pain assessment. During a review of Patient 9’s physician orders dated 9/15/2024 at 9 p.m., the physician orders indicated STAT (emergent) physician orders :Nitroglycerin (medicine used to treat chest pain), aspirin 81 milligrams (mg, a unit of measurement); IV saline; continuous cardiac monitor; continuous pulse oximetry; oxygen cannula; undress and gown patient; electrocardiogram; notification of admission to telemetry ; complete blood count; basic metabolic panel; D- dimer (a protein that is released when blood clots break down); B type natriuretic peptide (a hormone released by the heart in response to increased stress); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged), Chest X-ray. During further review of Patient 9’s medical record, the Lab (laboratory) results included a Critical Value Troponin (found in heart muscle and usually elevated when heart muscle is damaged) level which was elevated= 54 (normal 3 to 34). At 9:10 p.m., lab attempted twice to notify a registered nurse (RN) of critical Troponin result but with no response. D-Dimer (a protein that is released when blood clots break down) was elevated 18.37 (normal<0.50). B type natriuretic peptide was181 (normal o to 100). Follow-up Troponin level drawn at 10:51 p.m. showed a Troponin level of 51 (normal 3 to 34), reported to RN at 12:22 a.m. on 9/16/2024. The EKG result indicated: incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart). During a review of Patient 9’s physician orders dated 9/16/2024 at 1 a.m., the Stat orders included Enoxaparin (injectable blood thinner that prevents and treats blood clots), Ultrasound (US) Venous lower extremity (US of leg veins for blood clots); Lung perfusion studies (to evaluate for blood clots in the lung). During a review of Patient 9’s physician orders dated 9/16/2024 at 1:49 a.m., the record indicated to Request Admit from ED. During a review of Patient 9’s ED Physician Documentation, dated 9/15/2024, the record indicated Patient 9 had elevated Troponin and D -dimer and Patient 9 needed evaluation and treatment for Pulmonary embolus. Same document indicated Patient 9’s EKG included incomplete Right Bundle branch block (RBBB, heart condition where electrical signal is delayed on the right side of the heart), inverted T wave (could be heart attack) and no ST elevation (elevation indicated heart artery blockage). Patient 9’s diagnosis included; acute coronary syndrome (Chest pain that can lead to heart attack); NSTEMI (heart attack with damage to heart without ST elevation); rule out pulmonary embolus (artery in the lung is blocked by a blood clot), and acute kidney injury (AKI, kidneys suddenly lose their ability to function). Plan indicated to admit Patient 9 to telemetry (a specialized ward where patients receive continuous cardiac [heart] monitoring) unit and facility Hospitalist notified. The same document indicated that findings and plan was explained to Patient 9 and that Patient 9 was provided aftercare instructions and instructions to return for worsening symptoms. The record also indicated that Patient 9 had to follow-up with PMD and indicated Patient 9’s condition improved. Patient 9’s ED Physician Documentation was signed 9/16/ 2024 at 1:27 p.m. During a concurrent interview and record review on 3/7/2025 at 11:10 a.m. with the Director of Emergency Department (DED), Patient 9’s Emergency Department Summary, dated 9/15/2024, was reviewed. DED was asked if Patient 9 was on continuous cardiac monitor and continuous oximetry, DED stated there was no documentation Patient 9 was on continuous cardiac monitor or continuous pulse oximetry. DED was asked would the continuous Cardiac monitor and continuous oximetry alarm make noise if Patient 9 was disconnected, DED stated yes and verified there was no documentation by RN of Patient 9 being disconnected from the cardiac monitor. DED was also asked if Patient 9 received medications ordered STAT by physician including Aspirin, Morphine Sulphate, Nitroglycerin, and Lovenox. DED stated Aspirin was ordered at 9 p.m. and given at 10:14 p.m. and Nitroglycerin was given by a licensed vocational nurse (LVN) at 10:27 p.m.; DED confirmed that Morphine, Lovenox, and Normal Saline IVF were not given as per physician orders. During the same concurrent interview and record review, on 3/7/2025 at 11:25 a.m. with the Director of Emergency Department (DED), the DED stated Patient 9 left sometime after 10 p.m., not sure when Patient 9 left. Patient 9’s Emergency Department Summary, documented by an LVN, under section Notes, indicated “Patient (Patient 9) not found in ED common areas” on 9/16/2024 at 12 midnight. DED also confirmed there was no Discharge orders written by MD. During a review of Patient 9’s “ED Physician Documentation,” dated 9/16/2024 at 2:38 a.m., the documentation indicated Patient 9 could not be found and might have eloped. Physician tried to telephone Patient 9 twice, left voicemail that cardiac enzymes were elevated and could have blood clot in lungs both of which were life threatening and to return to ED. During a review of the facility’s policy and procedure (P&P) titled, “RN standardized procedures emergency department,” dated 7/20/2024, the P&P indicated “RN is responsible for a patient for whom a standardized procedure has been implemented including: showing EKG to the physician notifying the physician of any abnormal lab or radiology result , any change in patient condition abnormal vital signs or any other concern regarding the patient... the RN is responsible to ensure physician orders are received ... and implemented in a timely manner.” During a review of a facility’s policy and procedure titled, “Medical Screening Exam,” dated 10/20/2023, under section: stabilizing treatment, the P&P indicated “if it is determined that an individual has an emergency medical condition the emergency department will provide the individual with the capabilities of the hospital such further medical examination and treatment as required to stabilize the medical condition.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46238 Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met as evidenced by: 1. The facility failed to ensure that a patient’s rights requirement pertaining to care and treatment was met when the facility failed to obtain and verify an accurate past medical history (a comprehensive record of a patient’s previous health conditions, treatments, and diagnoses) regarding seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), for one of 34 sampled patients (Patient 2), despite being documented that family was at the bedside to provide information and contact information being charted in Patient 2’s medical record in the ED (Emergency Department, a specialized hospital unit providing acute [sudden and severe] care for patients with severe or urgent medical conditions) on 7/1/2024 (date of Patient 2’s ED arrival). This deficient practice resulted in Patient 2’s past medical history not to be timely verified, potentially causing a delay in the implementation of a timely and appropriate treatment and care plan to address Patient 2’s stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients), which was later confirmed on 7/2/2024 (Patient 2 arrived at the ED on 7/1/2024). (Refer to A-0129) 2. The facility failed to ensure for one of 34 sampled patients (Patient 19), Patient 19’s conservatorship (a court-ordered arrangement where a judge appoints a person to manage the affairs of another person who is unable to do so themselves) was verified for its existence upon admission to the facility. This deficient practice had the potential to result in Patient 19 or the patient’s conservator (the person or organization appointed by the court who would be responsible of one person’s physical health and medical care) rights to not be exercised by not knowing who is legally able to make medical decision for Patient 19. This deficient practice also had the potential to impede the conservator’s involvement to work with the healthcare team to achieve recovery for Patient 19. (Refer to A-0129) 3. The facility failed to ensure safety precautions were in place for two of 34 sampled patients (Patients 4 and 34), when safety straps (immobilizes patients on a table to prevent falls [unplanned descent to the floor with or without injury to the patient]) were not utilized, in accordance with the manufacturer’s instructions, for Patients 4 and 34 while on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table, and Patients 4 and 34 fell off the cath lab table. This deficient practice had the potential for Patients 4 and 34 to suffer bodily injury, including but not limited to head trauma, broken bones, and skin injuries. (Refer to A-0144) 4. The facility failed to ensure for one of 34 sampled patients (Patient 19), a code green (the facility’s notification of emergency to the staff indicating a missing/eloping patient who is determined to be a danger to themselves or has been identified as a safety risk) was activated, in accordance with the facility’s policy and procedure regarding “Emergency Management,” when Patient 19 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 11/12/2024 at 1:40 p.m. This deficient practice resulted in Patient 19 leaving the facility unsupervised and may have the potential to result in Patient 19 harming self and could cause injury and/or death to the patient. (Refer to A-0144) 5. The facility failed to ensure one of 34 sampled patients (Patient 22), was free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 22’s four siderails of the bed were observed raised without a physician’s order and in accordance with the facility’s policy and procedure regarding use of restraints. This deficient practice resulted in inappropriate, unnecessary use of restraints, and had violated Patient 22’s rights regarding being free from inappropriate restraints use. In addition, this deficient practice had the potential for Patient 22 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc. (Refer to A-0154) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1. The facility failed to ensure one of 34 sampled patients (Patient 3), who was identified as cognitively impaired (having limitations in mental functions that affect their ability to process or communicate information) and nonverbal (unable to use spoken words to communicate), was properly assessed using a pain scale specifically designed for non-verbal patients, in accordance with the facility’s policy regarding pain assessment and management of patients who are unable to speak or express pain verbally and/or have mental impairment. This deficient practice had the potential to result in Patient 3 not receiving accurate pain assessment and management and potentially placing Patient 3 at risk for uncontrolled pain, worsening pain level, psychological distress such as anxiety (feeling of uneasiness), etc. (Refer to A-0395) 2. The facility failed to ensure one of 34 sampled patient’s (Patient 3), pain re-assessment (the process of re-evaluating a patient’s pain level after an intervention, such as medication, to determine its effectiveness and ensure proper pain management) was conducted, following the administration of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] used for short-term management of moderate to severe pain), in accordance with the facility’s policy regarding pain management and re-assessment. This deficient practice had the potential to result in Patient 3’s pain not being sufficiently managed/addressed, leading to discomfort or progression to uncontrolled pain or psychological distress such as anxiety (feeling of uneasiness), etc. (Refer to A-0395) 3. The facility failed to ensure that nursing staff activated the stroke protocol (a set of standardized procedures designed to rapidly assess, diagnose, and treat patients presenting with stroke [interruption of blood flow to the brain leading to potential brain damage] symptoms to minimize brain damage and improve outcomes) for one of 34 sampled patients (Patient 2), when on 7/2/2024 at 8:01 a.m., Patient 2 started showing signs and symptoms of stroke (observable indicators of a stroke, such as sudden paralysis [the loss of muscle function or control, on one side of the body]; aphasia [a language disorder caused by brain damage, affecting the ability to speak, understand, read, or write]; and facial droop [weakness or paralysis of the facial muscles, often causing one side of the face to sag or appear asymmetrical]). The deficient practice had the potential to result in delayed diagnosis and treatment for Patient 2 and increase the risk of permanent neurological damage or other complications associated with untreated stroke symptoms. (Refer to A-0395) 4. The facility failed to ensure one of 34 sampled patient’s (Patient 3) nutritional status (the condition of a patient’s health as influenced by the intake and utilization of nutrients necessary for maintaining bodily functions, growth, and repair) and hydration status (the balance of fluids in the body required to support normal physiological processes, such as circulation, temperature regulation, and organ function) were monitored, assessed, and documented in accordance with the facility’s policy regarding “Standard of Care” and “Nursing Documentation.” This deficient practice had the potential to result in complications such as dehydration, unexpected weight loss, etc., when the patient’s (Patient 3) nutritional and hydration status are not properly assessed and monitored leading to a delay in making informed decisions to meet Patient 3’s individual nutritional and hydration needs. (Refer to A-0395) 5. The facility failed to ensure one of 34 sampled patient’s (Patient 24) pain was reassessed (reevaluation), in accordance with the facility’s policy and procedure regarding pain management, after Patient 24 received pain medication of Ibuprofen (Motrin, pain medication) 600 milligram (mg, metric unit of measurement, used for medication dosage and/or amount), which was administered by mouth. This deficient practice had the potential to result in Patient 24’s pain to not be appropriately managed in which Patient 24’s pain remains unresolved, leading to worsening of pain, psychological distress due to pain, and a prolonged hospitalization. (Refer to A-0395) 6. The facility failed to ensure for two of 34 sampled patients (Patient 11 and Patient 12), the following: 6.a. For Patient 11, an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for fall (unplanned descent to the floor with or without injury to the patient) precaution (proactive steps to prevent someone from falling by addressing potential hazards in their environment and promoting behaviors that minimize the risk of a fall), was developed upon admission, in accordance with the facility’s policy and procedure regarding care planning.. This deficient practice had the potential for Patient 11’s needs and risks not to be identified and addressed, which may result in a fall with complications such as fracture (break in the bones), etc. (Refer to A-0396) 6.b. For Patient 12, an individualized nursing care plan for management of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) was developed upon admission, in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in the delayed provision of care to Patient 12 by not identifying Patient 12’s need and risks, which may result in complications such as hypoglycemia (low blood sugar), diabetic coma (a life-threatening complication when a patient’s blood sugar levels are dangerously high or low, causing them to become unconscious), and/or death. (Refer to A-0396) 7. The facility failed to ensure that for one of 34 sampled patients (Patient 3), nursing staff documented intake and output (the measurement and recording of all fluids a patient takes in, such as through drinking or IV fluids [intravenous fluids, which are liquids administered directly into a vein to provide hydration, medications, or nutrients], and fluids they lose, such as through urination or vomiting) throughout Patient 3’s admission stay at the facility, in accordance with the facility’s policy regarding “Standard of Care” and “Nursing Documentation.” This deficient practice potentially placed Patient 3 at risk for missed opportunities to detect and address changes in the patient’s fluid status (the balance of fluids in the body, which is essential for maintaining normal bodily functions), which may result in complications such as dehydration (excessive loss of fluid), low blood pressure, etc. (Refer to A-0398) 8. The facility failed to ensure that, for one patient out of 34 sampled patients (Patient 3), nursing staff obtained a urine sample (a collection of urine used for diagnostic purposes, such as detecting infections, assessing kidney function) as indicated by the physician’s order and in accordance with the facility’s policy regarding carrying-out all physician’s orders. This deficient practice had the potential to result in Patient 3’s delayed diagnosis and treatment of underlying medical conditions such as urinary tract infections (UTIs, infections occurring in any part of the urinary system, including the bladder, urethra [the tube that carries urine out of the body], or kidneys, which can cause symptoms such as pain, burning during urination, and fever, and if untreated, may lead to serious kidney complications) leading to worsening of symptoms and compromising patient’s (Patient 3) health and recovery. (Refer to A-0398) 9. The facility failed to ensure that, for one of 34 sampled patients (Patient 2), the mental status (assessed to identify abnormalities such as confusion, disorientation, or unresponsiveness) during the triage assessment (the initial evaluation of a patient upon arrival to the emergency department), was accurately documented based on Patient 2’s presenting condition, in accordance with the facility’s policy regarding documentation in the ED patient care record (a comprehensive record of care provided in the emergency department). This deficient practice resulted in Patient 2 not being assigned a correct ESI level (Emergency Severity Index, a triage tool used to categorize patients based on acuity-the severity of a patient’s condition and the urgency of medical intervention required-and resource needs, such as diagnostic tests or treatments), which could potentially lead to delayed prioritization of care (failure to provide timely or suitable medical attention based on the patient’s actual condition and needs, potentially compromising outcomes). (Refer to A-0398) 10. The facility failed to ensure one of 34 sampled patient’s (Patient 6’s) pain was assessed and addressed after sustaining an unwitnessed fall (an unplanned descent to the floor with or without injury to the patient) and on two other occasions when Patient 6’s family reported that Patient 6 had pain, in accordance with the facility policy and procedure regarding assessment, reassessment, and pain management. This deficient practice likely resulted in Patient 6 experiencing unrelieved pain and had the potential for delay in needed treatment, which can result in complications such as worsening pain level, psychological distress due to uncontrolled pain, etc. (Refer to A-0398) 11. The facility failed to ensure one of 34 sampled patient’s (Patient 6’s) fall risk was reassessed using the Morse Fall Scale (MFS, a tool to identify patients at risk for falling that includes history of falling, secondary diagnosis, ambulatory [related to walking] aids [example: cane], intravenous [medication administered into the vein] therapy, gait abnormalities [the pattern of how a person walks], and mental status, with the summed range from 0 to 125, higher scores indicating a higher risk for falling) after sustaining a fall (unplanned descent to the floor with or without injury to the patient) on 10/4/2024 and for the MFS score to reflect Patient 6’s post-fall status. This deficient practice may lead to the wrong fall preventative measures used and compromise Patient 6’s safety, which may result in another fall with complications such as fracture (broken bones). (Refer to A-0398) 12. The facility failed to ensure, the facility staff followed the chain of command (crucial for ensuring patient safety by providing a structured process for staff to escalate concerns about patient care, report issues, and seek necessary interventions through a clear hierarchy of authority, ultimately leading to better decision-making and addressing problems promptly when they arise) when unable to immediately contact and notify the physician regarding one of 34 sampled patient’s (Patient 6’s) critical laboratory values (potentially life-threatening laboratory results that must be conveyed immediately to the physician so that therapeutic measures can be instituted rapidly) such as elevated Troponin (is a protein that’s found in the cells of the heart muscle) level of 80.0 ng (nanograms, a unit of measurement) per milliliter (mL, a unit of measurement, a normal troponin levels range is from 0-0.04 ng/ml) and a Hemoglobin level of 6.2 (normal range of hemoglobin for adult men is 13.5 to 17.5 g/dL ) , in accordance with the facility’s policy and procedure regarding utilization of chain of command. This deficient practice may lead to a delay in necessary interventions and jeopardize Patient 6’s safety, resulting in complications such as cardiac arrest [when the heart stops beating], dizziness, fatigue, shortness of breath [difficulty breathing], etc. (Refer to A-0398) 13. The facility failed to ensure one of 34 sampled patients (Patient 5) was turned and repositioned (to change someone’s body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) every 2 hours, in accordance with facility policy and procedure regarding skin integrity (refers to the health and unbroken state of the skin). This deficient practice had the potential for patient 34’s existing sacrogluteal (buttock [butt] area) pressure injuries (localized damage to the skin or soft tissue caused by prolonged or severe pressure, often over a bony part of the body) to worsen, resulting in complications such as infection, the need for surgery to debride (remove) dead tissue, etc. (Refer to A-0398) 14. The facility failed to ensure for one of 34 sampled patients (Patient 9), Patient 9’s seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions (refers to safety measures taken before a patient experiences a seizure) was implemented, in accordance with the facility’s policy and procedure regarding seizure management when, Patient 9 was observed to not have all the four side rails padded. This deficient practice had the potential for Patient 9 to suffer from pain and injury (such as fracture [broken bones]) during a seizure activity. (Refer to A-0398) 15. The facility failed to ensure for one of 30 sampled patients (Patient 20), the facility’s policies and procedures (P&P) for fall (an unplanned descent to the floor with or without injury to the patient) reduction was implemented when, Patient 20, who was a high risk for fall, was not wearing yellow socks (yellow socks indicate the patient was at risk for fall) and the patient’s (Patient 20) bed alarm was not turned on/activated (a bed alarm will go off to alert staff when a patient gets out of bed). This deficient practice had the potential to result in an unsafe care that may lead to Patient 20 suffering from a fall injury with possible complications such as fracture (broken bones), the need for surgery (in case of severe injury requiring surgery), brain bleed (if the patient hits the head on the floor), etc. (Refer to A-0398) 16. The facility failed to ensure one of seven sampled emergency crash carts (Crash Cart 2, a wheeled container carrying medicine and equipment for use in emergency resuscitations [procedure used to restart a patient’s breathing and heartbeat when they have stopped]), had complete and readily available equipment for use when, Crash Cart 2 was missing a cardiac backboard (rigid surface used to support a patient during a cardiopulmonary resuscitation [CPR, a life-saving emergency procedure that combines chest compressions and rescue breathing to help someone who is not breathing or heartbeat has stopped]). This deficient practice had the potential to delay critical emergency care if the crash cart equipment was not inspected for completeness and verified for availability potentially leading to worsened patient outcomes and/or patient death. (Refer to A-0398) 17. The facility failed to ensure that for one patient out of 34 sampled patients (Patient 3), the ordered medications- Colace (a stool softener taken orally), Mag-Al Plus (a magnesium-aluminum-based oral laxative (a medication that makes it easier to pass stool) used to relieve constipation and reduce stomach acid), and Dulcolax suppository (a rectal medication that stimulates bowel movements to alleviate constipation)- were administered on an as-needed basis (PRN; a medical directive to provide medication only when symptoms or conditions, such as constipation, are present and require intervention), in accordance with the physician’s order, when indicated, and in alignment with the facility’s nursing standard of care. This deficient practice had the potential to compromise Patient 3’s overall health and well-being, leading to worsened constipation, increased discomfort or pain, and progression to more severe complications such as bowel obstruction (a serious condition where the intestine is partially or completely blocked, preventing the normal passage of stool, gas, or fluids, which can cause severe pain, nausea, and vomiting) or impaction (a condition where hardened stool becomes lodged in the rectum, making it extremely difficult or impossible to pass without medical intervention). (Refer to A-0406) 18. The facility failed to ensure one of 34 sampled patients (Patient 6’s), was administered a PRN (as needed) Levophed (norepinephrine bitartrate, a prescribed medication used to treat life-threatening low blood pressure) when Patient 6’s mean arterial pressure (MAP, the average blood pressure during a single cardiac [heart] cycle) was at 53 (on 10/7/2024 at 9:00 a.m.), below 65 mmHg (millimeters of mercury, unit of measurement), as ordered by the physician. This deficient practice resulted in a delay in the intervention that was prescribed to prevent low blood pressure for Patient 6 and likely contributed to a code blue (an overhead page to summon trained staff to a patient having a medical emergency, usually cardiac [heart] or respiratory [breathing] arrest [when breathing stops or when the heart stops beating]) being called. (Refer to A-0406) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 46238 Based on observation, interview, and record review, the facility failed to meet the Condition of Participation (CoP) for Discharge Planning as evidenced by: 1.The facility failed to ensure that, for one of 34 sampled patients (Patient 1), the discharge planning evaluation (a process conducted by healthcare providers to identify a patient’s post-hospital care needs, including medical equipment, support services, and living arrangements, to ensure a safe and effective transition from the facility) was completed upon admission, in accordance with the facility’s policy regarding Discharge Planning. In addition, the facility failed to ensure that the discharge planning assessment included a functional assessment (an evaluation conducted to determine a person’s ability to perform activities necessary for daily living and maintain independence) of the patient (Patient 1) and an evaluation of whether the patient (Patient 1) required any specialized durable medical equipment (DME, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane) prior to discharge to a recuperative care facility (a type of transitional housing or facility that provides short-term medical care and supportive services for individuals who are homeless or lack stable housing). This deficient practice resulted in Patient 1 falling shortly and sustaining a fracture (break in the bone) of the left humerus (the long bone that connects the shoulder to the elbow) while Patient 1 was walking to the recuperative care facility after being dropped off by arranged transportation at the discharge destination point. This deficient practice also led to Patient 1 being readmitted to the facility only a few hours after discharge. (Refer to A-0807) 2. The facility failed to include a discharge planning evaluation (an assessment required to identify a patient’s post-hospital needs, including the likelihood of requiring services such as rehabilitation, home care, or follow-up treatment, and the capacity for self-care or support in their living environment, as part of ensuring a safe and effective transition from the hospital) in the medical record for two of 34 sampled patients (Patient 1 and Patient 3), in accordance with the facility’s policy regarding discharge planning when: 2.a. Patient 1’s discharge planning evaluation was not documented during Patient 1’s admission stay at the facility. Additionally, Patient 1 was not actively engaged in the development of their (Patient 1’s) discharge plan (a detailed plan developed by healthcare providers to ensure a patient transitions safely and effectively from a healthcare facility to their next care setting). This deficient practice resulted in unsafe transition with no continuity of care and unmet post-discharge needs for Patient 1, leading to Patient 1’s re-admission to the facility the same day Patient 1 was discharged (7/5/2024). In addition, this deficient practice violated Patient 1’s right (the right of a patient to participate in decisions about their care, including being informed, consulted, and involved in the planning and implementation of patient’s treatment and discharge plans) to be involved in the development and implementation of their (Patient 1’) discharge plan. (Refer to A-0808) 2.b. Patient 3’s discharge planning evaluation was not conducted or documented in Patient 3’s medical record during Patient 3’s admission at the facility. This deficient practice violated Patient 3’s right to be involved in the development and implementation of their (Patient 3’s) discharge plan. In addition, this deficient practice resulted in Patient 3 being placed at risk for an unsafe transition and unmet post-discharge needs, potentially leading to complications such as readmission, or a decline in health. (Refer to A-0808) 3. The facility failed to ensure one of 34 sampled patients (Patient 4) received care coordination for cardiac follow-up care prior to discharge (the formal release of a hospitalized individual due to conclusion of the hospitalization stay, either by death, return home, or transfer to another institution), in accordance with the facility’s policy regarding Discharge Planning, when Patient 4 was discharged to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay). Patient 4’s pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) remained in end of battery life since 2/8/2024 and needed battery replacement. This deficient practice had the potential for Patient 4’s pacemaker device failure, resulting in cardiac (heart) complications including death. (Refer to A-0813) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to: 1. Ensure that a patient’s rights requirement pertaining to care and treatment was met when the facility failed to obtain and verify an accurate past medical history (a comprehensive record of a patient’s previous health conditions, treatments, and diagnoses) regarding seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), for one of 34 sampled patients (Patient 2), despite being documented that family was at the bedside to provide information and contact information being charted in Patient 2’s medical record in the ED (Emergency Department, a specialized hospital unit providing acute [sudden and severe] care for patients with severe or urgent medical conditions) on 7/1/2024 (date of Patient 2’s ED arrival). This deficient practice resulted in Patient 2’s past medical history not to be timely verified, potentially causing a delay in the implementation of a timely and appropriate treatment and care plan to address Patient 2’s stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients), which was later confirmed on 7/2/2024 (Patient 2 arrived at the ED on 7/1/2024). 2. Ensure for one of 34 sampled patients (Patient 19), Patient 19’s conservatorship (a court-ordered arrangement where a judge appoints a person to manage the affairs of another person who is unable to do so themselves) was verified for its existence upon admission to the facility. This deficient practice had the potential to result in Patient 19 or the patient’s conservator (the person or organization appointed by the court who would be responsible of one person’s physical health and medical care) rights to not be exercised by not knowing who is legally able to make medical decision for Patient 19. This deficient practice also had the potential to impede the conservator’s involvement to work with the healthcare team to achieve recovery for Patient 19. Findings: 1. During a review of Patient 2’s EMS (Emergency Medical Services, prehospital care provided by paramedics or emergency responders) Patient Care Report (PCR), dated 7/1/2024 at 10:47 a.m., the PCR indicated that paramedics (healthcare professionals trained to provide emergency medical care and transport patients to medical facilities) brought Patient 2 to the facility’s Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 at 11:29 a.m. The PCR also indicated that Patient 2 was alert and oriented to none (meaning the patient was not oriented to person, place, time, or situation, typically indicating a state of confusion or altered mental status). The PCR also indicated that bystanders on scene witnessed the patient (Patient 2) come out of the bathroom, fall down, and start having full body shakes. The PCR also stated that patient (Patient 2) had a history of seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), unknown if compliant with medications and that the patient (Patient 2 was possibly postictal [a state following a seizure characterized by confusion, drowsiness, or disorientation as the brain recovers]). During a review of Patient 2’s “Triage Assessment” (the initial evaluation performed upon a patient’s arrival to the emergency department to prioritize care based on the severity of their condition), dated 7/1/2024, at 11:46 a.m., the record indicated that Patient 2 had a history (a documented account of a patient’s past medical conditions, behaviors, or treatments that may influence their current health status) of alcoholism (a chronic disease characterized by an inability to control alcohol consumption despite negative consequences). During an interview on 11/13/2024 at 10:12 a.m. with the Emergency Department Supervisor (EDS), regarding the documented history of alcoholism in the triage assessment and after reviewing Patient 2’s EMS Patient Care Report (PCR), dated 7/1/2024, the EDS stated that the history of alcoholism was not documented in the PCR report. The EDS said that paramedics often provide additional verbal information about the patient and stated that the paramedics must have provided this information to the triage nurse upon Patient 2’s admission to the ED (on 7/1/2024). During the same interview on 11/13/2024 at 10:12 a.m. with the Emergency Department Supervisor (EDS), the EDS stated, “Triage nurses obtain patients’ history directly from the patient. If the patient is unable to provide their history, triage nurses rely on paramedic’s report for the information. Nurses [triage nurses and primary nurses] should verify the patient’s history with family members if they are available. Taking a patient’s history is an important part of the nursing assessment.” During a review of Patient 2’s HPI (History of Present Illness, a detailed narrative of the patient’s current health complaint, including onset, progression, and associated symptoms), dated 7/1/2024, the HPI indicated that Patient 2 presented to the Emergency Department (ED) on 7/1/2024 after experiencing a seizure. The HPI also indicated that Patient 2 had no prior visits to the facility’s ED. Additionally, the HPI stated that Patient 2 had a past medical history (PMH, a record of previously diagnosed medical conditions, treatments, and surgeries) of seizures and alcoholism. During a review of Patient 2’s medical record (MR) titled, “Nurses Notes,” dated 7/1/2024, at 11:55 a.m., the primary nurse documented that the patient (Patient 2) “had seizure at home, unreliable witnesses and narrator ...” During a review of Patient 2’s medical record (MR) titled, “Nurses Notes,” dated 7/1/2024 at 3:43 p.m., the primary nurse documented the following: “Family at bedside.” During a review of Patient 2’s medical record (MR) titled, “Nurses Notes,” dated 7/1/2024 at 4:28 p.m., the MR indicated the following: “Family contact is at bedside, phone number also documented.” During a review of Patient 2’s medical record (MR) titled, “Nurses Notes,” dated 7/1/2024 at 6:06 p.m., the MR indicated the following: “Patient (Patient 2) is alert and oriented to none (not oriented to time, person, place, and situation), responds to pain, making noise, no words. Patient’s (Patient 2) family member is at bedside.” During a review of Patient 2’s MR titled, Nurses Notes,” dated 7/1/2024, at 7:05 p.m., the MR indicated the following: “ ...Patient’s (Patient 2) family is at bedside ...” During a review of Patient 2’s MR titled, “Nurses Notes,” dated 7/1/2024, at 8:33 p.m., the MR indicated the following: “ ...Family member at bedside ...” During a concurrent interview and record review on 11/13/2024 at 11:30 a.m. with the Quality Assurance Nurse (QAN), Patient 2’s ED Visit Records (EVR, documentation of care and services provided during an Emergency Department visit), dated 7/1/2024, were reviewed. The QAN reviewed Patient 2’s medication reconciliation record (a process of creating an accurate list of all medications a patient is taking to ensure safe and effective care) and stated that no medication reconciliation was completed for Patient 2 on 7/1/2024. The QAN then reviewed the documentation of Patient 2’s past medical history (PMH) documentation and stated that no PMH was recorded for Patient 2 on 7/1/2024 or 7 2/2024. During a review of Patient 2’s History and Physical (H&P, a detailed medical record documenting the patient’s current health complaint, medical history, physical examination findings, and initial diagnosis or treatment plan), dated 7/1/2024, at 5:20 p.m., the H&P indicated that Patient 2 was admitted due to altered mental status (a condition characterized by changes in awareness, orientation, behavior, or mental function) and seizure. The H&P also stated that Patient 2 had a past medical history (PMH) of seizure disorder, was confused, and unable to provide history. Additionally, the H&P stated: “We will try to locate the family to get further information ...” During a review of the History and Physical (H&P) dated 7/1/2024, the H&P noted the following: the patient’s (Patient 2) alcohol level was negative, indicating no measurable alcohol in the patient’s (Patient 2) system at the time of evaluation. The CT scan (computed tomography, an imaging diagnostic test) of the head revealed nonspecific hypoattenuation (refers to an area of lower density [thickness]on the scan that may indicate potential abnormalities such as ischemia (lack of blood supply to a part of the body), edema, or other conditions) in the posterior [refers to the back] left parietal lobe (a region of the brain associated with sensory perception and integration, spatial reasoning [the ability to understand, visualize, and manipulate objects or shapes in a given space], and coordination). During further review of Patient 2’s medical record (MR) titled, “Neurological Consultation (a specialized evaluation conducted by a neurologist (diagnoses, treats, and manages conditions affecting the brain, spinal cord, and nerves) to assess and diagnose conditions related to the nervous system, including the brain, spinal cord, and nerves),” dated 7/3/2024, the MR indicated the following: “The patient (Patient 2) with unclear PMH (past medical history) has not seen a primary physician for years. History obtained with family at the bedside and on the phone. The patient (Patient 2) presented to the ED after a seizure with no prior history of seizures. Patient (Patient 2) was diagnosed with a stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients) and presented on exam aphasic (a condition characterized by an impaired ability to speak, understand, or process language, typically due to brain damage such as from a stroke) and with left-sided hemiparesis (weakness or partial loss of strength on the left side of the body, often caused by a neurological event like a stroke). Patient (Patient 2) was started on stroke protocol (standardized, evidence-based set of procedures designed to ensure the timely identification, evaluation, and treatment of patients presenting with symptoms of a stroke).” During an interview on 11/13/2024 at 11:44 a.m. with the physician (MD 11), MD 11 stated the following: “I remember the patient somewhat; I just reviewed the chart. I remember the patient (Patient 2) was confused. What I got from the ED, was questionable alcohol use and seizure. I wanted to rule out (r/u) alcohol seizure. Based on the imaging results (diagnostic tests) there was a questionable mass. If it’s a mass, I am not going to entertain the idea of a stroke. I carried the diagnosis of alcohol disorder. I did order the MRI, and it happened within 24 hours. If stroke was a strong possibility, we would have done the MRI much faster. The patient was unresponsive, and I had no family available to interview regarding past medical history. If I have a number, I usually call the family.” During a concurrent interview and record review on 11/13/2024 at 1:40 p.m. with the Director of the Emergency Department (DED), the DED stated the following regarding obtaining a patient’s relevant medical history: “Nurses get a verbal report from paramedics, and they chart the information in the assessment as much as possible. They assign the interventions based on the presentation of the patient. We rely on the paramedics’ description. Nurses should follow up on the assessment, and if the family is present, we try to obtain patient’s history and medications, vaccination history, social habits, and primary physician information. Whenever possible, the nurse should obtain accurate information, and if the family arrives, we interview them.” During an interview on 11/13/2024 at 1:57 p.m. with the Director of the Emergency Department (DED), the DED stated: “We expect staff to collect a thorough history, gathering any information that pertains to the patient. Medical history and medication history are especially important because, for example, if the patient stopped taking medications abruptly, that could be critical to understanding their current condition and making an accurate diagnosis. The triage nurse typically gathers the initial information about the patient, and the assigned registered nurse should follow up on the patient’s pertinent history and ensure accurate documentation.” During an interview on 11/13/2024 at 2:40 p.m. with the Medical Director of the Emergency Department (MD 9), MD 9 stated: “Obtaining medical history and contacting the family is common practice in the ED. We typically approach the family and ask. Nurses and physicians both do this. I did not see the family [Patient 2’s family]; I signed off (the process by which a physician transfers responsibility for the care of a patient to another provider, typically at the end of their shift or upon the patient’s admission to another unit) shortly after the patient was admitted.” During a review of the facility’s policy and procedure (P&P) titled, “Standards of Care,” dated 7/2023, the P&P indicated that the collection of data pertinent to the health status of an individual is to be systematic and continuous. After recording, such data is to be communicated to and retrievable by appropriate persons. During a review of the facility’s policy and procedure (P&P) titled, Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated that patients have the right to considerate care. During a review of the facility document “Medical Staff: General Rules and Regulations (section of the medical staff bylaws that describes more detailed operational policies for a hospital’s medical staff),” reviewed/revised 10/2024, the Rules and Regulations indicated the following: “The admitting physician or designee is responsible for completion of the admission history and physical examination. There shall be communication among all practitioners involved in patient care, treatment, and services.” 2. During a review of Patient 19’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/31/2024, the report indicated Patient 19 was admitted to the facility with a diagnosis of spinal stenosis (a medical condition that occurs when the spinal canal narrows, putting pressure on the spinal cord [a column of nerve tissues that runs from the base of the skull to the lower back] and nerves.) The H&P further indicated Patient 19 had a history of seizures disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Patient 19’s “Letters of Conservatorship (Mentally Disoriented),” with a file date of 11/18/2015, the letter indicated “These letters are in effect for one year and shall expire on 12/13/2016.” During an interview on 11/14/2024 at 11:28 a.m. with Clinical Nursing Supervisor (CNS 6), CNS 6 stated for a patient who was conserved, an official conservatorship (a court-ordered arrangement where a judge appoints a person to manage the affairs of another person who is unable to do so themselves) letter should be filed in the patient’s record. CNS 6 stated the nurses should check that the patient’s conservatorship letter was filed on the patient’s record. During an interview on 11/14/2024 at 2:30 p.m. with the Manager of Social Services (MSS, plan, direct, or coordinate the activities of a social service program). The MSS stated, “I did not know this conservatorship form for Patient 19 was expired...is important to validate conservatorship because the patient is unable to make his own decision, and the conservator is the decision maker. The main reason they are the decision maker.” During an interview on 11/14/2024 at 12:04 p.m., with the Social Worker (SW, offer counseling services, advocating for patient care, and assist patients in the admission and discharge process during hospitalization). The SW stated, “I am not aware of a policy for the conservatorship ...I was told verbally that this patient (Patient 19) has a conservator. Usually, I will keep the legal documents in the patient’s chart.” The SW stated, “On my notes entered (11/8/2024) I informed the conservator, the patient (Patient 19) and Regional Director they verbally corroborated that this patient has conservator.” In the same interview on 11/14/2024 at 12:04 p.m., the SW stated she (SW) had never seen a conservatorship legal document. The SW stated when a patient was under conservatorship, she would document it on the patient’s record. The SW further stated she was not aware of the facility’s procedure for a patient with conservatorship and that she was not aware of the facility’s conservatorship policy. During an interview on 11/14/2024 at 2:19 p.m. with the Manager of Social Services (MSS), the MSS stated she had not seen the facility’s conservatorship policy. The MSS stated when a patient was known to be conserved, this should be verified by calling the county and ask if the patient has a conservator. The MSS stated it usually takes 48 hours for the county to call back and verify the patient’s conservatorship status. During a concurrent interview and record review on 11/14/2024 at 2:30 p.m., with the MSS, the Patient 19’s “Letters of Conservatorship (Mentally Disordered),” dated November 2015, was reviewed. The MSS verified Patient 19’s conservatorship letter was expired. The MSS stated, “I do not know this (Patient 19’s) conservator form is expired. I do not know who provided this (Patient 19’s) conservatorship. Family members can be a conservator, and we must validate.” In the same interview on 11/14/2024 at 2:30 p.m., the MSS stated the patient’s conservatorship status should be validated because the patient was not capable of making his own decision and the patient’s conservator would be the decision maker. The MSS stated when a conservatorship letter was expired, the regional center should be involved, and the facility should ask for the updated conservatorship. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights & Responsibilities,” dated 06/2022, the P&P indicated, “You or your representative(s) have the right to: Be informed before care is given or discontinued whenever possible. Receive accurate and current information regarding your health status in terms you can understand, allowing you to make informed decisions. Participate in planning for your treatment care and discharge recommendations. Surrogate who you may select can represent you if you cannot make your own decisions according to state law.””

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48186 Based on observation, interview and record review, the facility failed to: 1. Ensure safety precautions were in place for two of 34 sampled patients (Patients 4 and 34), when safety straps (immobilizes patients on a table to prevent falls [unplanned descent to the floor with or without injury to the patient]) were not utilized, in accordance with the manufacturer’s instructions, for Patients 4 and 34 while on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table, and Patients 4 and 34 fell off the cath lab table. This deficient practice had the potential for Patients 4 and 34 to suffer bodily injury, including but not limited to head trauma, broken bones, and skin injuries. 2. Ensure for one of 34 sampled patients (Patient 19), code green (the facility’s notification of emergency to the staff indicating a missing/eloping patient who is determined to be a danger to themselves or has been identified as a safety risk) was activated, when Patient 19 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 11/12/2024 at 1:40 p.m., in accordance with the facility’s policy and procedure regarding “Emergency Management.” This deficient practice resulted in Patient 19 leaving the facility unsupervised and may have the potential to result in Patient 19 harming self and could cause injury and/or death to the patient. Findings: 1.a. During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/22/2024 at 9:41 a.m., the H&P indicated that Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar). During a concurrent observation and interview on 11/12/2024 at 11:40 a.m. with the Registered Nurse 13 (RN 13) in the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) room 3, the cath lab table was observed. RN 13 confirmed the cath lab table (in cath lab room 3) did not have safety straps (immobilizes patients on the table to prevent falls) attached to the table. RN 13 verified that all cath lab rooms (1, 2, and 3) have two black safety straps (not attached to the table) used for cath lab tables. RN 13 stated the following: There were two straps used to attach patients to the cath lab tables (1, 2, and 3). Two straps should have been used, whenever a patient was on the cath lab table. During an interview on 11/12/2024 at 3:00 p.m. with the Radiological Technologist 2 (RAT 2), the RAT 2 stated the following: Patient 4 was on the cath lab table, when Patient 4 fell off the table. Safety straps were not used to strap the patient to the table. There have never been safety straps for the cath lab tables. After Patient 4 fell, two safety straps were ordered and implemented for patient use on the cath lab table. During an interview on 11/12/2024 at 3:24 p.m. with the Radiological Technologist 1 (RAT 1), the RAT 1 stated the following: Patient 4 was brought to the cath lab (room 3) for a procedure. The Certified Registered Anesthetist 1 (CRNA 1, assigned to Patient 4’s procedure) was upset that the room (cath lab room 3) was not prepared prior to CRNA 1’s arrival. The CRNA 1 verbally stated that CRNA 1 was unhappy that the room was not ready. The CRNA was very irritated with [facility] staff and made this very clear in front of the patient (Patient 4). This agitated Patient 4, and Patient 4 stated that he (Patient 4) did not feel comfortable with CRNA 1 and wished CRNA 1 would just calm down. Patient 4 was tilting his (Patient 4’s) head back in CRNA 1’s direction. CRNA 1 kept arguing with Patient 4. Patient 4 fell off the cath lab table in the same direction he (Patient 4) was looking back (towards CRNA 1). Patient 4’s fall was prior to the procedure, before Patient 4 was fully sedated (a state of calmness, relaxation, or sleepiness caused by certain drugs). During the same interview on 11/12/2024 at 3:24 p.m. with the RAT 1, the RAT 1 further stated the following: At the time of Patient 4’s procedure (7/26/2024), safety straps were not in use for the cath lab table. Patient 4 fell off the cath lab table (room 3) and Cardiovascular Technician 2 (CVT 2) was able to catch the patient before he (Patient 4) hit the floor, and then assisted Patient 4 to the floor. During an interview on 11/12/2024 at 3:00 p.m. with the CVT 2, the CVT 2 stated the following: Patient 4 fell off the cath lab table and CVT 2 was able to catch Patient 4’s upper body and head. Patient 4 was assisted to the floor by staff. Patient 4 did not have any safety straps applied at the time he (Patient 4) fell from the table. During a concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), the CNS 3 verified the following information in Patient 4’s medical record: Patient 4’s “Clinical Cardiac Electrophysiology (the study of the heart’s electrical activity, including its function, performance, and mechanisms) Progress Note (a document that outlines a patient’s condition and the rationale for their treatment),” dated 7/26/2024, indicated “ ...[Patient 4] suffered an accidental fall (unplanned descent to the floor with or without injury to the patient) from the cath lab table. Fortunately, his fall was broken by the Cardiovascular Technician [CVT 2] who was standing nearby. She prevented [Patient 4] from striking his head on the x-ray (creates pictures of the inside of your body) equipment on the floor. He did land on his right side and hip ...” During a concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the Biomed Engineering Manager (BEM) and the Cardiovascular Technician 3 (CVT 3), the document titled “GE HealthCare: Safety and Regulatory,” no date, provided by the facility for the cath lab tables (1, 2, and 3), was reviewed. BEM and CVT 3 verified this was the user manual for the Innova Table (cath lab tables 1, 2, and 3). The user manual indicated “ ...The Innova Table Top mattress is provided with a set of Velcro strips on the bottom side. While loading or unloading the patient it is recommended to grip the Velcro strips to avoid the mattress shifting. Ensure the Velcro strips are well stuck on the tabletop prior to loading or unloading the patient ...” The BEM acknowledged safety straps should be used as indicated in the user manual. During the same concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the BEM and the CVT 3, the CVT 3 stated that the cath lab has had the Innova (cath lab) tables for at least 6 years. The CVT 3 further stated that the standard of practice was to strap the patient to the cath lab table when using the table. During an interview on 11/15/2024 at 2:25 p.m. with the Director of Cardiovascular Services (DCVS), the DVCS stated the following in regard to Patient 4’s fall: It was important to use safety straps to immobilize patients on the cath lab table. If straps were not used, this could lead to patient falls and harm. The safety straps should have been used when patients were on the table. During a record review the document (cath lab table user manual) titled, “GE HealthCare: Safety and Regulatory,” no date, provided by the facility indicated “ ...Never leave a patient unattended. An unattended patient could fall from the table ..., which could be hazardous. In addition, it is recommended to use restraints (a device to restrict a person’s movement or access to their body), such as Velcro straps ...” 1.b. During a review of Patient 34’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/3/2024, the H&P indicated that Patient 34 was admitted to facility on 9/3/2024 with a past medical history of obesity (when there is an excessive amount of fat in the body which can negatively affect health), atrial fibrillation (a heart disorder that causes irregular heart beat) and diastolic heart failure (a part of the heart that stiffens and does not relax to allow the heart to properly pump blood). During a concurrent observation and interview on 11/12/2024 at 11:40 a.m. with the Registered Nurse 13 (RN 13) in the cardiac catheterization laboratory (cath lab,a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) room 3, the cath lab table was observed. RN 13 confirmed the cath lab table (in cath lab room 3) did not have safety straps (immobilizes patients on the table to prevent falls [unplanned descent to the floor with or without injury to the patient) attached to the table. RN 13 verified that all cath lab rooms (1, 2, and 3) have two black safety straps (not attached to the table) used for cath lab tables. RN 13 stated the following: There were two straps used to attach patients to the cath lab tables (1, 2, and 3). Two straps should have been used, whenever a patient was on the cath lab table. During an interview on 11/13/2024 at 10:36 a.m. with the Registered Nurse 14 (RN 14), RN 14 stated the following: Following Patient 34’s cath lab procedure (on 9/10/2024 in cath lab room 2), Patient 34 fell off the cath lab table and RN 14 assisted Patient 34 to the floor. RN 14 was attempting to place a hold belt (applies pressure to prevent bleeding after a procedure) on Patient 34 when Patient 34 fell. RN 14 did not recall if safety straps (immobilizes patients on the table to prevent falls) were applied to Patient 34 at the time of the fall. It was important to use the safety straps for patients, so they would not fall. During a concurrent interview on 11/13/2024 at 11:20 a.m. with the Radiological Technologist 3 (RAT 3), the RAT 3 stated the following: RAT 3 was applying pressure to Patient 34’s arterial site (a location in the body where a catheter can be inserted into an artery for medical procedures) following a cath lab procedure. RAT 3 was placing pressure device (hold belt) on Patient 34’s arterial site, when Patient 34 fell. Patient 34 was assisted to the floor. Safety straps were not applied to Patient 34 when Patient 34 was on the cath lab table and they (referring to the safety straps) should have been. Straps should have only been removed immediately before transferring a patient from the cath lab table to a gurney (a wheeled stretcher used for transporting hospital patients). During a concurrent interview and record review on 11/14/2024 at 8:45 a.m. with the Clinical Nursing Supervisor 5 (CNS 5), the CNS 5 verified the following in Patient 34’s medical record: Patient 34’s medical record titled, “Cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) Progress Note,” dated 9/10/2024 at 9:42 a.m., indicated “[Patient 34] unfortunately fell off the cath table during transport ...” During a concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the Biomed Engineering Manager (BEM) and the Cardiovascular Technician 3 (CVT 3), the document titled “GE HealthCare: Safety and Regulatory,” no date, provided by the facility for the cath lab tables (1, 2, and 3), was reviewed. BEM and CVT 3 verified this was the user manual for the Innova Table (cath lab tables 1, 2, and 3). The user manual indicated “ ...The Innova Table Top mattress is provided with a set of Velcro strips on the bottom side. While loading or unloading the patient it is recommended to grip the Velcro strips to avoid the mattress shifting. Ensure the Velcro strips are well stuck on the tabletop prior to loading or unloading the patient ...” The BEM acknowledged safety straps should be used as indicated in the user manual. During the same concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the BEM and the CVT 3, the CVT 3 stated that the cath lab has had the Innova (cath lab) tables for at least 6 years. The CVT 3 further stated that the standard of practice was to strap the patient to the cath lab table when using the table. During an interview on 11/15/2024 at 2:25 p.m. with the Director of Cardiovascular Services (DCVS), the DVCS stated the following in regard to Patient 34’s fall: It was important to use safety straps to immobilize patients on the cath lab table. If straps were not used, this could lead to patient falls and harm. The safety straps should have been used when patients were on the table. During a review of the document (cath lab table user manual) titled, “GE HealthCare: Safety and Regulatory,” no date, provided by the facility indicated “ ...Never leave a patient unattended. An unattended patient could fall from the table ..., which could be hazardous. In addition, it is recommended to use restraints (a device to restrict a person’s movement or access to their body), such as Velcro straps ...” 2. During a review of Patient 19’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 10/31/2024, the H&P indicated Patient 19 was admitted to the facility with a diagnosis of spinal stenosis (a medical condition that occurs when the spinal canal narrows, putting pressure on the spinal cord and nerves). The H&P further indicated Patient 19 had a history of seizures disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Patient 19’s “Columbia-Suicide Severity Rating Scale (CSSRS, a suicidal ideation and behavior rating scale),” dated 11/5/2024, Patient 19’s CSSRS indicated Patient 19 had a high suicidal risk. During a concurrent interview and record review on 11/14/2024 at 10:40 a.m., with Clinical Nursing Supervisor 6 (CNS 6), CNS 6 verified Patient 19’s “Progress Notes,” dated 11/12/2024 at 2:29 p.m. (after Patient 19’s elopement [the act of leaving a facility unsupervised and without prior authorization] incident on 11/12/2024 at 1:40 p.m.), authored by the psychiatrist (a medical doctor that specialist in mental health), indicated “denies suicidal (thoughts of self-harm with the intent to die) or homicidal ideation (thoughts about killing another person), able to contract safety.” CNS 6 verified Patient 19 had no other psychiatric note prior to the 11/12/2024. During a review of Patient’s 19 “ARU (Acute Rehabilitation Unit, provides intensive, specialized therapy for patients who need to regain abilities or adapt to new limitations after an injury, surgery, or medical event) OT (Occupational Therapist, helps patient live more independently by developing, recovering, or maintaining skills for daily living and working) Treatment Note,” dated 11/12/2024, the note indicated, “Pt. (Patient 19) cleared for OT treatment session by (RN 15). Pt. Received sitting at edge of bed eating lunch... Pt. was very agitated (a feeling of severe restlessness or uneasiness) beginning of session...Therapist (OT 1) attempted to calm pt. down...Pt. suddenly got up and got his FWW (Front wheel walker - a mobility aid with two wheels on the front legs and two straight legs on the back) and started walking out. Therapist attempted to request for help from nursing staff. Therapist also notified Rehab Tech (RT 1) for assistance. RT 1 went to notify nursing staff. Pt. went down elevator. Therapist notified security for assistance, security guards attempted to stop the pt. and talk with the pt. Pt. continued to ambulate outside of the hospital and non-compliant towards security guards. Security reported that they are unable to physically stop the pt. And pt. Has right to leave AMA (Against Medical Advice -when a patient leaves a hospital without the physician’s recommendation). Pt. does not need to sign anything and is able to leave AMA. Therapist notified Director of Medical Surgical (DMS), Director of Acute Rehabilitation (DAR), and Director of Physical Therapy (DPT) regarding the situation. DPT notified therapist that they will look for pt. (Patient 19).” During an interview on 11/13/2024 at 11:43 a.m., with OT 1, OT 1 stated she (OT 1) went to see Patient 19 at around 1:40 p.m., to do therapy. OT 1 stated Patient 19 became agitated and was resistant, Patient 19 got the walker and walked outside his room. OT 1 stated she asked for help and told her coworker “I need help, nobody will help me.” In the same interview on 11/13/2024 at 11:43 a.m., OT 1 stated she (OT 1) followed Patient 19 to the elevator down to the entrance lobby of the facility. OT 1 stated she told the security guard that Patient 1 was trying to leave, and the security guard told her, “We can’t avoid patient from AMA.”. OT 1 stated she last saw Patient 19, after exiting the facility, turned left, and kept walking out towards the street and the security told her (OT 1), “patients have the right to leave.” OT 1 stated Patient 19 was alone for about 10-20 minutes on the street at the corner of the facility. During an interview on 11/13/2024 at 11:57 a.m., with the Director of Physical Therapy (DPT), the DPT stated when OT reported to her that Patient 19 left the facility, she went to look for the patient (Patient 19). The DPT stated, “I found (Patient 19) on Flower Street sitting alone by the sidewalk. The DPT stated Patient 19’s nurse came down and the other staff to help bring Patient 19 back to the unit. The DPT stated, “I did not hear anyone call a Code Green (when Patient 19 eloped).” During an interview on 11/13/2024 at 10:23 a.m., with Clinical Nursing Supervisor of Medical Surgical Unit (CNS 2), CNS 2 stated when a patient elopes, she first calls the physician, the family and/or the conservator (a legally responsible person who has the power to make healthcare decisions for another person). CNS 2 stated, “we call rapid response (Rapid Response Team [RRT] - a group of trained medical professionals who are called to a patient’s bedside to assess and treat a medical emergency), the security, and document the circumstances to make sure the patient understands the situation and the danger to discharge themselves.” In a follow-up interview on 11/13/2024 at 10:42 a.m., CNS 2 stated, “I always call Rapid Response Team for any issue,” “to be honest I do not know the codes.” CNS 2 stated she (CNS 2) knew Patient 19 was a high-risk patient and she should have called the code for elopement, “but I am not familiar.” CNS 2 stated she was notified about Patient 19 elopement on 11/12/2024 before 6:00 p.m. During an interview on 11/13/2024 at 11:43 a.m., with OT 1, OT 1 stated, “I never got training to call for Code Green (a missing /eloping patient who is determined to be a danger to themselves or has been identified as a safety risk).” OT 1 stated she (OT 1) only informed her Director (DPT) when Patient 19 eloped. During an interview on 11/13/2024 at 11:57 a.m., with the Director of Physical Therapy (DPT), DPT stated Code green is called by the nurse or whoever identified that the patient was missing or eloped. The DPT stated, “I did not hear anyone call Code Green. The security did not get involved.” During an interview on 11/14/2024 at 11:56 a.m., with the Clinical Nursing Supervisor (CNS 6), CNS 6 stated when a patient eloped, it was important to call a Code Green to alert everyone to look for the patient. CNS 6 stated anybody can call a Code Green. During a review of the facility’s policy and procedure (P&P) titled, “Emergency Management,” dated 10/2024, the P&P indicated the following: - “To provide appropriate staff notification of emergency situations utilizing the overhead paging system.” - (Section II, Definitions) “Code Green- a missing /eloping patient who is determined to be a danger to themselves or has been identified as a safety risk.” - “When an emergency occurs, call the emergency page operator at ext. 5555 and provide the nature of the emergency and the location of the incident.” - “The emergency page operator will immediately notify the appropriate management authority and response personnel in accordance with the corresponding policy is listed in “Section II, Definitions.” - “If an overhead page is required, the emergency page operator will use the appropriate emergency code and repeat it three times via the overhead paging system.” - “Terminating an emergency code a. when the incident response is complete, the appropriate authority (e.g., Incident Commander, Team Leader, House Supervisor, etc ...) will call the emergency page operator and request that they announce an “All Clear.” b. When instructed by the appropriate authority, the emergency page operator will announce “the [Code Name] is All Clear” three times via the overhead paging system.” - “All employees must be familiar with the following: a. Code Names”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 50521 Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled patients (Patient 22), was free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 22’s four siderails of the bed were observed raised without a physician’s order and in accordance with the facility’s policy and procedure regarding use of restraints. This deficient practice resulted in inappropriate, unnecessary use of restraints, and had violated Patient 22 rights regarding being free from inappropriate restraints use. In addition, this deficient practice had the potential for Patient 22 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc. Findings: During a concurrent observation and interview on 11/12/2024 at 3:15 p.m. with Registered Nurse (RN) 16, Patient 22 was observed in bed, awake and oriented to person. Patient 22’s four side rails of the bed were raised. RN 16 stated she (RN 16) was the RN assigned to Patient 22. RN 16 stated Patient 22’s four side rails should not be raised as it is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). RN 16 stated having all four side rails up could cause a risk for the patient (Patient 22) to fall (unplanned descent to the floor with or without injury to the patient). During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/3/2024, the H&P indicated Patient 22 was admitted to the facility for cerebrovascular accident (CVA, referred to as stroke which is the loss of blood flow to a part of the brain). During a review of Patient 22’s “Critical Care/Step Down Shift” physical assessment, dated 11/12/2024, the assessment indicated Patient 22 had right side mild weakness and left side severe weakness. Patient 22’s mobility was “very limited,” with a fall risk score of 50 (using the Morse fall scale [a tool used to assess a patient’s risk of falling], score of 45 and above is a high risk for fall]). During a concurrent interview and record review on 11/15/24 at 10:30 a.m. with the Clinical Nursing Supervisor (CNS) 3, CNS 3 stated Patient 22’s record did not indicate an order for restraints including having 4 siderails up. CNS 3 stated “the patient (Patient 22) do not need 4 side rails up, if they have 4 side rails up the patient can fall, he can hang, is considered restriction.” During a review of the facility’s policy and procedure (P&P) titled, “Restraints,” reviewed on 4/2024, the P&P indicated, “Patient’s Rights Related to Restraint/Restraint Alternatives: All patients have the right to be free from restraint of any form as means of coercion, discipline, convenience or retaliation by staff ...The use of side rails to assist a patient with safety, unless the use is such that the side rails prevent patient’s mobility (e.g. all four side rails up). Such usage is intended to achieve a proper body position, balance, alignment, or to allow greater mobility.””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 48186 Based on interview and record review, the Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all the services provided by the hospital) Committee failed to develop and implement a corrective action plan (a detailed plan outlining the specific actions that will be taken to address the root causes of a problem to prevent the issues from occurring again) following a root cause analysis (RCA, a structured process for identifying the underlying causes of a problem or adverse event and developing corrective actions) to ensure that safety straps are used when patients are placed on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table for procedures, in accordance with the facility’s policy and procedure (P&P) titled, “Root Cause Analysis,” after one of 34 sampled patients (Patient 4) fell off the cardiac catheterization laboratory table on 7/26/2024. This deficient practice led to a second patient’s (Patient 34’s) fall from the cath lab table, when safety straps (immobilizes patients on a table to prevent falls) were not applied on Patient 34 who was undergoing a cath lab procedure on 9/10/2024. This deficient practice also had the potential for increased risk of similar incidents occurring in the future, which has a negative impact on patient safety (Example: fractures [broken bones], etc.). Findings: During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/22/2024 at 9:41 a.m., the H&P indicated that Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar). During an interview on 11/12/2024 at 3:00 p.m. with the Radiological Technologist 2 (RAT 2), the RAT 2 stated the following: Patient 4 was on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table, when Patient 4 fell off the table. Safety straps (immobilizes patients on a table to prevent falls [unplanned descent to the floor with or without injury to the patient]) were not used to strap the patient to the table. After Patient 4 fell, two safety straps were ordered and implemented for patient use on the cath lab table. There was no manufacturer’s instructions or information for the use of the safety straps. The facility did not provide an in-service or education on the use of the safety straps. During the same interview on 11/12/2024 at 3:24 p.m. with the Radiological Technologist 1 (RAT 1), the RAT 1 stated the following: At the time of Patient 4’s procedure {on 7/26/2024}, safety straps were not in use for the cath lab tables. Patient 4 fell off the cath lab table (room 3) and the Cardiovascular Technician 2 (CVT 2) was able to catch the patient before he (Patient 4) hit the floor, and then assisted Patient 4 to the floor. There was another patient fall (happened on 9/10/2024) after Patient 4’s fall, where the other patient (Patient 34) fell off the cath lab table. There was no in-service or education provided by the facility for staff once the new safety straps were ordered and implemented after patient 4’s fall (fall happened on 7/26/2024). During a concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), the CNS 3 verified the following information in Patient 4’s medical record: Patient 4’s “Clinical Cardiac Electrophysiology (the study of the heart’s electrical activity, including its function, performance, and mechanisms) Progress Note (a document that outlines a patient’s condition and the rationale for their treatment),” dated 7/26/2024, indicated “ ...[Patient 4] suffered an accidental fall from the cath lab table. Fortunately, his fall was broken by the Cardiovascular Technician (CVT 2) who was standing nearby. She (CVT 2) prevented [Patient 4] from striking his (Patient 4) head on the x-ray (creates pictures of the inside of your body) equipment on the floor. He (Patient 4) did land on his right side and hip ...” During a concurrent interview and record review on 11/15/2024 at 9:44 a.m. with the Director of Quality and Performance Improvement (DQPI), the DQPI verified there was no corrective action plan (a detailed plan outlining the specific actions that will be taken to address the root causes of a problem to prevent the issues from occurring again) submitted following the root cause analysis (RCA, a structured process for identifying the underlying causes of a problem or adverse event and developing corrective actions) [completed 11/15/2024], after Patient 4’s fall. The DQPI stated the following: The RCA identified there was no safety straps being used on the cath lab beds, and new safety straps were subsequently ordered. It was the responsibility of the cath lab Director to create and implement the corrective action plan (to address the use of safety straps on patients who are placed on the cath lab tables for a procedure) and send this (referring to the corrective action plan) to the Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all the services provided by the hospital) Committee, for review. The QAPI committee did not receive an action plan following Patient 4’s fall. There should have been a corrective action plan completed within 30 days of the identified adverse event (an undesirable outcome that results from a medical treatment or procedure). During the same interview on 11/15/2024 at 9:44 a.m. with the DQPI, the DQPI said the Chief Nursing Officer (CNO) was responsible to ensure that any education provided to staff was completed. It was the responsibility of the QAPI Committee to follow up and ensure the corrective action plan was completed to determine the appropriateness of the corrective action plan. Since the action plan was not completed, this could not be communicated to the Medical Executive Committee (MEC, a governing body in a hospital or healthcare organization that represents the medical staff and makes decisions about patient care, medical staff, and clinical services) and the Governing Board (GB, a group of people who are legally responsible for the management and direction of an organization) to ensure oversight [for the prevention of future adverse events]. During the same interview and record review on 11/15/2024 at 9:44 a.m. with the DQPI, the DQPI verified that there was a second fall in the cath lab on 9/10/2024, when Patient 34 fell off the cath lab table (Patient 34 also did not have safety straps on). The DQPI further verified the facility in-service document provided, titled, “Increased awareness of fall prevention measures,” dated September 2024, did not include education of cath lab staff for use of safety straps (on patients being placed on the cath lab tables for procedures). The DPQI also stated the following: Following Patient 4’s fall (7/26/2024), there was an in-service (a type of education that is provided to the employees to improve their working capacity and efficiency) completed for fall prevention. The DPQI said an in-service was completed for the use of the new safety straps, but the DQPI did not have documentation to support when this occurred, what was educated, and who attended. The DQPI also verified that the fall prevention in-service was not completed by all cath lab staff listed on the in-service document. The DQPI acknowledged that the fall reduction in-services should have been completed by all cath lab staff. During an interview on 11/15/2024 at 12:13 p.m. with the CNO, the CNO stated that when the new safety straps were brought into the facility, cath lab staff should have been in-serviced to understand how to use the safety straps in a safe way, so there was no patient harm. During a review of the facility’s policy and procedure (P&P) titled, “Root Cause Analysis,” dated 6/2023, the P&P indicated, “ ...Policy Statement: When an unexpected occurrence takes place and is determined to meet the definition of “Sentinel Event,” [the facility] will act immediately to protect the patient(s), family member(s), visitors, volunteers, employees or physicians, from further injury. [The facility] will provide a formal process for thorough and credible root cause analysis of the event; implement improvements to reduce the probability of similar occurrences; and evaluate the effectiveness of these improvements ... These events will be addressed promptly by a multidisciplinary team (a diverse group of professionals who work collaboratively to provide coordinated, patient-centered care) comprised of medical staff and employees in order to: 1. Protect all parties from further injury 2. Gather facts surrounding the event 3. Identify the root cause of the event within 30 days 4. Recommend system or process changes to reduce the probability of a similar occurrence in the future ... Procedure: ...4.2 Follow-up actions: ...4.2.1.6 Perform root cause analysis (RCA) ... 4.2.1.12 Develop an action plan to eliminate or reduce risks; 4.2.1.13 Determine improvement strategies for casual processes or systems identified by the root cause analysis, which could reduce the probability of a similar occurrence in the future, by redesign of existing processes or development of a new system of process; 4.2.1.14 determine tasks necessary to complete above strategies; 4.2.1.15 Develop timeline for completion of these tasks; 4.2.1.16 Identify who is responsible for all tasks; 4.2.1.17 Determine how the effectiveness of the strategies will be measured; 4.2.1.18 Present findings and action plan to the Quality Council (a group of people within an organization that is responsible for driving quality improvement) and Medical Executive Committee ...””

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure Medical Staff (an organized body of licensed physicians) adhered to facility Medical Staff Bylaws (a document that provides the framework for the organization, responsibilities and self-governance of the medical staff) for one of 34 sampled patients (Patient 4), when Patient 4, who had been assessed by cardiology (the branch of medicine concerned with the diagnosis and treatment of heart-related diseases and disorders) consultant as clinically unstable for discharge from the facility, was transferred to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay) without the primary medical team obtaining medical clearance (a physician, or another health care provider has determined that a person is medically stable) from cardiology or conferring with cardiology prior to hospital discharge. This deficient practice had the potential for Patient 4’s pacemaker device’s (a small, battery-powered device that prevents the heart from beating too slowly) failure (Patient 4’s pacemaker remained in end of battery life since 2/8/2024 and needed battery replacement), which may result in cardiac (heart) complications including death. Findings: During a review of Patient 4’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/22/2024 at 9:41 a.m., the H&P indicated that Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar). The H&P further indicated that Patient 4 required a consultation with a Cardiologist (a physician who is an expert in the care of the heart). During a review of Patient 4’s “Cardiology Progress Notes,” dated 7/22/2024 through 7/30/2024, the progress notes indicated Patient 4 was not stable for discharge and required telemetry monitoring (the process of automatically measuring and transmitting cardiac [heart] data from the patient to a central location for analysis and monitoring). During a review of Patient 4’s Physician “Progress Notes,” dated 7/25/2024 at 2:25 p.m., the progress notes indicated the following: “ ...Plan for discharge once cleared by Cardiology to SNF versus home with home health with Physical Therapy (PT, treatment that helps improve how the body performs physical movements) and visiting nurse ...” During a review of Patient 4’s “(Clinical Cardiac Electrophysiology, a medical specialty that focuses on diagnosing and treating heart rhythm disorders) Consultation Report,” dated 7/25/2024 at 7:53 p.m., the progress note indicated the following: “Reason for visit: Evaluation of pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) end of battery life ... Pacemaker analysis shows (Patient 4) remains in Elective Replacement Indicator (ERI, a status that indicates a pacemaker is nearing the end of its life and needs to be replaced) status which [Patient 4] reached on February 8 of this year (2024).” During a concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), Patient 4’s medical record (MR) titled, “Cardiac Electrophysiology Consultation Report (a document that outlines a patient’s condition and the rationale for their treatment),” dated 7/25/2024, was reviewed. The MR indicated Patient 4’s pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) remained in end of battery life since 2/8/2024 and needed battery replacement at [name of the facility]. During a review of Patient 4’s medical record (MR) titled, “Clinical Cardiac Electrophysiology Progress Note,” dated 7/26/2024, the progress note indicated the following: “Assessment: Pacemaker generator replacement (a surgical procedure that replaces the battery and electrical circuitry in a pacemaker) an upgrade to cardiac resynchronization therapy pacemaker (CRT-P, a device that helps treat heart failure) was canceled today (7/26/2024) due to an accidental fall (unplanned descent to the floor with or without injury to the patient) from the cardiac catheterization laboratory (Cath Lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table. During further record review of Patient 4’s MR titled, “Clinical Cardiac Electrophysiology Progress Note,” dated 7/26/2024, the MR indicated that Patient 4 and the physician (MD 2) discussed two treatment options for Patient 4’s pacemaker: “Option 1: The patient’s pacemaker device would be checked the following day (7/27/2024) to obtain an accurate assessment of the remaining battery longevity. If adequate battery longevity was confirmed, the patient could choose to go to another facility for treatment.” “Option 2: Proceed with the generator replacement and insertion of a new left bundle branch pacing lead to upgrade to a CRT-P as previously planned on Tuesday [7/30/2024].” The MR also indicated that Patient 4 elected to remain hospitalized and undergo the pacemaker battery replacement and CRT pacemaker upgrade with left bundle branch area pacing on Tuesday morning [7/30/2024] and expressed a desire to remain at the current facility, stating, “My healthcare team and doctors are here, so I want to stay here, and have it done before I go home.” During a review of Patient 4’s “Internal Medicine (a medical specialty that focuses on the diagnosis, prevention, and treatment of adult diseases without surgery) Progress Notes,” dated 7/29/2024 at 11:32 a.m., the progress notes indicated the following: “ ...await pacer generator exchange ...” During a review of Patient 4’s “Nursing Discharge Note,” dated 7/30/2024 at 11:41 p.m., the discharge note indicated the following: Patient 4 was discharged from the facility on 7/30/2024 at 11:20 p.m. During the same concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the CNS 3, Patient 4’s MR titled, “Patient Orders (communicates the medical care that the patient is to receive) Detail,” dated 7/30/2024, was reviewed. The MR indicated MD 3’s physician’s order to discharge (the formal process of a patient leaving a hospital after receiving treatment or care) Patient 4 to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay) was placed on 7/30/2024. During an interview on 11/13/2024 at 1:23 p.m. with the CNS 3, Patient 4’s MR titled, “Internal Medicine Progress Notes,” dated 7/30/2024 and “Discharge Summary (a clinical document that summarizes a patient’s hospital stay and care plan so that the patient’s primary care provider can continue their care),” dated 7/30/2024, were reviewed. The CNS 3 stated that Patient 4’s medical records contained no documentation indicating that Patient 4 was medically cleared (a physician, or another health care provider has determined that a person is medically stable) by Cardiology prior to discharge. The CNS 3 also stated that there was no documentation that Patient 4 had a pacemaker interrogation (a procedure that allows a cardiologist to check the function of a pacemaker) prior to discharge. During an interview on 11/14/2024 at 2:15 p.m. with Medical Doctor 2 (MD 2) regarding Patient 4’s pacemaker replacement procedure, MD 2 stated that Patient 4 was referred to MD 2 several times over 6-8-month period but was non-compliant with following-up to have the pacemaker replacement done. The MD 2 stated that on 7/26/2024 (on the day of procedure) Patient 4 fell off the Cath Lab table and the procedure got postponed and got rescheduled for 7/30/2024. The MD 2 then stated, on 7/30/2024, Patient 4 had a fever, and MD 2 postponed the procedure again, and made the hospitalist aware about the need to reschedule the procedure. During the same interview on 11/14/2024 at 2:15 p.m. with MD 2 regarding Patient 4’s discharge, the MD 2 stated that on 7/30/2024, MD 2 was not involved with Patient 4’s discharge. MD 2 also stated they (MD 2’s team) believed the patient (Patient 4) left against medical advice (AMA, when a patient leaves before their doctor recommends discharge) and stated, “I would not have recommended to discharge the patient (Patient 4).” During an interview on 11/14/2024 at 2:32 p.m. with Medical Doctor 3 (MD 3), MD 3 stated the following: (MD 3) was the Internal Medicine Doctor for Patient 4 during their [July 2024] admission at the facility. If there was an active cardiac issue, there should have been a Cardiology clearance. If the [Cardiology] Consultant was called for clearance, this would have been documented in the discharge summary. If Cardiology follow-up was needed, there should have been documentation that the patient needed follow-up at discharge. During an interview on 11/14/2024 at 2:41 p.m. with Medical Doctor 4 (MD 4), MD 4 stated the following: [MD 4] was a Cardiology Consultant for Patient 4. Patient 4’s pacemaker was at the end of life when seen in the office, prior to admission. Patient 4 had been completely non-compliant with dates for follow-up for pacemaker replacement. Patient 4 was supposed to see [MD 2] and it never happened. If a patient was in the hospital and was unable to have the pacemaker replacement, there should have been documentation within the cardiology notes that the patient could be discharged, although the procedure was not completed. There should have been a clearance by Cardiology prior to Patient 4’s discharge. There was a potential cardiac risk when Patient 4 was discharged without being cleared by Cardiology. During a review of the facility document “Medical Staff: General Rules and Regulations (section of the medical staff bylaws that describes more detailed operational policies for a hospital’s medical staff),” reviewed/revised 10/2024, the Rules and Regulations indicated the following: “ ...1.8 Duties of Attending Physician: ...1.8-3 Coordinating the selection of consultants, including personally contacting them except in case of emergency in which attending is physically occupied with a patient requiring immediate attention. 1.8-4 Communicating with consultants regarding the findings of their examination and recommendations ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated that “Patients have the right to be informed by the physician, or a delegate of the physician, about continuing healthcare requirements and options following discharge and/or transfer within or outside the hospital.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46238 Based on the interview and record review, the facility failed to: 1.a. Ensure one of 34 sampled patients (Patient 3), who was identified as cognitively impaired (having limitations in mental functions that affect their ability to process or communicate information) and nonverbal (unable to use spoken words to communicate), was properly assessed using a pain scale specifically designed for non-verbal patients, in accordance with the facility’s policy regarding pain assessment and management of patients who are unable to speak or express pain verbally and/or have mental impairment. This deficient practice had the potential to result in Patient 3 not receiving accurate pain assessment and management and potentially placing Patient 3 at risk for uncontrolled pain, worsening pain level, psychological distress such as anxiety (feeling of uneasiness), etc. 1.b. Ensure one of 34 sampled patient’s (Patient 3), pain re-assessment (the process of re-evaluating a patient’s pain level after an intervention, such as medication, to determine its effectiveness and ensure proper pain management) was conducted, following the administration of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] used for short-term management of moderate to severe pain), in accordance with the facility’s policy regarding pain management and re-assessment. This deficient practice had the potential to result in Patient 3’s pain not being sufficiently managed/addressed, leading to discomfort or progression to uncontrolled pain or psychological distress such as anxiety (feeling of uneasiness), etc. 2. Ensure that nursing staff activated the stroke protocol (a set of standardized procedures designed to rapidly assess, diagnose, and treat patients presenting with stroke [interruption of blood flow to the brain leading to potential brain damage] symptoms to minimize brain damage and improve outcomes) for one of 34 sampled patients (Patient 2), when on 7/2/2024 at 8:01 a.m., Patient 2 started showing signs and symptoms of stroke (observable indicators of a stroke, such as sudden paralysis [the loss of muscle function or control, on one side of the body]; aphasia [a language disorder caused by brain damage, affecting the ability to speak, understand, read, or write]; and facial droop [weakness or paralysis of the facial muscles, often causing one side of the face to sag or appear asymmetrical]). The deficient practice had the potential to result in delayed diagnosis and treatment for Patient 2 and increase the risk of permanent neurological damage or other complications associated with untreated stroke symptoms. 3. Ensure one of 34 sampled patient’s (Patient 3) nutritional status (the condition of a patient’s health as influenced by the intake and utilization of nutrients necessary for maintaining bodily functions, growth, and repair) and hydration status (the balance of fluids in the body required to support normal physiological processes, such as circulation, temperature regulation, and organ function) were monitored, assessed, and documented in accordance with the facility’s policy regarding “Standard of Care” and “Nursing Documentation.” This deficient practice had the potential to result in complications such as dehydration, unexpected weight loss, etc., when the patient’s (Patient 3) nutritional and hydration status are not properly assessed and monitored leading to a delay in making informed decisions to meet Patient 3’s individual nutritional and hydration needs. 4. Ensure one of 34 sampled patient’s (Patient 24) pain was reassessed (reevaluation), in accordance with the facility’s policy and procedure regarding pain management, after Patient 24 received pain medication of Ibuprofen (Motrin, pain medication) 600 milligram (mg, metric unit of measurement, used for medication dosage and/or amount), which was administered by mouth. This deficient practice had the potential to result in Patient 24’s pain to not be appropriately managed in which Patient 24’s pain remains unresolved, leading to worsening of pain, psychological distress due to pain, and a prolonged hospitalization. Findings: 1.a. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient’s current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic (long-duration) encephalopathy (worsening of brain function). During a review of Patient 3’s medical record (MR) titled, “Urology Consultation (a formal assessment by a specialist in urology to evaluate and manage conditions affecting the urinary tract [the system responsible for removing waste and excess fluids from the body, including the kidneys, ureters, bladder, and urethra] or the male reproductive system),” dated 9/10/2024, the MR indicated that a urologist (a physician specializing in the diagnosis and treatment of disorders related to the urinary system, including the kidneys, ureters, bladder, and urethra [the tube that carries urine from the bladder out of the body], as well as the male reproductive organs) was consulted to evaluate Patient 3’s medical condition related to a left mid urethral stone (a hard, solid mass that forms in the ureter, the tube connecting the kidneys to the bladder, potentially causing pain and urinary obstruction [blockage]), with hydronephrosis (swelling of a kidney due to a buildup of urine caused by an obstruction or blockage in the urinary tract), and possible colic (severe, intermittent pain caused by spasms or contractions in the urinary tract, often associated with kidney stones or other obstructions). During a review of Patient 3’s medical record (MR) titled, “Pain Assessment,” dated 9/13/2024 at 4:00 a.m., the MR indicated that Patient 3’s pain level was documented using a numerical pain scale (a tool where patients rate their pain intensity on a scale from 0 to 10, with 0 meaning no pain and 10 representing the worst pain imaginable) as 7 out of 10 (7 out of 10 typically indicates severe pain). During a record review on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), Patient 3’s “Pain Assessment” medical record, dated 9/13/2024, was reviewed. The QAN verified that Patient 3’s MR indicated that Patient 3’s pain intensity level was assessed using a numerical pain scale. During a concurrent interview and record review on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), Patient 3’s medical record (MR) titled, “Nursing Shift Assessment (an evaluation completed by nurses to document a patient’s physical, emotional, and mental status during each shift),” dated 9/13/2024, was reviewed. The QAN stated that the MR documentation indicated that Patient 3’s mental status was recorded as confused and non-verbal on 9/13/2024. The QAN said that nurses were expected to use a pain scale tailored to the patient’s ability to communicate pain. Since Patient 3 was unable to communicate verbally, the QAN stated that the nurses should have used a pain scale specifically designed for non-verbal patients to accurately assess the patient’s pain intensity level. Instead, the nurses used a numerical rating pain scale, which implies that the patient verbalized their pain level, despite the patient (Patient 3) being identified as confused and non-verbal. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated July 2023, the P&P stated that pain intensity should be assessed using one of the following pain scales consistently, based on the patient’s age and developmental level. For non-verbal patients, the FLACC Behavioral Scale (a tool used to evaluate pain based on five behavioral criteria: Face, Legs, Activity, Cry, and Consolability) or the Checklist of Nonverbal Pain Indicators (CNPI, a tool used for adults who are nonverbal to measure pain behaviors, particularly in cognitively impaired older adults, where “cognitively impaired” refers to limitations in memory, attention, reasoning, or other mental functions) may be used to assess pain intensity. The P&P also indicated that other measures may be used to detect pain and evaluate interventions, particularly when self-reporting is not possible. In such cases, staff should document that self-reporting cannot be used. Additional considerations for pain management outlined in the P&P included: Identifying pathological conditions or procedures that may cause pain. Listing behaviors observed by caregivers or others familiar with the patient that may indicate pain. Documenting “Assume Pain Present” (APP) in cases where pain is suspected but cannot be directly reported by the patient. 1.b. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient’s current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic (long-duration) encephalopathy (worsening of brain function). During a review of Patient 3’s “Medication Administration Record (MAR),” dated 9/11/2024, the MAR indicated that on 9/11/2024 at 6:36 p.m., Patient 3 received 15 milligrams (mg, a unit of measurement) of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] used for short-term management of moderate to severe pain) for a reported pain level of 6 out of 10 (a pain numeric scale is a tool used to rate pain intensity on a scale from 0 to 10, where 0 indicates no pain, 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain). During a review of Patient 3’s medical record (MR) titled, “Pain Assessment,” dated 9/11/2024 through 9/12/2024, the MR indicated that Patient 3’s pain intensity level was not re-assessed after the administration of Toradol on 9/11/2024 at 6:36 p.m. The MR further indicated that the next pain assessment for Patient 3 was not documented until 3:36 a.m. on 9/12/2024 (9 hours from the time the Toradol was administered). During an interview on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), the QAN stated that nurses were expected to reassess a patient’s pain intensity level after administering pain medication. The QAN further stated that, according to the facility’s policy, the reassessment of pain should be performed within 30 minutes of administering pain medication to ensure the intervention was effective. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated 7/2023, the P&P stated: “After each pain management intervention, once sufficient time has elapsed for the treatment to reach peak effect (the time when a medication achieves its maximum therapeutic impact), the goal is reassessment and documentation within one hour of the intervention. Documentation should include the patient’s response to the intervention and any side effects or adverse responses.” 2. During a review of Patient 2’s EMS (Emergency Medical Services, prehospital care provided by paramedics or emergency responders) Patient Care Report (PCR), dated 7/1/2024 at 10:47 a.m., the PCR indicated that paramedics (healthcare professionals trained to provide emergency medical care and transport patients to medical facilities) brought Patient 2 to the facility’s Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 at 11:29 a.m. The PCR also indicated that Patient 2 was alert and oriented to none (meaning the patient was not oriented to person, place, time, or situation, typically indicating a state of confusion or altered mental status). The PCR also indicated that bystanders on scene witnessed the patient (Patient 2) come out of the bathroom, fall down, and start having full body shakes. The PCR also indicated that patient (Patient 2) had a history of seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), unknown if compliant with medications and that the patient (Patient 2 was possibly postictal [a state following a seizure characterized by confusion, drowsiness, or disorientation as the brain recovers]). During a review of Patient 2’s HPI (History of Present Illness, a detailed narrative of the patient’s current health complaint, including onset, progression, and associated symptoms), dated 7/1/2024, the HPI indicated that Patient 2 presented to the Emergency Department (ED, a specialized unit in a hospital equipped to provide immediate care for urgent and life-threatening medical conditions) on 7/1/2024 at 11:29 a.m. after experiencing a seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or level of consciousness). The HPI also noted that Patient 2 had no prior visits to the facility’s ED. Additionally, the HPI stated that Patient 2 had a past medical history (PMH, a record of previously diagnosed medical conditions, treatments, and surgeries) of seizures and alcoholism (a chronic disease characterized by an inability to control or stop alcohol use despite negative social, occupational, or health consequences). During a review of Patient 2’s HPI, dated 7/1/2024, the HPI indicated that Patient 2 was treated with Versed (medication used to control seizures and provide sedation) upon arrival to the ED and Intravenous (IV, administered through a vein) Keppra (levetiracetam, medication used to prevent and treat seizures). The workup (a series of diagnostic tests and evaluations performed to identify the cause of a patient’s symptoms) was done with head CT (computed tomography, an imaging study to produce detailed pictures of the brain and skull to detect conditions like strokes, tumors, or trauma), CBC (complete blood count, a blood test to identify infection, anemia [when the body does not have enough red blood cells that carries oxygen to other parts of the body], or other abnormalities), BMP (basic metabolic panel, a blood test to identify metabolic [related to the body’s metabolism- the conversion of food into energy] or organ dysfunction), and toxicology screen (a test to detect drugs, toxins, or alcohol in the body). The HPI indicated that Patient 2 continued to remain postictal (a state of altered consciousness or confusion following a seizure) and required to be admitted (the process of formally entering a patient into a hospital for inpatient care and monitoring) to the facility. During a review of Patient 2’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/1/2024, at 5:20 p.m., the H&P indicated that Patient 2 was admitted due to altered mental status (a condition characterized by changes in awareness, orientation, behavior, or mental function) and seizure. The H&P also indicated that Patient 2 had a past medical history (PMH, a record of previously diagnosed medical conditions, treatments, and surgeries) of seizure disorder, was confused, and unable to provide history. Most of the history was taken from the chart and EMR (Electronic Medical Record, a digital version of a patient’s medical chart that contains their medical history, treatment plans, lab results, and other health information). Additionally, the H&P stated: “We will try to locate the family to get further information ...” During a review of Patient 2’s History & Physical (H&P) dated 7/1/2024, the H&P indicated that Patient 2 was alert, awake, oriented to none (not oriented to person, place, or time, indicating severe confusion or altered mental status); opened eyes with painful stimuli (a response to a physical stimulus, such as a pinch, used to assess consciousness level); followed commands, but was falling back to sleep; moved all extremities spontaneously (able to move arms and legs without assistance, indicating intact motor function and absence of significant paralysis). During further review of the History and Physical (H&P) dated 7/1/2024, the H&P noted the following: the patient’s (Patient 2) alcohol level was negative, indicating no measurable alcohol in the patient’s (Patient 2) system at the time of evaluation. The CT scan of the head revealed nonspecific hypoattenuation [refers to an area of lower density [thickness]on the scan that may indicate potential abnormalities such as ischemia, edema, or other conditions] in the posterior [refers to the back] left parietal lobe [a region of the brain associated with sensory perception and integration, spatial reasoning [the ability to understand, visualize, and manipulate objects or shapes in a given space], and coordination]). During a review of Patient 2’s medical record (MR) titled, “Patient Order Details,” dated 7/1/2024, the MR indicated that on 7/1/2024 at 2:38 p.m., the physician ordered an MRI (magnetic resonance imaging, a diagnostic test that creates detailed images of the brain and other structures) brain with and without contrast (contrast refers to a special dye injected into the body to enhance the clarity of the images and help detect abnormalities) as a routine order (a routine MRI is typically scheduled for the next available slot, which could be later the same day or within a few days, depending on the facility’s workflow and patient volume. Routine orders are not prioritized over urgent or emergent cases). During a review of Patient 2’s medical record (MR) titled, “Shift Assessment (a routine evaluation conducted by nursing staff during a shift to monitor a patient’s condition and document any changes),” dated 7/2/2024 at 8:00 a.m., the MR indicated that Patient 2’s speech was garbled (unclear or slurred speech that is difficult to understand, often indicative of neurological impairment). Strength assessment (an evaluation of a patient’s muscle strength, typically graded on a scale from normal to severe weakness) was documented as mild weakness (reduced muscle strength that limits function but does not significantly impair movement). The focus of care (the primary concern or objective of medical or nursing care during a given time, often guided by the patient’s current condition or complaints) was recorded to be “pain.” During a review of Patient 2’s MR (Medical Record) titled, “Shift Assessment,” dated 7/2/2024 at 8:01 a.m., the MR indicated that Patient 2’s speech was aphasic (a condition characterized by the inability to produce or understand speech, often resulting from brain damage such as a stroke). Strength assessment of the left leg and left arm was recorded as flaccid (a state of complete loss of muscle tone, resulting in limp and unresponsive muscles, often indicative of significant neurological damage). The focus of care was recorded to be “neurological” (relating to the diagnosis, treatment, or monitoring of disorders affecting the nervous system, including the brain, spinal cord, and nerves). During further review of Patient 2’s medical record (MR) titled, “NIH Stroke Scale(National Institutes of Health Stroke Scale, a standardized scoring system used to evaluate the severity of stroke-related neurological deficits, based on assessments of various functions such as consciousness, vision, motor ability (movement), sensation, and language), dated 7/2/2024, at 8:01 a.m., the MR indicated that the NIH score was 21 (a score on the NIH Stroke Scale ranging from 0 to 42; a score of 21 indicates a severe stroke with significant neurological impairment, such as loss of motor function, speech difficulties, or cognitive deficits). The MR also indicated that that the onset (the time when symptoms of the stroke first began or were last known to occur) was more than 24 hours. The MR also stated that MD was not notified on 7/2/2024 at 8:01 a.m. During a review of Patient 2’s Medical Record (MR) titled, “NIH Stroke Scale,” dated 7/2/2024 at 10:00 a.m., the MR indicated the NIH score was 21 (a severe stroke, indicating significant neurological impairment), and the attending physician (a medical doctor responsible for overseeing a patient’s care, coordinating the treatment plan, and guiding other healthcare team members) (MD 11) was notified at 10:00 a.m. on 7/2/2024. During further review of Patient 2’s medical record (MR) titled, “Progress Note (a section of the medical record where physicians document updates on a patient’s condition, treatment, and response over time),” dated 7/2/2024 at 3:41 a.m., the MR indicated that patient (Patient 2) was not moving the left side. The note stated, “Probable stroke, await neurology consult (a formal request for evaluation and recommendations from a neurologist, a specialist in diagnosing and treating disorders of the nervous system, including strokes).” During further review of Patient 2’s medical record (MR) titled, “Neurological Consultation (a specialized evaluation conducted by a neurologist to assess and diagnose conditions related to the nervous system, including the brain, spinal cord, and nerves),” dated 7/3/2024, the MR indicated the following: “The patient (Patient 2) with unclear PMH (past medical history) has not seen a primary physician for years. History obtained with family at the bedside and on the phone. The patient (Patient 2) presented to the ED status after a seizure with no prior history of seizures. Patient (Patient 2) was diagnosed with a stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients) and presented on exam aphasic (a condition characterized by an impaired ability to speak, understand, or process language, typically due to brain damage such as from a stroke) and with left-sided hemiparesis (weakness or partial loss of strength on the left side of the body, often caused by a neurological event like a stroke). Patient (Patient 2) was started on stroke protocol (standardized, evidence-based set of procedures designed to ensure the timely identification, evaluation, and treatment of patients presenting with symptoms of a stroke).” During an interview on 11/13/2024 at 11:44 a.m. with the physician (MD 11), MD 11 stated the following: “I remember the patient somewhat; I just reviewed the chart. I remember the patient (Patient 2) was confused. The CT (computed tomography (CT), an imaging technique used to create detailed internal images of the body) results were abnormal, showing a questionable mass. I did an MRI (magnetic resonance imaging, a detailed imaging method used to diagnose conditions such as strokes or masses), and it showed multiple infarcts (areas of dead tissue caused by a lack of blood supply). The patient (Patient 2) ended up with a PEG (percutaneous endoscopic gastrostomy, a feeding tube placed directly into the stomach), and might have aspirated, leading to intubation (the insertion of a breathing tube to maintain an airway). The patient (Patient 2) was later extubated (removal of the breathing tube) and ultimately discharged to a SNF (skilled nursing facility, a healthcare facility providing medical and rehabilitative care).” In the same interview on 11/13/2024 at 11:46 a.m. with the physician (MD 11), MD 11 stated the following: I received the patient [Patient 2] from the ED with questionable alcohol use and seizure, so I initially wanted to rule out an alcohol-related seizure. Based on the CT scan, there was a questionable mass, and the findings were abnormal. If it’s a mass, I am not going to entertain the idea of a stroke. Unfortunately, we did not give the appropriate treatment at the beginning. I did not start any treatment because I had to consider the possibility that the patient might need surgery. The time frame was within 24 hours, and I ordered the MRI as soon as I saw the patient. However, I carried the diagnosis of alcohol use disorder, which influenced my initial assessment. The MRI happened within 24 hours, but I acknowledge that MRI should have been done faster, especially since this is a stroke center. If stroke had been a possibility from the start, we would have expedited the MRI process much faster. The patient was unresponsive, and I had no family available to provide further history or clarification through an interview. During an interview on 11/13/2024 at 12:00 p.m. with the Chief of Staff (MD 10), MD 10 stated the following regarding Patient 2’s head CT images (a computed tomography [CT] scan of the head that produces detailed images of the brain and skull, commonly used to identify bleeding, trauma, or other abnormalities) obtained on 7/1/2024 at 12:36 p.m.: “Initial CT [on 7/1/2024 at 12:36 p.m.] - typically, I don’t comment on the cerebellum (the part of the brain located at the back of the skull, responsible for balance, coordination, and fine motor skills, and affected by Patient 2’s stroke) if the findings are unremarkable. If there’s nothing notable, it’s not something we (radiologists, medical doctors specializing in interpreting imaging studies like CTs) would specifically mention in a non-contrast (a type of imaging study performed without contrast dye, primarily used to detect large abnormalities such as bleeding or mass effect) head CT. The follow-up MRI (magnetic resonance imaging, a detailed imaging technique that produces high-resolution images of the brain and other structures) was done on 7/2/2024 at 12:02 p.m. and demonstrated a large area of acute ischemia (restricted blood flow to brain tissue leading to oxygen deprivation and potential brain cell death), which was already subacute (occurring 24 hours to 7 days after the initial ischemic event). It was unusual to find these results after an unremarkable head CT was done the day before.” In the same interview on 11/13/2024 at 12:00 p.m. with the Chief of Staff (MD 10), MD 10 stated the following: The initial CT scan (for Patient 2) was not performed under a Code Stroke protocol but was ordered due to (Patient 2’s) altered mental status. If it had been a stroke order, the radiologist would have followed a different protocol. The MRI would show the stroke immediately. We would need to know the last known well time (the last time the patient was observed to be neurologically normal), and a CT angiography (a specialized CT imaging technique using contrast dye to visualize blood vessels and identify blockages or abnormalities) might have warranted a different intervention (for Patient 2). A negative head CT is only sufficient to rule out a hemorrhagic stroke (a type of stroke caused by bleeding in or around the brain, rather than a blockage). During an interview on 11/13/2024 at 2:40 p.m. with the Medical Director of the Emergency Department (MD 9), MD 9 stated the following: Patient (Patient 2) presented altered to the ED. I would assume the patient was post-ictal. I ordered a head CT, which is common for altered patients. The patient was found altered and down and was outside the window for stroke intervention because we did not know the patient’s (Patient 2) last known well time. I would not call a code stroke for such a patient. Altered mental status is not an indicator to call a Code Stroke. If an MRI was ordered, it would be more sensitive than a CT, but there was no indication to call a Code Stroke (for Patient 2). The patient was admitted first, and only then started showing symptoms of stroke. During an interview on 11/14/2024 at 10:45 a.m. with the Quality Assurance Nurse/Stroke Coordinator (QAN), the QAN stated the following: “In our policy, the Code Stroke (a hospital protocol activated to expedite the assessment, diagnosis, and treatment of patients presenting with acute (sudden) stroke symptoms) is activated for someone who has stroke (a medical condition where blood flow to the brain is interrupted, leading to potential brain damage and neurological deficits) symptoms within 24 hours of onset. Once the nurse identifies a change in condition [stroke], and the symptoms are within 24 hours, she [the nurse] can activate the Code Stroke. If it is more than 24 hours, she [the nurse] should call the physician regarding signs and symptoms of a stroke.” During a review of Patient 2’s medical record (MR), dated 7/2/2024, the MR indicated that Code Stroke [for Patient 2] was never activated on 7/2/2024. Additionally, the MR indicated that there were no previously documented neurological changes in Patient 2’s condition (from 7/1/2024 at 11:46 a.m. to 7/2/2024 at 8:01 a.m.) to suggest that the onset of stroke symptoms occurred more than 24 hours prior to the time Patient 2’s NIH Stroke Scale was documented as 21 (severe stroke) on 7/2/2024 at 8:01 a.m. The QAN (Quality Assurance Nurse) reviewed the record and verified that the first recorded Patient 2’s neurological changes were documented only on 7/2/2024 at 8:01 a.m. During a review of the facility’s policy and procedure (P&P) titled, “Acute Stroke,” dated 10/2023, the P&P indicated that the purpose of the policy is to outline the standard of care provided to all patients arriving or admitted with a working diagnosis of ischemic stroke ...and to outline the role of the Code Stroke Team responding to any acute stroke patients or inpatient with suspected stroke. Consistent care will be delivered to all patients with a working diagnosis of ischemic stroke ...throughout the continuum of care ...The Code Stroke Team will respond to all acute onset stroke patients 24 hours a day, year-round. Acute onset is defined as any patients identified within 6 hours of the onset of stroke symptoms. Acute phase: Patients presenting acute symptoms of stroke: 3.1.1 when an inpatient is suspected of sustaining an acute stroke, the RN calls the Code Stroke. 3.1.2. The primary care nurse or RRT (Rapid Response Team, a group of healthcare professionals trained to respond quickly to acute changes in a patient’s condition to prevent further deterioration) will contact the primary care physician. 3.1.3. The Code Stroke Team arrive within 10 minutes. 3.1.4. Code Stroke Orders are initiated. 3.1.8. All Code Stroke Patients will be evaluated via Tele-Neurology (a remote consultation service where neurologists evaluate and provide recommendations for patients using telecommunication technologies, such as video conferencing or electronic data exchange), and it is available 24/7 ... 3. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient’s current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic encephalopathy (a sudden worsening of brain function). During a review of Patient 3’s medical record (MR) titled, “Nutritional Intake (a section of the medical record used to document the amount and type of food and beverages consumed by the patient to monitor their nutritional status),” dated 9/9/2024 through 9/13/2024, the MR indicated that during Patient 3’s stay at the facility (9/9/2024 through 9/13/2024), Patient 3 had only one meal intake documented on 9/13/2024 at 8:00 a.m. indicating that Patient 3 ate 75% (seventy-five percent, meaning three-quarters of the total meal provided) of their (Patient 3) breakfast. During a review of Patient 3’s MR titled, “Patient Orders Detail (a section of the medical record that documents physician orders for tests, treatments, or interventions),” the MR indicated that on 9/9/2024 at 7:46 p.m., a dietary consultation (an evaluation by a dietitian to assess a patient’s nutritional needs and develop a plan to address dietary concerns) was ordered due to poor PO intake (poor oral [by mouth] intake, meaning insufficient oral consumption of food and fluids) for more than three days (prior to hospital admission). During a review of Patient 3’s medical record (MR) titled, “Patient Orders Detail,” the MR indicated that on 9/9/2024 at 7:15 p.m., the physician ordered a cardiac diet, which was canceled at 7:41 p.m., and a new order for NPO, except medications (nothing by mouth except for prescribed medications) was placed. The MR further indicated that on 9/10/2024 at 9:22 p.m., the physician ordered NPO at midnight (a restriction on all oral intake starting at midnight) due to an upcoming surgical procedure scheduled for 9/11/2024. Additionally, the MR indicated that on 9/11/2024 at 6:45 p.m., the physician ordered a cardiac diet. During a review of the medical record (MR) titled, “Nutritional Intake,” dated 9/10/2024 through 9/13/2024, the MR indicated that for each meal (breakfast, lunch, dinner), Patient 3’s status was documented as NPO (a medical abbreviation for nil per os, meaning “nothing by mouth,” indicating that the patient is restricted from consuming food or liquids). The MR also stated that on 9/13/2024 at 6:00 p.m., Patient 3 was documented as NPO for dinner, with a nurse’s note stating that Patient 3 was refusing to eat and unable to tolerate food. During a review of Patient 3’s MR titled, “Intake and Output, (I&O, is a medical term referring to the monitoring and recording of all fluids a patient consumes [intake] and eliminates [output] over a specified period, typically 24 hours.) the MR indicated the following: On 9/9/2024 Total Oral Intake: 0 milliliters (ml, measuring unit); On 9/10/2024 Total Oral Intake: 0 ml On 9/11/2024 Total Oral Intake: 0 ml; On 9/12/2024 Total Oral Intake: 0 ml; On 9/13/2024 Total Oral Intake: 0 ml. During a review of Patient 3’s MR titled, “Nutrition Assessment (an evaluation performed by a dietitian to assess a patient’s dietary intake, nutritional status, and specific needs to develop a tailored nutrition plan),” dated 9/13/2024, the MR indicated that a dietitian first evaluated Patient 3’s nutritional intake on 9/13/2024 at 5:39 p.m. (The order for consult was placed on 9/9/2024). During a review of Patient 3’s medical record (MR) titled, “Discharge,” dated 9/13/2024, the MR indicated that Patient 3 was discharged on 9/13/2024 at 8:00 p.m. During an interview on 11/15/2024 at 10:10 a.m., with the Director of the Medical-Surgical Unit (Med-Surg, a hospital unit providing care for patients undergoing medical treatment or recovering from surgery) (DMS), the DMS stated, “Documenting intake and output (I&Os) is a requirement. Nurses are expected to document I&Os at least by the end of each shift. Intake means recording everything the patient receives orally or intravenously. Tracking the amount of fluid intake allows nurses and physicians to assess the hydration status of the patient (the balance of fluids in the body required to maintain normal physiological functions, such as temperature regulation, circulation, and organ performance).” During the same interview on 11/15/2024 at 10:10 a.m. with the DMS, the DMS stated that nurses complete daily head-to-toe patient assessments (an evaluation of a patient’s physical condition, covering all major body systems, to identify any abnormalities, changes, or needs). The DMS further said that patients’ needs can change, and nurses should tailor the plan of care and interventions based on the findings from these assessments. The DMS then said, “If patient is not eating, nurses should re-assess nutritional status of the patient and check for physician’s order. If there is a dietary consult pending, nurses should follow-up with the dietitian and escalate (the process of bringing an issue, concern, or situation to the attention of higher-level staff, management, or specialized personnel when it cannot be resolved at the current level).” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Care,” dated July 2024, the P&P stated that the collection of data pertinent to an individual’s health status must be conducted systematically and continuously. The policy further indicated that, once recorded, such data should be communicated to appropriate personnel and remain retrievable for use as needed. During a review of the facility’s policy and procedure (P&P) titled, “Nursing documentation,” dated 10/2023, the P&P indicated that meal intakes and Intake and Output will be charted within the appropriate assessments within patient’s electronic care system. Documentation will include implementation of physician orders and nursing actions, clinical observations and outcomes. During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated, “ ...Patient Rights 1. Considerate and respectful care. During a review of the facility’s policy and procedure (P&P) titled, “Scope of Service - Medical Surgical Units,” dated 1/2024, the P&P stated that Medical-Surgical Nurses strive to provide holistic care in a respectful and sensitive manner. Assessment findings are utilized to prioritize patient problems and guide the development of the patient’s plan of care. The policy further indicated that the Registered Nurse assigns priorities to the patient’s needs to ensure adequate, safe, and competent nursing care is delivered at all times. 4. During a review of Patient 24’s “Face Sheet (front page of the chart contains a summary of basic information about the resident),” (undated), the Face Sheet indicated Patient 24 was admitted to the facility on 11/12/2024, with a medical diagnosis of assault (a physical attack). During a review of Patient 24’s “Medication Detail Order,” dated 11/12/2024 at 7:45 a.m., the order indicated Ibuprofen (Motrin, pain medication) 600 milligram (mg, metric unit of measurement, used for medication dosage and/or amount) to be given by mouth, once. During a review of Patient 24’s “Medication Administration History Report (MAR),” dated 11/12/2024, the MAR indicated Patient 24 was given Motrin 600 mg tablet by mouth at 7:49 a.m. During a concurrent interview and record review on 11/14/2024 at 9:34 a.m. with Registered Nurse 18 (RN 18), RN 18 verified Patient 24’s “Vital Sign Report,” dated 11/12/2024, indicated, Patient 24’s pain score at 7:49 a.m., prior to receiving the Motrin, was eight (a pain level of 8 [on a pain scale of 1 through 10, with 10 representing the highest level of pain imaginable], would indicate a high level of experienced pain). In the same interview and record review, on 11/14/2024 at 9:34 a.m., RN 18 verified Patient’s 24’s “Vital Sign Report,” dated 11/12/24, had no documentation of Patient 24’s pain reassessment after the patient (Patient 24) received pain medication on 11/12/24 at 7:49 a.m. RN 18 stated the patient’s pain should be reassessed within an hour after administration of pain medication to evaluate the effectiveness of the medication and to know if the plan for pain management needed to be modified. During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” revised in 4/2023, the P&P indicated, “Assess for pain using a pain scale (numeric, visual analog or text based) consistently as follows: after each pain management intervention once sufficient time has elapsed for the treatment to reach peak effect, the goal is reassessment and documentation within 1 hour of intervention.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” revised in 4/2023, the P&P indicated, “Assessment and reassessment information includes the patient’s perception of the effectiveness of, and any side effects related to medication. E.g., relief of symptoms of nausea or pain.””

“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: 50594 Based on interview and records review, the facility failed to ensure for two of 34 sampled patients (Patient 11 and Patient 12), the following: 1. For Patient 11, an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for fall (unplanned descent to the floor with or without injury to the patient) precaution (proactive steps to prevent someone from falling by addressing potential hazards in their environment and promoting behaviors that minimize the risk of a fall), was developed upon admission, in accordance with the facility’s policy and procedure regarding care planning.. This deficient practice had the potential for Patient 11’s needs and risks not to be identified and addressed, which may result in a fall with complications such as fracture (break in the bones), etc. 2. For Patient 12, an individualized nursing care plan for management of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) was developed upon admission, in accordance with the facility’s policy and procedure regarding care planning. This deficient practice had the potential to result in the delayed provision of care to Patient 12 by not identifying Patient 12’s need and risks, which may result in complications such as hypoglycemia (low blood sugar), diabetic coma (a life-threatening complication when a patient’s blood sugar levels are dangerously high or low, causing them to become unconscious), and/or death. Findings: 1. During a review of Patient 11’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/05/24, the H&P indicated Patient 11 was admitted to the facility with chief complaints of being unable to walk and poor oral (by mouth) intake. During an interview and record review on 11/14/2024 at 10:43 a.m., with Clinical Nurse Supervisor 1 (CNS 1), CNS 1 verified Patient 11’s Morse Fall Scale (a tool used for patient to identify risk factors for falls [unplanned descent to the floor with or without injury to the patient]) score upon admission on 11/06/2024 was 35 (Moderate risk score is between 25-44). CNS 1 stated Patient 11 was a moderate risk for fall and a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for fall precaution should have had been initiated upon admission. In the same interview on 11/14/2024 at 10:43 a.m., CNS 1 stated care plans were initiated at the time of patient admission to know how patient care would be communicated among the nurses. During a review on 11/15/2024 at 10:49 a.m. with CNS 1, Patient 11’s care plan was reviewed. CNS 1 verified Patient 11’s care plan for fall precaution was initiated on 11/08/2024 (three days after Patient 11 was admitted to the facility). During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care: Patient, Interdisciplinary,” last reviewed in 4/2023 , the P&P indicated, “ ...ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs ...Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission ...” 2. During a review of Patient 12’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/06/2024, the H&P indicated, Patient 12 was admitted to the facility with a chief complaint of weakness. The H&P also indicated Patient 12 had a past medical history of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview and record review on 11/14/2024 at 11:11 a.m., with Clinical Nurse Supervisor 1 (CNS 1) and Registered Nurse 10 (RN 10), CNS 1 stated Patient 12’s care plan for DM was not initiated at the time patient was admitted to the facility. RN 10 stated a care plan helps nurses focus on care and monitor the progress of the patients. During a review on 11/15/24 at 10:33 a.m. with CNS 1, Patient 12’s care plan regarding Diabetes Mellitus management, was reviewed. CNS 1 verified Patient 12’s care plan for management of DM was initiated on 11/08/2024 (two days after Patient 12’s admission to the facility). During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care: Patient, Interdisciplinary,” last reviewed in 4/2023, the P&P indicated, “ ...ensure that a Plan of Care is developed for each patient that is individualized to meet the patients’ unique needs ...Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission ...””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46333 Based on observation, interview and record review, the facility failed to: 1. Ensure that for one of 34 sampled patients (Patient 3), nursing staff documented intake and output (the measurement and recording of all fluids a patient takes in, such as through drinking or IV fluids [intravenous fluids, which are liquids administered directly into a vein to provide hydration, medications, or nutrients], and fluids they lose, such as through urination or vomiting) throughout Patient 3’s admission stay at the facility, in accordance with the facility’s policy regarding “Standard of Care” and “Nursing Documentation.” This deficient practice potentially placed Patient 3 at risk for missed opportunities to detect and address changes in the patient’s fluid status (the balance of fluids in the body, which is essential for maintaining normal bodily functions), which may result in complications such as dehydration (excessive loss of fluid), low blood pressure, etc. 2. Ensure that, for one patient out of 34 sampled patients (Patient 3), nursing staff obtained a urine sample (a collection of urine used for diagnostic purposes, such as detecting infections, assessing kidney function) as indicated by the physician’s order and in accordance with the facility’s policy regarding carrying-out all physician’s orders. This deficient practice had the potential to result in Patient 3’s delayed diagnosis and treatment of underlying medical conditions such as urinary tract infections (UTIs, infections occurring in any part of the urinary system, including the bladder, urethra [the tube that carries urine out of the body], or kidneys, which can cause symptoms such as pain, burning during urination, and fever, and if untreated, may lead to serious kidney complications) leading to worsening of symptoms and compromising patient’s (Patient 3) health and recovery. 3. Ensure that, for one of 34 sampled patients (Patient 2), the mental status (assessed to identify abnormalities such as confusion, disorientation, or unresponsiveness) during the triage assessment (the initial evaluation of a patient upon arrival to the emergency department), was accurately documented based on Patient 2’s presenting condition, in accordance with the facility’s policy regarding documentation in the ED patient care record (a comprehensive record of care provided in the emergency department). This deficient practice resulted in Patient 2 not being assigned a correct ESI level (Emergency Severity Index, a triage tool used to categorize patients based on acuity-the severity of a patient’s condition and the urgency of medical intervention required-and resource needs, such as diagnostic tests or treatments), which could potentially lead to delayed prioritization of care (failure to provide timely or suitable medical attention based on the patient’s actual condition and needs, potentially compromising outcomes). 4. Ensure one of 34 sampled patient’s (Patient 6’s) pain was assessed and addressed after sustaining an unwitnessed fall (an unplanned descent to the floor with or without injury to the patient) and on two other occasions when Patient 6’s family reported that Patient 6 had pain, in accordance with the facility policy and procedure regarding assessment, reassessment, and pain management. This deficient practice likely resulted in Patient 6 experiencing unrelieved pain and had the potential for delay in needed treatment, which can result in complications such as worsening pain level, psychological distress due to uncontrolled pain, etc. 5. Ensure one of 34 sampled patient’s (Patient 6’s) fall risk was reassessed using the Morse Fall Scale (MFS, a tool to identify patients at risk for falling that includes history of falling, secondary diagnosis, ambulatory [related to walking] aids [example: cane], intravenous [medication administered into the vein] therapy, gait abnormalities [the pattern of how a person walks], and mental status, with the summed range from 0 to 125, higher scores indicating a higher risk for falling) after sustaining a fall (unplanned descent to the floor with or without injury to the patient) on 10/4/2024 and for the MFS score to reflect Patient 6’s post-fall status. This deficient practice may lead to the wrong fall preventative measures used and compromise Patient 6’s safety, which may result in another fall with complications such as fracture (broken bones). 6. Ensure, the facility staff followed the chain of command (crucial for ensuring patient safety by providing a structured process for staff to escalate concerns about patient care, report issues, and seek necessary interventions through a clear hierarchy of authority, ultimately leading to better decision-making and addressing problems promptly when they arise) when unable to immediately contact and notify the physician regarding one of 34 sampled patient’s (Patient 6’s) critical laboratory values (potentially life-threatening laboratory results that must be conveyed immediately to the physician so that therapeutic measures can be instituted rapidly) such as elevated Troponin (is a protein that’s found in the cells of the heart muscle) level of 80.0 ng (nanograms, a unit of measurement) per milliliter (mL, a unit of measurement, a normal troponin levels range is from 0-0.04 ng/ml) and a Hemoglobin level of 6.2 (normal range of hemoglobin for adult men is 13.5 to 17.5 g/dL) , in accordance with the facility’s policy and procedure regarding utilization of chain of command. This deficient practice may lead to a delay in necessary interventions and jeopardize Patient 6’s safety, resulting in complications such as cardiac arrest [when the heart stops beating], dizziness, fatigue, shortness of breath [difficulty breathing], etc. 7. Ensure one of 34 sampled patients (Patient 5) was turned and repositioned (to change someone’s body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) every 2 hours, in accordance with facility policy and procedure regarding skin integrity (refers to the health and unbroken state of the skin). This deficient practice had the potential for patient 34’s existing sacrogluteal (buttock [butt] area) pressure injuries (localized damage to the skin or soft tissue caused by prolonged or severe pressure, often over a bony part of the body) to worsen, resulting in complications such as infection, the need for surgery to debride (remove) dead tissue, etc. 8. Ensure for one of 34 sampled patients (Patient 9), Patient 9’s seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions (refers to safety measures taken before a patient experiences a seizure) was implemented, in accordance with the facility’s policy and procedure regarding seizure management when, Patient 9 was observed to not have all the four side rails padded. This deficient practice had the potential for Patient 9 to suffer from pain and injury (such as fracture [broken bones]) during a seizure activity. 9. Ensure for one of 30 sampled patients (Patient 20), the facility’s policies and procedures (P&P) for fall (an unplanned descent to the floor with or without injury to the patient) reduction was implemented when, Patient 20, who was a high risk for fall, was not wearing yellow socks (yellow socks indicate the patient was at risk for fall) and the patient’s (Patient 20) bed alarm was not turned on/activated (a bed alarm will go off to alert staff when a patient gets out of bed). This deficient practice had the potential to result in an unsafe care that may lead to Patient 20 suffering from a fall injury with possible complications such as fracture (broken bones), the need for surgery (in case of severe injury requiring surgery), brain bleed (if the patient hits the head on the floor), etc. 10. Ensure one of seven sampled emergency crash carts (Crash Cart 2, a wheeled container carrying medicine and equipment for use in emergency resuscitations [procedure used to restart a patient’s breathing and heartbeat when they have stopped]), had complete and readily available equipment for use when, Crash Cart 2 was missing a cardiac backboard (rigid surface used to support a patient during a cardiopulmonary resuscitation [CPR, a life-saving emergency procedure that combines chest compressions and rescue breathing to help someone who is not breathing or heartbeat has stopped]). This deficient practice had the potential to delay critical emergency care if the crash cart equipment was not inspected for completeness and verified for availability potentially leading to worsened patient outcomes and/or patient death. Findings: 1. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient’s current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic (long-duration) encephalopathy (worsening of brain function). During a review of Patient 3’s medical record (MR) titled, “Urology Consultation (a formal assessment by a specialist in urology to evaluate and manage conditions affecting the urinary tract [the system responsible for removing waste and excess fluids from the body, including the kidneys, ureters, bladder, and urethra] or the male reproductive system),” dated 9/10/2024, the MR indicated that a urologist (a physician specializing in the diagnosis and treatment of disorders related to the urinary system, including the kidneys, ureters, bladder, and urethra [the tube that carries urine from the bladder out of the body], as well as the male reproductive organs) was consulted to evaluate Patient 3’s medical condition related to a left mid urethral stone (a hard, solid mass that forms in the ureter, the tube connecting the kidneys to the bladder, potentially causing pain and urinary obstruction [blockage]), with hydronephrosis (swelling of a kidney due to a buildup of urine caused by an obstruction or blockage in the urinary tract), and possible colic (severe, intermittent pain caused by spasms or contractions in the urinary tract, often associated with kidney stones or other obstructions). During a review of Patient 3’s medical record (MR), specifically the “Post-Operative Note (a note documenting the patient’s condition and care following a surgical procedure),” dated 9/11/2024, the record indicated that on 9/11/2024, Patient 3 underwent left ureteroscopy (a procedure involving the insertion of a thin scope [tube] into the ureter (the duct through which urine passes from the kidney to the bladder), laser lithotripsy (a procedure using laser energy to break kidney stones into smaller pieces for easier removal), and double-J stent placement (a medical device placed in the ureter to ensure proper drainage of urine from the kidney to the bladder). During a review of Patient 3’s MR titled, “Intake and Output, (I&O, is a medical term referring to the monitoring and recording of all fluids a patient consumes [intake] and eliminates [output] over a specified period, typically 24 hours),” the MR indicated the following: On 9/9/2024 Total Oral Intake: 0 milliliters (ml, measuring unit); Total Output: not recorded. On 9/10/2024 Total Oral Intake: 0 ml Total Output:1 ml. On 9/11/2024 Total Oral Intake: 0 ml; Total Output for 9/11/2024: 4 ml + 1 void (act of urination) On 9/12/2024 Total Oral Intake: 0 ml; Total Output for 9/12/2024: 3 voids On 9/13/2024 Total Oral Intake: 0 ml; Total Output for 9/13/2024: 3 voids During a concurrent interview and record review on 11/15/2024 at 10:10 a.m. with the Quality Assurance Nurse (QAN), Patient 3’s “IV Spreadsheet (a document used to record the amount and type of intravenous (IV) fluids administered to a patient over a specified period),” was reviewed. The QAN reviewed the IV Spreadsheet and verified that Patient 3’s IV Spreadsheet contained no documentation of the amount of IV fluids administered during the patient’s stay at the facility from 9/9/2024 through 9/13/2024. The QAN stated that nurses were required to document the 24-hour cumulative (total) intake of intravenous fluids for each patient daily in accordance with the facility’s practice. During an interview on 11/15/2024 at 11:35 a.m. with the Director of the Medical-Surgical Unit (Med-Surg, a hospital unit specializing in the care of patients requiring medical treatment or surgical intervention) (DMS), the DMS stated the following: “Documenting intake and output (I&Os) is a requirement. Nurses are expected to document I&Os at least by the end of each shift. Intake means recording everything the patient receives orally or intravenously, while output measures fluids such as urine and emesis (vomited stomach contents). It’s important to document I&Os because they allow nurses and physicians to track the patient’s fluid balance and determine if the patient is dehydrated (a condition in which the body loses more fluid than it takes in, leading to insufficient fluids for normal functioning) or fluid overloaded (a condition where there is too much fluid in the body, often causing swelling and strain on the heart and lungs). Proper documentation is essential to maintain body fluid balance, and effectively manage the patient’s hydration status. The DMS also stated that for a patient with identified kidney stones and urinary tract problems, it is especially important to ensure there is no retention (inability to fully empty the bladder during urination) of urine and that the intake and output remain balanced.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Care,” dated July 2024, the P&P stated that the collection of data pertinent to an individual’s health status must be conducted systematically and continuously. The policy further indicated that, once recorded, such data should be communicated to appropriate personnel and remain retrievable for use as needed. During a review of the facility’s policy and procedure (P&P) titled, “Documentation in the ED Patient Care Record,” dated October 2023, the P&P indicated that Intake and Output (I&Os) must be documented and tallied for all patients receiving IV fluids, diuretics (medications that promote urine production to help remove excess fluid from the body), and for patients being admitted. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Re-assessment of the Patient,” dated 7/2023, the P&P indicated that to effectively monitor a patient’s status and to evaluate the patient’s response to the treatment or care, reassessment of the patient will occur, at a minimum, at the time of change in shift or at any time there is a change in the condition of the patient. During a review of the facility’s policy and procedure (P&P) titled, “Nursing documentation,” dated 10/2023, the P&P indicated that Intake and Output will be charted within the appropriate assessments within patient’s electronic care system. Documentation will include implementation of physician orders and nursing actions, clinical observations and outcomes. 2. During a review of Patient 3’s “HPI (History of Present Illness, a detailed account of the patient’s current medical issues),” dated 9/9/2024, the HPI indicated that Patient 3 was admitted due to decreased appetite and constipation for one week. The HPI also stated that Patient 3 had significant renal insufficiency (impaired kidney function affecting waste filtration and fluid balance), a left mid ureteral stone (a stone located in the ureter, the tube that carries urine from the kidney to the bladder, causing pain or obstruction), and hydronephrosis (swelling of the kidney due to a buildup of urine from obstruction). During a review of Patient 3’s medical record (MR) titled, “Patient Orders Detail (a section of the medical record that documents physician orders for tests, treatments, or interventions),” the MR indicated that on 9/9/2024 at 3:09 p.m., the physician ordered a urine sample to be obtained STAT (immediately, as a matter of urgent priority). The order specified that the sample was to be collected from Patient 3 by performing a straight catheterization (a medical procedure in which a thin, flexible tube is inserted into the bladder to obtain a sterile [free of bacteria] urine sample). During further review of Patient 3’s medical record (MR) titled, “Patient Orders Detail,” the MR indicated that on 9/9/2024 at 7:15 p.m., the physician placed an order for a urinalysis (a diagnostic test used to examine the content and characteristics of urine to detect abnormalities, such as infections, kidney disease, or other medical conditions). During further review of Patient 3’s medical record (MR) titled, “Lab Reports (a section of the medical record documenting laboratory test results ordered to diagnose, monitor, or treat medical conditions),” dated 9/9/2024 through 9/11/2024, the MR indicated that Patient 3’s Lab Report contained no urinalysis results. During an interview on 11/15/2024 at 9:56 a.m. with the Quality Assurance Nurse (QAN), the QAN reviewed Patient 3’s laboratory results and stated that Patient 3’s medical record contained no documentation of urinalysis results. The QAN further stated that Patient 3’s urine sample was not obtained at any time during Patient 3’s stay at the facility, from 9/9/2024 through 9/13/2024, despite a physician order for urinalysis on 9/9/2024. During an interview on 11/15/2024 at 11:35 a.m. with the Director of the Medical-Surgical Unit (Med-Surg, a hospital unit providing care for patients recovering from surgery or being treated for various medical conditions) (DMS), the DMS stated that if there was an order for a urinalysis, it should be carried out. The DMS further stated that the nurse on each shift was responsible for reviewing orders that have not been completed and following up. The DMS said, “Nurses document the 24-hour chart check (a process in which nurses review the patient’s medical record to ensure all physician’s orders are acknowledged and carried out within a 24-hour period). Nurses are expected to review physician orders each shift to ensure they are completed, as the goal is to always ensure that all physician orders are followed through.” During a review of the facility’s policy and procedure (P&P) titled, “Chart Checks - 24 Hour,” dated 10/2023, the P&P indicated the following: To ensure that all physician orders from the previous 12/24 hours have been correctly noted and/or completed by the Registered Nurse (RN). Written orders within the patient’s medical record must be reviewed every 12 hours. If a specific order has not been noted or completed by the primary RN, it becomes the responsibility of the oncoming primary RN to note or complete the order. This process is repeated every 12 hours. 3. During a review of Patient 2’s EMS (Emergency Medical Services, prehospital care provided by paramedics or emergency responders) Patient Care Report (PCR), dated 7/1/2024 at 10:47 a.m., the PCR indicated that paramedics (healthcare professionals trained to provide emergency medical care and transport patients to medical facilities) brought Patient 2 to the facility’s Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 at 11:29 a.m. The PCR also indicated that Patient 2 was alert and oriented to none (meaning the patient was not oriented to person, place, time, or situation, typically indicating a state of confusion or altered mental status). During a review of Patient 2’s HPI (History of Present Illness, a detailed narrative of the patient’s current health complaint, including onset, progression, and associated symptoms), dated 7/1/2024, the HPI indicated that Patient 2 presented to the emergency department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 after experiencing a seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness). The HPI also indicated that Patient 2 was post-ictal (a state following a seizure characterized by confusion, drowsiness, or disorientation as the brain recovers). During a review of Patient 2’s “Triage Assessment (the initial evaluation performed upon a patient’s arrival to the emergency department to prioritize care based on the severity of their condition),” dated 7/1/2024, at 11:46 a.m., the record indicated that Patient 2 arrived altered (exhibiting changes in awareness, orientation, or behavior that differ from their baseline mental state). The record also indicated that the triage nurse documented that Patient 2 did not have an acute change in mental status (a sudden or rapid alteration in cognition, behavior, or consciousness compared to the patient’s normal baseline) and assigned an ESI level 3 to Patient 2 (The Emergency Severity Index [ESI] is a five-level triage tool used in emergency departments to categorize patients based on the severity of their condition and the resources they are likely to require. ESI Level 3 indicated a patient required urgent attention but remained stable [the patient’s condition is not rapidly changing or life-threatening]). During an interview on 11/13/2024 at 10:43 a.m. with the Emergency Department Supervisor (EDS), the EDS reviewed Patient 2’s “Triage Assessment” record, dated 7/1/2024, and stated that the triage nurse, in the section where it was asked, “Does the patient have an acute change in mental status?” marked the answer as “no.” The EDS stated, that if a patient arrives with altered mental status (a significant deviation from the patient’s baseline mental state), the triage nurse should have marked the box as “yes,” and assign Patient 2 an ESI level 2 (indicating a high-risk, more critical condition requiring immediate care). The EDS further stated that the ESI level was crucial because it determines the urgency of the patient’s care, and the priority of resources needed. An incorrect ESI level can delay timely evaluation and treatment, potentially worsening the patient’s condition. During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Care,” dated 7/2023, the P&P stated that the Registered Nurse (RN) will carry out the nursing process by following the Standards of Nursing Practice. These include: 1.A.1. Assessment: The process of identifying and collecting information concerning the health status of assigned patients. 1.A.3. Organization of Information: The organization of information should be conducted in a manner that promotes accuracy. During a review of the facility’s policy and procedure (P&P) titled, “Documentation in the ED Patient Care Record,” dated 10/2023, the P&P indicated that triage classification should utilize the Emergency Severity Index (ESI) algorithm to ensure quality and accurate documentation. 4. During a review of Patient 6’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/28/2024, the “H&P” indicated that Patient 6’s past medical history included diabetes (a disease that occurs when the body is unable to regulate the amount of sugar in the blood) and hypertension (high blood pressure). Patient 6 was admitted to the facility on 9/28/2024 for generalized weakness and decreased oral (by mouth) intake for a few days. The H&P further indicated, “Patient (Patient 6) recently discharged from (name of another facility) after testing positive for COVID (Coronavirus disease [COVID-19] is an infectious disease caused by a virus, causing respiratory illness). Patient (Patient 6) reports congestion (when mucus builds up in the lungs making it difficult to breathe) and says he has been eating less ...” During a concurrent interview and record review on 11/12/2024 at 2:30 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s electronic medical record (EMR, digitizes a patient’s paper chart. It collects the patient’s history of conditions, tests and treatments) titled, “Nursing Notes,” dated 10/4/2024 at 5:15 a.m., was reviewed. The nursing notes indicated Patient 6 sustained an “unwitnessed fall [unplanned descent to the floor with or without injury to the patient)” Observed on the floor, right side of the bed, sitting on buttocks during rounds ...” During a concurrent interview and record review on 11/13/2024 at 9:35 a.m. with the Quality Assurance Nurse (QAN), Patient 6’s EMR titled, “Pain Assessment,” dated 10/4/2024, was reviewed. QAN verified that there was no pain assessment completed after Patient 6 fell on 10/4/2024 at 5:15 a.m. until 8:00 a.m. when a routine every 4 hours assessment was done indicating Patient 6 had no pain. During a concurrent interview and record review on 11/13/2024 at 11:00 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s EMR titled, “Nursing Notes,” documented by RN 17, dated 10/5/2024 at 6:45 p.m., was reviewed. The nursing notes indicated, “PT (Patient 6) reports right sided hip pain. Unable to assess further details due to mentation change. New order received for hip x-ray (a type of medical imaging that uses radiation to take pictures of the inside of the body). Will enter and carry out order.” CNS 3 verified there was no assessment for pain using a nonverbal pain tool which will not require Patient 6 to verbalize the pain. During a concurrent interview and record review on 11/13/2024 at 11:05 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s EMR titled, “Nursing Notes,” documented by RN 6, dated 10/7/2024 at 7:59 p.m., was reviewed. The nursing note indicated, “PT’s (Patient 6’s) daughter asked about pain medication because patient complained whole body ache during night.” CNS 3 confirmed there was no documentation of intervention implemented to address Patient 6’ pain. During a concurrent interview and record review on 11/13/2024 at 11:10 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s EMR titled, “Medication Administration Record (MAR, a report detailing the drugs administered to a patient) dated from 10/4/2024 through 10/7/2024, was reviewed. There was no pain medication order for Patient 6. CNS 3 stated it was important that patient’s pain be addressed. CNS 3 stated the RN should assess for pain intensity, location of the pain, if there are relieving factor, and use a scale that is appropriate for the patient to document the level of pain, call the physician for pain medication, and reassess after administration of pain medication to see if this is working. CNS 3 stated, “the RN failed to do these.” During a review of the facility’s policy and procedure (P&P) titled, “Pain Management,” dated April 2023, the P&P indicated, “(Name of the facility) respects and supports the rights of patients to safe, timely, and effective pain management. We place emphasis on improving the outcomes of pain management including comfort, managing side effects and complications, and patient satisfaction. Patient age, developmental status, physical, emotional, cultural, spiritual, and cognitive condition and preferences shall be considered. Patient participation in the pain management process is imperative and expected. The single most reliable indicator of the existence and intensity of pain is the patient’s self-report. A comprehensive pain assessment is conducted as appropriate to the patient’s condition and the scope of care, treatment, and services. Patients will define their goals for pain relief and participate in a plan of care to achieve these goals. Behavioral and physiological indicators are important indices for assessment of pain in patients unable to self-report. Assess for pain using a pain scale (numeric, visual analog, or text based) consistently as follows: With each new report of pain ... Pain intensity will be assessed using one of the following pain scales consistently according to age and developmental level as appropriate: Neonatal Infant Pain Scale, FLACC Behavioral Scale, Pain Faces Scale, Numeric Pain Intensity Scale, CPOT tool can be used to assess intubated or sedated patient pain based on facial expressions, muscle tension and movement as well as compliance with ventilated breaths for intubated patient or vocalized pain for non-intubated patients.” During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated July 2023, the P&P indicated, “Each patient will have an initial assessment completed upon admission based on unit-specific parameters and interdisciplinary variables. The initial assessment is documented on the Admission Assessment form. Assessment and reassessment information includes the patient’s perception of the effectiveness of, and any side effects related to medications. e.g., relief of symptoms of nausea or pain. Reassessment occurs at regular intervals and will be defined by each discipline, based on the patient’s diagnosis, care setting, significant changes in condition, and response to any previous care in order to determine the patient’s response to intervention...” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated July 2023, the P&P indicated, “to provide all patients with ongoing assessment of their physical and emotional needs during the nursing process. which is defined as the ongoing assessment planning and implementation and evaluation of a patient’s care. Based on these processes, the practice of nursing shall be in compliance with hospital policies, protocols, and procedures. Quality, productivity, and responsiveness, to the needs of patients, physicians, and employees are foundational to such care. The RN will carry out the nursing process by following the Standards of Nursing Practice: Assessment: This is the process of identifying and collecting Information concerning the health status of assigned patients on the unit. assessment is to be complete, continuous, and systematic... Information obtained from the patient family and other caregivers on the unit, from other departments and from the community... Assuming responsibility and accountability for ensuring that a stated 1eve of quality is maintained as it relates to individual patents.” 5. During a review of Patient 6’s electronic medical record (EMR, digitizes a patient’s paper chart. It collects the patient’s history of conditions, tests and treatments) titled, “Emergency Department Report,” dated 9/28/2024, the report indicated, “Presenting with generalized weakness and decreased oral intake for a few days. Per family, the patient was discharged from (name of another facility) two weeks ago for a fall (an unplanned descent to the floor with or without injury to the patient) ...” During a concurrent interview and record review on 11/12/2024 at 2:30 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s EMR titled, “Nursing Notes,” dated 10/4/2024 at 5:15 a.m. was reviewed. The nursing notes indicated Patient 6 sustained an “unwitnessed fall.” Observed on the floor, right side of the bed, sitting on buttocks during rounds ...” During a concurrent interview and record review on 11/12/2024 at 2:49 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s EMR titled, “Morse Fall Scale (MFS), a quick tool to identify patients at risk for falling, including history of falling, secondary diagnosis, ambulatory (related to walking) aids (example: cane), intravenous therapy, gait abnormalities (the pattern of how a person walks), and mental status, with the scores summed from 0 to 125, with higher scores indicating a higher risk for falling. A low fall risk score is 0-24, a moderate fall risk score is 25-44, and a high fall risk score is 45 and above (or falls during hospitalization), dated from 10/2/2024 through 10/5/2024, was reviewed. The flowsheet indicated the following: -On 9/30/2024 at 8:00 a.m., MFS total score was 85, indicating a high fall risk: history of fall within 12 months (score 25), secondary diagnosis (score 15), ambulatory aids used (scored 15), intravenous (medication administered into the vein) therapy (scored 20), gait impairment (scored 10), and mental status was oriented to own ability (scored 0). On 10/1/2024 at 8:00 p.m., the MFS score that was assigned was 75, indicating a high fall risk and indicating Patient 6 had a fall history. -On 10/2/2024 at 8:00 p.m., the MFS score that was assigned was 50; although indicating a high fall risk, the MFS score did not account for Patient 6 having a fall history. CNS 3 stated, “Patient 6’ had fallen at home prior to admission to the facility.” CNS 3 stated this should be documented “yes,” for the history of fall in the MFS, which will make the MFS score total at 85. CNS 3 stated when the fall history is not documented, there is a potential for the overall score to put the patient at low fall risk, and thus the intervention would not meet Patient 6’s safety needs. -On 10/3/2024 at 8:00 p.m., the MFS score was assigned was 50; although indicating a high fall risk, the MFS score did not account for Patient 6 having a fall history. -On 10/4/2024 at 8:00 p.m., the MFS score assigned was 50; although indicating a high fall risk, the MFS score did not account for Patient 6 having a fall history (CNS 3 confirmed that Patient 6 fell prior to admission and sustained a fall while in the facility on 10/4/2024). CNS 3 also verified that there was no reassessment using the MFS tool when Patient 6 fell on 10/4/2024 at 5:15 a.m. -On 10/5/2024 at 8:00 p.m., the MFS score assigned was 50, although indicating a high fall risk, the MFS score did not account for Patient 6 having a fall history (CNS 3 further confirmed that Patient 6 fell prior to admission and sustained a fall while in the facility on 10/4/2024). During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction, “dated June 2023, the P&P indicated, “To establish a framework for assessing risk factors for patient falls, reducing the risk of falling, and protecting patients from injury if a fall should occur. Patient safety will be maximized through appropriate risk assessment, fall prevention, reduction, and protection in the event of a fall. On admission to the hospital system, a nurse will complete a fall risk screening tool such as the Morse Fall Scale and document this assessment and score on the screening tool. Intervention will be planned, implemented, and documented according to each patient’s risk level and individual needs. These will be documented within the interdisciplinary plan of care. Follow-up Assessment/Screening: Each patient will be reassessed for fall every shift or as needed with a change in status. This will be documented on the fall risk screen tool in the EMR, and the interdisciplinary plan of care will be updated/modified as needed. Repeat Morse Fall Scale screening in the EMR if changes in risk factors occur. Post Fall Management: Complete post fall assessment in the EMR ...” 6. During a review of Patient 6’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/28/2024, the “H&P” indicated that Patient 6’s past medical history included diabetes (a disease that occurs when the body is unable to regulate the amount of sugar in the blood) and hypertension (high blood pressure). Patient 6 was admitted to the facility on 9/28/2024 for generalized weakness and decreased oral intake for a few days. The H&P further indicated, “Patient (Patient 6) recently discharged from (name of another facility) after testing positive for COVID (Coronavirus disease [COVID-19] is an infectious disease caused by a virus, causing respiratory illness). Patient (Patient 6) reports congestion (when mucus builds up in the lungs making it difficult to breathe) and says he has been eating less ...” During a concurrent interview and record review on 11/12/2024 at 2:49 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s electronic medical record (EMR, digitizes a patient’s paper chart. It collects the patient’s history of conditions, tests and treatments) titled, “Nursing notes,” documented by RN 19, dated 10/6/2024 at 2:54 a.m., were reviewed. The nursing note indicated, “critical lab (laboratory) troponin of 80 at 2:54 a.m. MD attempt twice. No response. Will attempt again.” Another note documented by RN 19 on 10/6/2024 at 3:25 a.m. indicated, “Critical lab. HGB (hemoglobin, a protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) 6.6 HCT (hematocrit, the percentage by volume of red cells in your blood) 20.4. Packed RBCs ready to transfuse.” CNS 3 stated there were no documents indicating what happened after RN 19 attempted twice to reach the physician and was unsuccessful; there was no documentation indicating if the physician was notified after several attempts between 2:54 a.m. on 10/6/2024 until 8:59 a.m. on 10/6/2024. CNS 3 stated on 10/6/2024 at 9:00 a.m., during physician rounding (over 6 hours later) that a nursing note by RN 7 indicated, “(name of MD 5) here to see patient.” During a concurrent interview and record review on 11/12/2024 at 3:00 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s EMR titled, “Nursing notes,” documented by RN 6, was reviewed and indicated the following: -On 10/6/2024 at 5:51 p.m., the nursing note indicated, “Received call from lab for critical value. H (HCT, hematocrit, a percentage by volume of red cells in your blood)/H (HGB, a protein contained in red blood cells that is responsible for delivery of oxygen to the tissues) is 7.6 and 20.6. Will notify NP or MD.” -On 10/6/2024 at 5:55 p.m., the nursing note indicated, “Tried paging (name of nurse practitioner [NP 1]) regarding H/H result; however, we do not have contact information. Confirmed with charge nurse. Tried paged (name of [MD 7]) regarding H/H result; however, phone number is not in service. Paged (name of gastroenterology [physician specializing in structure, functions, diseases, and pathology of the stomach] [MD 8]) regarding H/H result and further intervention. Left voice message.” -On 10/6/2024 at 6:15 p.m., the nursing note indicated, “Call (Name of primary physician [MD 5]) regarding H/H result. Operator told (name of another physician [MD 6]) to cover tonight. Paged (MD 6 name) and informed GI (gastrointestinal) bleeding and H/H result, he (MD 6) does not want to transfuse him and page again GI staff.” CNS 3 verified that Patient 6 received one unit of PRBC (packed red blood cells) for hemoglobin of 6.2 (normal range of hemoglobin for adult men is 13.5 to 17.5 g/dL) on 10/7/2024 at 1:13 a.m. (over 7 hours after initial critical H/H). CNS 3 stated, “Nursing staff did not follow the facility policy and process when notifying the physician of a critical lab value.” CNS 3 stated the process was to follow the chain of command (crucial for ensuring patient safety by providing a structured process for staff to escalate concerns about patient care, report issues, and seek necessary interventions through a clear hierarchy of authority, ultimately leading to better decision-making and addressing problems promptly when they arise) when nursing staff was unable to reach the physician. During an interview on 11/14/2024 at 9:55 a.m. with Registered Nurse (RN) 8, RN 8 stated RN 8 had been working in the ICU unit for about eight years. RN 8 stated, “It is important that when a critical lab value is received, the nurse call the physician immediately, within 15 minutes.” RN 8 further stated if the RN was unable to reach the physician, they (the nursing staff) will notify the charge nurse, and the charge nurse will notify the house supervisor, who will be able to contact the physician directly. RN 8 stated that when the patient has a critical lab value, such as low hemoglobin, it may indicate that the patient requires immediate intervention. During a review of the facility’s policy and procedure (P&P) titled, “Chain of Command, “dated July 2023, the P&P indicated, “To provide a process to facilitate prompt resolution of problems related to patient care, medical practice, emergency call schedule, or interpersonal communication. The physicians manage the medical and surgical care of patients during hospitalization. Registered nurses (RNs) and other associates (including non-nursing disciplines) work collaboratively with physicians to assist the patient in reaching optimal health outcomes during their hospital stay. In situations requiring acute medical care and the presence of a physician, it will be the responsibility of the RN or other associates (including non-nursing disciplines) caring for the patient to contact the treating primary or on-call physician immediately and report the condition of the patient. If unable to elicit timely (specified time frame) and appropriate physician response, the RN or other associates (including non-nursing disciplines) shall implement the chain of command. In situations where a conflict exists related to patient care, it is the responsibility of the RN or other associates (including non-nursing disciplines) involved to discuss the issue with the treating physician. If unable to resolve the conflict, the RN or other associates (including non-nursing disciplines) shall implement the chain of command. The Chain of Command policy shall serve as a guideline for associates to use in order to facilitate patient care or problem resolution. In the event that a problem cannot be resolved between the RN or other associates (including non-nursing disciplines) and the treating physician or on-call physician cannot be contacted, the RN or other associates (including non-nursing disciplines) will communicate with their immediate supervisor. If the immediate supervisor is unable to resolve the issue, then (s)he will contact the department director and/or administrative house supervisor ...” During a review of the facility’s policy and procedure (P&P) titled, “Critical Values,” dated July 2023, the P&P indicated, “Critical test results must be communicated via telephone or in person immediately to a licensed health care professional taking care of the patient. The receiving person must read back the result to the caller ... If the physician does not respond within 30 minutes, the chain of command is activated. Action taken and/or physician’s response/order is written in the physician orders sheet. All critical test results will be communicated to the appropriate provider within one hour of the test results being received. 7. During a review of Patient 5’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 7/10/2024 at 10:50 a.m., the H&P indicated Patient 5 was admitted to the facility on 7/10/2024 at 3:38 a.m. with a diagnosis of urinary tract infection (an infection in any part of the urinary system such as the bladder [stores the urine before it leaves the body), urethra [the tube that lets urine leave the bladder and the body], etc.). During a concurrent interview and record review on 11/14/2024 at 10:00 a.m. with the Clinical Nursing Supervisor 5 (CNS 5), Patient 5’s medical record, was reviewed. CNS 5 verified the following information within Patient 5’s medical record: Patient 5’s “Initial Skin Assessment,” dated 7/10/2024 at 6:42 p.m., indicated Patient 5 had left and right buttocks pressure injuries (localized damage to the skin or soft tissue caused by prolonged or severe pressure, often over a bony part of the body) on admission. Patient 5’s “Admission Initial Assessment,” dated 7/11/2024 at 3:06 p.m. indicated a Skin Assessment (Braden, a tool used to assess a patient’s risk of developing pressure injuries) Score of 13 (moderate risk for pressure injuries). The CNS 5 verified there was no documentation of turning and repositioning (to change someone’s body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) for the following dates and times: 7/13/2024 2:00 p.m. through 8 p.m.; 7/14/2024 4:00 a.m. through 8 p.m. The CNS 5 further verified there was no documentation of Patient 5’s refusal of turning and repositioning or that Patient 5 was off of the unit. During the same concurrent interview and record review on 11/14/2024 at 10:00 a.m. with the Clinical Nursing Supervisor 5 (CNS 5), the CNS 5 stated the following: The standard of care was to turn and reposition all patients every 2 hours. Patient 5 should have been turned and repositioned every 2 hours. It was important to turn Patient 5 every 2 hours to ensure Patient 5’s existing wound did not worsen and to prevent new wounds. Turning and repositioning every 2 hours promoted wound healing and comfort. During a review of Patient 4’s “Wound Care Nurse” Progress Note, dated 7/13/2024 at 8:35 p.m., the progress note indicated “Sacrogluteal (buttock [butt] area); unstageable pressure injury (the base of the injury cannot be seen due to a layer of dead tissue and is unable to be staged [to determine the severity of the injury]) present on admission; measurement 10x12 cm (a unit of measurement) ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated, “ ...Patient Rights 1. Considerate and respectful care, and to be made comfortable ...” During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity,” dated 7/2024, the P&P indicated, “ ... Risk Prevention: ...B. Turning and Repositioning: ...1) Reposition patient at least every 2 hours ... clarify and document any limitations per physician or any patient refusal ... Braden Scale Score: Moderate risk 13-14; Prevention action: ...turning schedule ...” 8. During a concurrent observation and interview on 11/12/2024 at 3:00 p.m. with Charge Nurse 1 (CN 1), Patient 9’s door was observed to have a seizure precaution (safety measures taken before a patient experiences seizure [a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness]) signage. Patient 9 was in bed, awake and alert, with two upper side rails of the bed raised and padded. Patient 9’s two lower side rails of the bed were down with no pads. CN 1 stated Patient 9 was on seizure precaution and acknowledged only two upper side rails were padded. During a review of Patient 9’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/10/2024, the H&P indicated Patient 9 was admitted to the facility with chief complaints of alcohol withdrawal (a set of symptoms that can develop if you stop or significantly reduce alcohol intake after a long term use) and left shoulder pain. The H&P further indicated Patient 9 had a past medical history of seizures and non-compliant with Keppra (medication used for seizure) medication. During an interview on 11/15/2024 at 10:08 a.m. with Clinical Nurse Supervisor 1 (CNS 1), CNS 1 stated a patient with history of seizure should be on seizure precaution with four of the side rails raised and padded for patient safety to prevent injury to the patient during seizure activity. During a review of patient 9’s medical record on 11/15/2024 at 10:57 a.m., with CNS 1, CNS 1 verified that Patient 9 had an order for seizure precautions on 11/09/2024. CNS 1 further stated, seizure precaution interventions should be implemented in case the patient would have a seizure episode. During an interview on 11/14/2024 at 3:19 p.m. with the Performance Improvement Coordinator (PIC), the PIC stated for seizure precaution policy and procedure, the facility follows the seizure precaution protocol (a set of instructions that describe how to care for patients with specific conditions). During a review of the facility’s protocol titled, “Initiating Seizure Precautions for Adults,” undated, the protocol indicated, “Implementing seizure precautions reduces risk of seizure-related injuries. Seizure precautions modify the patient’s environment, so the patient remains as safe as possible if a seizure occurs...Collect information about patient’s risk for seizures ...Place padding around headboards, footboards, and side rails, if patient is at risk for generalized seizures.” During a review of the facility’s protocol titled, “Managing Seizure in Adults in the Hospital,” updated, the protocol indicated, “3. Assess patient’s risk for seizures upon admission and throughout inpatient stay as appropriate ...4. Implement seizure precautions...b. Place padding around side rails, headboard, and footboard of bed. Keep upper side rails up.” 9. During a review of Patient 20’s “History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 11/2/2024, the H&P indicated Patient 20 was admitted to the facility with chief complaint of status post (after) fall (an unplanned descent to the floor with or without injury to the patient). During a concurrent observation and interview on 11/12/2024 at 2:00 p.m. with Registered Nurse (RN) 15, Patient 20’s room was observed to have a “falling star (indicates the patient was at high risk for fall)” signage by the door. RN 15 stated the falling star signage indicated the patient (Patient 20) was at risk for fall. RN 15 stated fall risk interventions included a signage on the patient’s room, bed alarm, and the patient wearing the yellow wrist band and yellow socks. During an observation on 11/12/2024 at 2:00 p.m., Patient 20 was observed in bed, alert and oriented. Patient 20 was not wearing yellow socks, and the bed alarm was turned off. RN 15 stated Patient 20’s bed alarm should be turned on to alert us (the staff) when Patient 20 gets out of bed to ensure close monitoring to prevent a fall. RN 15 further stated Patient 20 should wear yellow socks as a visual reminder that the patient was a high fall risk patient. During a concurrent interview and record review on 11/14/2024 at 3:47 p.m. with the Clinical Nursing Supervisor (CNS) 1, CNS 1 verified Patient 20’s “Morse fall scale (a tool use to assess a patient’s risk of falling),” score on 11/12/2024 at 8:00 a.m., was 60 (High risk score is 45 and above). CNS 1 stated it was important for Patient 20 to have yellow socks and for the bed alarm to be activated for the patient’s safety. During a review of Patient 20’s “Fall Risk Checklist,” dated 11/12/2024, the checklist indicated, “bed alarm on, patient (Patient 20) is high risk for fall, appropriate footwear for patient ...” However, based on observation on 11/12/2024, the bed alarm was not activated, and the patient (Patient 20) did not have the yellow socks on. During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction,” dated 7/2023, the P&P indicated, “Patient safety will be maximized through appropriate risk assessment, fall prevention, reduction, and protection in the event of a fall ...Interventions will be planned, implemented, and documented according to each patient’s risk level and individual needs. These will be documented within the interdisciplinary plan of care ...All patients identified as high risk for falls (as defined by the fall risk screen tool) will have the following measures initiated ...Place a fall risk armband ...Non-skid yellow socks applied ...Bed alarm activated etc.” 10. During a concurrent observation and interview on 11/12/2024 at 11:30 a.m. with the Director of Emergency Department (DES), Crash Cart 2 (a wheeled container carrying medicine and equipment for use in emergency resuscitations [procedure used to restart a patient’s breathing and heartbeat when they have stopped]) was observed in the Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions). Crash Cart 2 was missing a cardiac backboard (rigid surface used to support a patient during a cardiopulmonary resuscitation [CPR, a life-saving emergency procedure that combines chest compressions and rescue breathing to help someone who is not breathing, or heartbeat has stopped]). The DES stated the cardiac backboard should be attached to the front of the emergency crash cart. The DES stated he needed to figure out what happened to the cardiac board of Crash Cart 2. During the same interview and record review on 11/12/2024 at 11:30 a.m., the DES verified Crash Cart 2’s “Emergency Department Crash Cart Checklist” log dated 11/2024, included the items needed to be checked: Cart lock number, defibrillator (device that apply an electric charge to the heart to restore a normal heartbeat), CPR record forms, gloves/sharps container (a puncture-resistant container used to safely dispose of sharp objects such as needles, lancets, etc.), ambu bag (handheld device used to help patient breathe when not breathing) / oral airway, crash cart expiration date, high suction machine, and oxygen tank. The DES stated emergency crash carts were checked daily to verify everything was working properly and readily available in case of emergency. During a concurrent interview and record review on 11/15/2024 at 9:43 a.m., with the DES, the DES verified Crash Cart 2’s “Emergency Department Crash Cart Checklist” log, dated 11/2024, did not include daily check of cardiac board present in the cart. The DES stated, the checklist log needed to be updated to include checking of the cardiac backboard. The DES further stated the cardiac backboard was important for an effective chest compression during CPR. During a review of the facility’s policy and procedure (P&P) titled, “Crash Cart Checks,” revised December 2023, the P&P indicated the following: - “A crash cart checklist will be used to check the emergency cart daily and after each use. Daily, a licensed staff member will use the Crash Cart Check list to verify that the cart is locked and all unsecured equipment on top and side of cart are present and ready for use.” - “After a Code Blue or an emergency requiring use of Crash Cart, the licensed staff member will: [ ...] 3. Close cart drawers and bins. Replace cardiac board in its housing on front of the cart and engage red latch downward to secure cart.””

“STANDING ORDERS FOR DRUGS CFR(s): 482.23(c)(1)(ii ),(c)(3) & (c)(3)(iii) (ii) Drugs and biologicals may be prepared and administered on the orders contained within pre-printed and electronic standing orders, order sets, and protocols for patient orders only if such orders meet the requirements of §482.24(c)(3). (3) With the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders in accordance with State law and hospital policy, and who is responsible for the care of the patient as specified under §482.12(c) ... This Standard is not met as evidenced by: 46333 Based on interview and record review, the facility failed to: 1. Ensure that for one patient out of 34 sampled patients (Patient 3), the ordered medications-Colace (a stool softener taken orally), Mag-Al Plus (a magnesium-aluminum-based oral laxative used to relieve constipation and reduce stomach acid), and Dulcolax suppository (a rectal medication that stimulates bowel movements to alleviate constipation)-were administered on an as-needed basis (PRN; a medical directive to provide medication only when symptoms or conditions, such as constipation, are present and require intervention), in accordance with the physician’s order, when indicated, and in alignment with the facility’s nursing standard of care. This deficient practice had the potential to compromise Patient 3’s overall health and well-being, leading to worsened constipation, increased discomfort or pain, and progression to more severe complications such as bowel obstruction (a serious condition where the intestine is partially or completely blocked, preventing the normal passage of stool, gas, or fluids, which can cause severe pain, nausea, and vomiting) or impaction (a condition where hardened stool becomes lodged in the rectum, making it extremely difficult or impossible to pass without medical intervention). 2. Ensure one of 34 sampled patients (Patient 6’s), was administered a PRN (as needed) Levophed (norepinephrine bitartrate, a prescribed medication used to treat life-threatening low blood pressure) when Patient 6’s mean arterial pressure (MAP, the average blood pressure during a single cardiac [heart] cycle) was at 53 (on 10/7/2024 at 9:00 a.m.), below 65 mmHg (millimeters of mercury, unit of measurement), as ordered by the physician. This deficient practice resulted in a delay in the intervention that was prescribed to prevent low blood pressure for Patient 6 and likely contributed to a code blue (an overhead page to summon trained staff to a patient having a medical emergency, usually cardiac [heart] or respiratory [breathing] arrest [when breathing stops or when the heart stops beating]) being called. Findings: 1. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient’s current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic encephalopathy (a sudden worsening of brain function). During further review of Patient 3’s H&P, dated 9/9/2024, the H&P indicated that Patient 3 was non-verbal (unable to communicate using spoken words) and that Patient 3’s dementia had been progressively worsening, leading to significant weight loss. The H&P also noted that Patient 3’s past medical history (PMH) was obtained from Patient 3’s caregiver, who reported that Patient 3 had been chewing on and swallowing parts of blankets. The caregiver expressed concern that this behavior might be causing a blockage in Patient 3’s intestines and noted that Patient 3 had been experiencing constipation for the past four days (prior to admission on 9/9/2024). During a concurrent interview and record review on 11/15/2024 at 9:56 a.m. with the Quality Assurance Nurse (QAN), Patient 3’s medical record (MR) titled, “Bowel Movements (a section of the medical record used to document the frequency, consistency, and characteristics of a patient’s bowel movements to monitor digestive health and identify potential issues such as constipation or diarrhea [loose stool]).” was reviewed. The record, dated 9/10/2024 through 9/13/2024, indicated that Patient 3 had no recorded bowel movements during that time period (9/10/2024 to 9/13/2024). The QAN stated that nursing documentation indicated that Patient 3 was constipated. During a concurrent interview and record review on 11/15/2024 at 10:43 a.m. with the Quality Assurance Nurse (QAN), Patient 3’s medical record (MR) titled, “Medication Administration Record (MAR),” dated 9/10/2024, was reviewed. The QAN stated that Patient 3 had three standing orders (pre-approved medical directives that allow medications or treatments to be administered under specific conditions without requiring additional physician authorization) for the following medications: 100 milligrams (mg, measuring unit) Colace (a stool softener to be administered orally twice a day, as needed [order date 9/9/2024]), 30 milliliters (ml, measuring unit) Mag-Al Plus (a magnesium-aluminum-based oral laxative used to relieve constipation and reduce stomach acid, to be given orally as needed, daily [order date 9/9/2024]), and 10 mg Dulcolax suppository, a rectal (anal route) medication that stimulates bowel movements to alleviate constipation) to be given as needed, daily [order date 9/10/2024]) to be administered for constipation as needed (PRN, a medical abbreviation for “pro re nata,” meaning the medication should be administered only when the patient’s condition or symptoms indicates a need). During the same interview on 11/15/2024 at 10:43 a.m. with the Quality Assurance Nurse (QAN), the QAN further stated that the MAR contained no record indicating that the medications were administered to Patient 3 at any time from 9/10/2024 through 9/13/2024. The QAN then stated, “Assessing patient needs, such as constipation, falls under the standards of nursing care (the level of professional nursing practice expected in providing safe, effective, and ethical care based on developed recommendations for patient care that are based on the best available research, clinical expertise, and patient values, facility policies, and the needs of the patient). It is expected of nursing staff to assess patient needs and address them by administering medications to relieve constipation, especially when there are PRN standing orders in place.” During an interview on 11/15/2024 at 11:51 a.m. with the Director of Medical-Surgical Unit (DMS) [a hospital department that provides care for a wide variety of patients recovering from surgery or managing other illnesses], the DMS stated the following: “When nurses complete their head-to-toe assessments (a systematic and comprehensive physical evaluation of a patient from head to toe, assessing all major body systems to identify any issues, monitor changes, and prioritize care needs), if they determine that the patient was constipated, they should review the physician’s orders to see if any medication can be administered and educate the patient about the condition. This is part of their assessment and intervention, especially if there was a standing PRN order. Nurses should ask the patient about their bowel movements and assess the patient every shift. For confused patients, nurses should monitor their bowel movements as part of their care. If a patient has not had a bowel movement for an extended time during their stay, the nurse should determine whether a laxative (medication used to relieve constipation by stimulating bowel movements or softening the stool to make it easier to pass) or other intervention was required. This is part of the nursing standard of care.” During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated September 2023, the P&P indicated that the base standards for nursing practice (the foundational principles and guidelines that ensure consistent, safe, and effective patient care across all nursing activities) govern the provision of patient care throughout the facility’s Nursing Services Department (the organizational unit responsible for delivering nursing care to patients, including the coordination and management of nursing staff and services). The P&P indicated that all patients should receive ongoing assessment of their physical and emotional needs during the nursing process, defined as the ongoing assessment, planning, implementation, and evaluation of a patient’s care. Based on these processes, nursing practice must comply with hospital policies, protocols, and procedures, ensuring responsiveness to the needs of patients, physicians, and employees as foundational to quality care. During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated September 2023, the P&P indicated that the Registered Nurse (RN) was responsible for carrying out the nursing process by identifying and collecting information concerning the health status of assigned patients on the unit. Assessment must be complete, continuous, and systematic, involving a comprehensive psychosocial and physical evaluation of the patient through interview, observation, inspection, palpation, and reports. Additionally, the RN must implement the plan of care necessary to achieve planned, desired outcomes, as evidenced by the delivery of quality nursing care. 2. During a review of Patient 1’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/28/2024, the “H&P” indicated that Patient 6’s past medical history included diabetes (a disease that occurs when the body is unable to regulate the amount of sugar in the blood) and hypertension (high blood pressure). Patient 6 was admitted to the facility on 9/28/2024 for generalized weakness and decreased oral intake for a few days. The H&P further indicated, “Patient (Patient 6) recently discharged from (name of another facility) after testing positive for COVID (Coronavirus disease [COVID-19] is an infectious disease caused by a virus, causing respiratory illness). Patient (Patient 6) reports congestion (when mucus builds up in the lungs making it difficult to breathe) and says he has been eating less ...” During a concurrent interview and record review on 11/12/2024 at 2:49 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s electronic medical record (EMR, digitizes a patient’s paper chart. It collects the patient’s history of conditions, tests and treatments) titled, “Nurses Notes,” documented by Registered Nurse (RN) 2 in the telemetry (continuous heart monitor) unit, dated 10/5/2024 at 1:30 p.m., indicated, “Provider notified of change of mental status (a disruption in how the brain works that causes a change in behavior) and decreased blood pressure.” CNS 3 verified that Patient 6 was transferred to ICU (a unit in a hospital providing intensive care for critically ill or injured patients that is staffed by specially trained medical personnel) on 10/5/2024 due to a drop in blood pressure and decline in mentation (the process of using the mind to consider something carefully). During an interview on 11/13/2024 at 3:34 p.m. by phone with Registered Nurse (RN) 7, RN 7 stated that on 10/7/2024, while assigned as the charge nurse in the ICU, RN 6 approached her in the hallway requesting assistance. RN 7 stated when she got to Patient 6’s bedside, the respiratory therapist (RT, a healthcare provider who helps diagnose, treat and manage conditions that affect your lungs) was placing a non-rebreather mask (a mask that delivers high level of oxygen) on Patient 6. RN 7 confirmed that Patient 6’s mean arterial pressure (MAP, the average blood pressure during a single cardiac [heart] cycle) dropped below 65, but Levophed was not at the bedside and was not administered. RN 7 stated, “Since the patient was transferred from the telemetry (continuous heart monitor) unit to ICU due to low blood pressure, the patient (Patient 6) has a PRN order for Levophed and should be started.” RN 7 further stated the primary physician was paged but had not returned the call, thus the resident (a medical school graduate and doctor in training) was called, and while on the phone with the resident, Patient 6’ lost pulse (rhythm made by the heartbeat), and a code blue was called. During a concurrent interview and record review on 11/14/2024 at 9:06 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s “Vitals flowsheet,” dated 10/7/2024, was reviewed. The flowsheet indicated the following: On 10/7/2024 at 7:30 a.m., the blood pressure was 154/116 and a MAP of 129. On 10/7/2024 at 7:45 a.m., the blood pressure was 129/60 and a MAP of 83. On 10/7/2024 at 8:00 a.m., the blood pressure was 110/65 and a MAP of 80. On 10/7/2024 at 8:30 a.m., the blood pressure was 102/56 and a MAP of 71. On 10/7/2024 at 8:45 a.m., the blood pressure was 117/61 and a MAP of 79. On 10/7/2024 at 9:00 a.m., the blood pressure was 64/46 and a MAP of 53. CNS 3 stated when the MAP dropped below 65, the Levophed should be administered to maintain the MAP above 65. CNS 3 verified that at 9:23 a.m., Patient 6’s MAP dropped to 40 mmHg, and at 9:31 a.m., Patient 6 lost pulse, and a code blue was called. CNS stated when Patient 6 MAP dropped to 53 at 9:00 a.m., “If the patient was on telemetry unit, a rapid response (RRT; when a patient demonstrates signs of imminent clinical deterioration [examples: changes in respiration, blood pressure, heart rate, difficulty breathing, etc.], a team of providers is summoned to treat the patient with the goal of preventing cardiac arrest [heart stop] or death), would be called but in the ICU we don’t call RRT because the team is here in the unit. The ICU nurse may start protocol during RRT in the ICU. During a concurrent interview and record review on 11/14/2024 at 10:10 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6’s “Medication Administration Record (MAR, a report detailing the drugs administered to a patient), dated from 10/5/2024 at 7:00 p.m. through 10/7/24 at 9:41 a.m., was reviewed. The MAR indicated Levophed at 8 mg (milligrams, a unit of measurement) per 250 mL (milliliters, a unit of measurement) to keep MAP (mean arterial pressure, the average pressure in an artery during one cardiac [heart] cycle) greater than 65. The CNS 3 verified that the MAR indicated Levophed was not scanned and administered. CNS stated, “When the patient (Patient 6’s) MAP dropped to 53 (on 10/7/2024 at 9:00 a.m.), the nurse should start the Levophed to maintain the MAP above 65.” During an interview on 11/14/2024 at 11:34 a.m. with Registered Nurse (RN) 6, RN 6 stated that when Patient 6’s daughter reported to RN 6 that Patient 6 looked anxious, RN 6 stated she (RN 6) checked on Patient 6, he (Patient 6) was “desatting (desaturating, saturation of oxygen levels dropping),” so she (RN 6) applied oxygen. RN 6 stated, Patient 6 looked agitated (appearing troubled or nervous), and the blood pressure was dropping. RN 6 further stated she (RN 6) had difficulty getting a reading for the blood pressure, so she (RN 6) asked another nurse (RN 7) to help. RN 6 stated she (RN 6) recalled pulling the Levophed medication and handing the Levophed to another nurse, but she (RN 6) did not recall if the medication was scanned or administered. During a review of the facility’s policy and procedure (P&P) titled, “Standard of Nursing Practice,” dated September 2023, the P&P indicated, “To describe the base standards for nursing practice that govern the provision of patient care throughout the Nursing Services Department at (name of the facility). It 1s the policy of (name of the facility) to provide all patients with ongoing assessment of their physical and emotional needs during the nursing process. which is defined as the ongoing assessment planning and implementation and evaluation of a patient’s care. Based on these processes, the practice of nursing shall be in compliance with hospital policies, protocols, and procedures. Quality, productivity, and responsiveness, to the needs of patients, physicians, and employees are foundational to such care ... The RN will carry out the nursing process by following the Standards of Nursing Practice: Assessment: This is the process of identifying and collecting Information concerning the health status of assigned patients on the unit. assessment is to be complete, continuous, and systematic as evidenced by: The complete psychosocial and physical assessment of the patent through interview. observation inspection, palpation, and reports. Implementation of the plan of care which is necessary to achieve the planned desired outcomes. This is evidenced by delivery quality nursing.” During a review of the facility’s policy and procedure (P&P) titled, “administration of Medications,” dated September 2023, the P&P indicated, “Medications shall be administered according to procedures and guidelines established by the Pharmacy and Therapeutics Committee, as approved, for the limitations on the intravenous administration of medications and the timing of administration of doses.””

“DISCHARGE PLANNING-EVALUATION CFR(s): §482.43(a)(2) Standard: Discharge Planning Evaluation (2)A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to ensure that, for one of 34 sampled patients (Patient 1), the discharge planning evaluation (a process conducted by healthcare providers to identify a patient’s post-hospital care needs, including medical equipment, support services, and living arrangements, to ensure a safe and effective transition from the facility) was completed upon admission, in accordance with the facility’s policy regarding Discharge Planning. In addition, the facility failed to ensure that the discharge planning assessment included a functional assessment (an evaluation conducted to determine a person’s ability to perform activities necessary for daily living and maintain independence) of the patient (Patient 1) and an evaluation of whether the patient (Patient 1) required any specialized durable medical equipment (DME, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane) prior to discharge to a recuperative care facility (a type of transitional housing or facility that provides short-term medical care and supportive services for individuals who are homeless or lack stable housing). This deficient practice resulted in Patient 1 falling shortly and sustaining a fracture (break in the bone) of the left humerus (the long bone that connects the shoulder to the elbow) while Patient 1 was walking to the recuperative care facility after being dropped off by arranged transportation at the discharge destination point. This deficient practice also led to Patient 1 being readmitted to the facility only a few hours after discharge. Findings: During a review of Patient 1’s history and physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/3/2024, the H&P indicated that Patient 1 was admitted to the facility on 7/3/2024 due to an episode of hypoglycemia (low blood sugar). The H&P also indicated that Patient 1 had a past medical history (a record of previous illnesses, conditions, and treatments) of diabetes (high blood sugar levels), but Patient 1 was unable to recall or name the medications Patient 1 was currently taking. During a review of Patient 1’s medical record (MR) titled, Discharge Planning Assessment (an evaluation conducted to identify a patient’s needs for post-hospital care, including living arrangements, medical equipment, follow-up services, and other resources to ensure a safe and effective discharge), the record indicated that there was no documented discharge planning assessment for Patient 1 within the first 24-48 hours after admission (7/3/2024 through 7/5/2024). During an interview on 11/12/2024 at 2:04 p.m. with the Director of Case Management and Social Services (DCM), the DCM stated the following: “Discharge planning starts on admission or within 24-48 hours upon admission to the inpatient. The Case Managers (CM) should do their discharge planning assessment where they assess prior living situation, interview the patient, and assess the need for outpatient services such as home health services, SNF (Skilled Nursing Facility, a healthcare facility providing medical and rehabilitative care), DMEs (Durable Medical Equipment, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane), etc. The CM should round (in-person visit) on patients every day. If there are any changes to the assessment, documentation must be done in the patient’s medical record. The DCM also stated that discharge planning was a collaborative process of a doctor, nurse, and a CM to determine what is the safest disposition (the process of arranging for the patient’s placement or care after discharge) plan, so “we (the multidisciplinary team) start with physical evaluation and can make necessary recommendations.” During a review of Patient 1’s medical record (MR) titled, “Nursing Notes,” dated 7/4/2024, the MR indicated that Patient 1 was identified as homeless on 7/4/2024, and an order for a Social Services Consultation was placed. During a review of Patient 1’s medical record (MR) titled, “Social Services,” dated 7/5/2024 at 12:01 p.m., the MR indicated that a social worker (SW) received a consultation order for “homeless.” The SW met with Patient 1 at the bedside, where Patient 1 confirmed being homeless, stated Patient 1 could walk with assistance from a walker or cane, and expressed agreement to be discharged to recuperative care (a short-term care program designed to provide medical oversight and support for individuals who are homeless or lack stable housing, allowing them to recover from an illness, injury, or surgery in a safe and structured environment). During an interview on 11/14/2024 at 11:17 a.m. with the Manager of Social Services (MSS) regarding the homeless needs assessment, the MSS stated that two very important components of the assessment were the functional mobility, which was the assessment of the patient’s mobility status, and the mental status, which was done to evaluate the patient’s reality orientation to ensure a safe discharge for homeless patients. The MSS then stated that typically, the functional assessment included reviewing the recommendations by physical therapy (PT, therapy focused on improving mobility, strength, and physical function) and occupational therapy (OT, therapy focused on enhancing the patient’s ability to perform daily activities), as well as input from the nurse, to determine the patient’s physical abilities and whether the patient can walk. During a concurrent interview and record review on 11/14/2024 at 11:21 a.m. with the Quality Assurance Nurse (QAN), Patient 1’s medical record (MR), was reviewed. The MR indicated that physical therapy (PT) and occupational therapy (OT) evaluations were not ordered and not conducted for Patient 1 during Patient 1’s stay at the facility from 7/2/2024 through 7/5/2024. The QAN stated that the MR also contained no documentation indicating whether Patient 1 was ambulated (related to walking) during Patient 1’s admission at the facility or whether Patient 1 required a walker or a cane for ambulation. The QAN further stated that on 7/5/2024, at 8 a.m., nursing assessment documentation indicated that Patient 1 had an unsteady gait (a condition characterized by difficulty walking or maintaining balance, often associated with a risk of falls [unplanned descent to the floor with or without injury to the patient]). During a concurrent interview and record review on 11/14/2024 at 11:27 a.m. with the Quality Assurance Nurse (QAN), Patient 1’s medical record (MR), was reviewed. The QAN stated that Patient 1’s medical record contained no documentation indicating that Patient 1 was discharged with a walker or a cane, nor whether a walker or a cane was provided to Patient 1 prior to discharge to the recuperative care facility on 7/5/2024. During an interview on 11/14/2024 at 11:30 a.m. with the Manager of Social Services (MSS) regarding durable medical equipment (DME), the MSS stated that nursing should be responsible for ensuring the patient had the necessary DMEs prior to discharge. During a review of Patient 1’s discharge instructions (DI, written guidelines provided to a patient at the time of discharge outlining care plans, medications, follow-up appointments, and any necessary equipment or resources), dated 7/5/2024, the DI indicated that Patient 1 was discharged on 7/5/2024 and picked up by arranged transportation at 2:23 p.m. The DI contained no record indicating that Patient 1 had a cane, or a walker provided prior to discharge. During a review of Patient 1’s HPI (History of Present Illness, a detailed account of the patient’s current medical issue and symptoms), dated 7/5/2024, at 6:05 p.m., the HPI indicated that Patient 1 was re-admitted to the facility’s emergency department (ED, a hospital unit specializing in the treatment of urgent and acute medical conditions) after being dropped off at a clinic a few hours earlier on the same day (7/5/2024). While walking to the clinic, Patient 1 tripped and fell onto their left side. The HPI further indicated that Patient 1 had fractured their left humerus (the long bone in the upper arm) with evidence of axillary nerve injury (damage to the nerve that runs through the armpit area, controlling the deltoid muscle and providing sensation to part of the shoulder) and had to be re-admitted to the facility on the same day (7/5/2024) for an Open Reduction and Internal Fixation (ORIF, is a surgical procedure used to repair and stabilize a broken bone) of the left humerus (the upper arm bone). During a review of the facility’s policy and procedure (P&P) titled “Discharge Planning,” dated 7/2023, the P&P indicated that discharge planning provides patients with a realistic, coordinated plan for hospital discharge. This plan ensures a smooth and timely transition from one level of care to another while addressing the patient’s overall healthcare needs. The process begins at the time of admission and is a multidisciplinary effort through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. During a review of the facility’s policy and procedure (P&P) titled, “Discharge Planning,” dated 7/2023, the P&P indicated that the hospital must identify, at an early stage of hospitalization, all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The hospital must complete this evaluation on a timely basis to ensure that appropriate arrangements for post-hospital care are made before discharge. During a review of the facility’s policy and procedure (P&P) titled, “Homeless Patient Discharge, Management of,” dated 7/2023, the P&P indicated that to ensure compliance with local ordinances governing homeless patient discharge, the facility must initiate discharge planning upon admission to the hospital or emergency department, recognizing that homelessness is a complex issue requiring early planning. In collaboration with the staff nurse, the social worker shall prepare the patient for discharge and ensure that all necessary steps regarding follow-up clinical care, placement, transportation needs, available local resources, and medication dispensations are addressed.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to include a discharge planning evaluation (an assessment required to identify a patient’s post-hospital needs, including the likelihood of requiring services such as rehabilitation, home care, or follow-up treatment, and the capacity for self-care or support in their living environment, as part of ensuring a safe and effective transition from the hospital) in the medical record for two of 34 sampled patients (Patient 1 and Patient 3), in accordance with the facility’s policy regarding discharge planning when: 1. Patient 1’s discharge planning evaluation was not documented during Patient 1’s admission stay at the facility. Additionally, Patient 1 was not actively engaged in the development of their (Patient 1’s) discharge plan (a detailed plan developed by healthcare providers to ensure a patient transitions safely and effectively from a healthcare facility to their next care setting). This deficient practice resulted in unsafe transition with no continuity of care and unmet post-discharge needs for Patient 1, leading to Patient 1’s re-admission to the facility the same day Patient 1 was discharged (7/5/2024). In addition, this deficient practice violated Patient 1’s right (the right of a patient to participate in decisions about their care, including being informed, consulted, and involved in the planning and implementation of patient’s treatment and discharge plans) to be involved in the development and implementation of their (Patient 1’) discharge plan. 2. Patient 3’s discharge planning evaluation was not conducted or documented in Patient 3’s medical record during Patient 3’s admission at the facility. This deficient practice violated Patient 3’s right to be involved in the development and implementation of their (Patient 3’s) discharge plan. In addition, this deficient practice resulted in Patient 3 being placed at risk for an unsafe transition and unmet post-discharge needs, potentially leading to complications such as readmission, or a decline in health. Findings: 1. During a review of Patient 1’s history and physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/3/2024, the H&P indicated that Patient 1 was admitted to the facility on 7/3/2024 due to an episode of hypoglycemia (low blood sugar). The H&P also indicated that Patient 1 had a past medical history (a record of previous illnesses, conditions, and treatments) of diabetes (high blood sugar levels), but Patient 1 was unable to recall or name the medications Patient 1 was currently taking. During a review of Patient 1’s medical record (MR) titled, “Discharge Planning Assessment (an evaluation or assessment conducted to identify a patient’s needs for post-hospital care, including living arrangements, medical equipment, follow-up services, and other resources to ensure a safe and effective discharge),” the MR indicated that there was no documented discharge planning assessment for Patient 1 within the first 24-48 hours after admission (7/3/2024 through 7/5/2024). During an interview on 11/12/2024 at 2:04 p.m. with the Director of Case Management and Social Services (DCM), the DCM stated the following: “Discharge planning starts on admission or within 24-48 hours upon admission to the inpatient area. The Case Managers (CM) should do their discharge planning assessment where they assess prior living situation, interview the patient, and assess the need for outpatient services such as home health services, SNF (Skilled Nursing Facility, a healthcare facility providing medical and rehabilitative care), DMEs (Durable Medical Equipment, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane), etc. The CM should round (in-person patient visits) on patients every day. If there are any changes to the assessment, documentation must be done in the patient’s medical record. The DCM also stated that discharge planning was a collaborative process of a doctor, nurse, and a CM to determine what is the safest disposition (the process of arranging for the patient’s placement or care after discharge) plan, so “we (the multidisciplinary team) start with physical evaluation and can make necessary recommendations.” The CM also stated that the patient or their family should be involved in their discharge planning process. During a review of Patient 1’s medical record (MR) titled, “Social Services,” dated 7/5/2024, at 12:01 p.m., the MR indicated that on 7/5/2024, a social worker (SW) documented to receive a consultation order for “homeless” (a designation used when a patient is identified as lacking stable, permanent housing, which prompts an evaluation to address their unique needs for post-discharge care, including housing, resources, and medical support). The MR also indicated, the SW met with Patient 1 at the bedside and educated Patient 1 of the importance of recuperative care (programs provide room, board, and medical care coordination in a post acute care setting for people experiencing homelessness who are too ill or frail to recover from a physical illness or injury on the streets or in shelter, but who are not ill enough to be in a hospital). The SW then documented that Patient 1 was agreeable to recuperative care. During a review of the medical record (MR) titled, “Social Services,” dated 7/5/2024, at 12:24 p.m., the MR indicated that the social worker (SW) obtained confirmation of Patient 1 being accepted to [Organization] recuperative care and documented the address where Patient 1 would be going after discharge. However, the SW did not document a discussion with Patient 1 regarding the recuperative care facility, nor did the record indicate that Patient 1 had agreed to go to the particular receiving facility. During a review of Patient 1’s medical record (MR) titled, “Discharge Note-Nurses Note,” dated 7/5/2024, at 2:40 p.m., the MR indicated the following: “Is the patient identified as homeless? If yes, be certain that the Homeless Waiver Form (a document confirming that the patient has been informed of their discharge plan and resources available to them) is signed and witnessed.” During a concurrent interview and record review on 11/14/2024 at 11:35 a.m. with the Quality Assurance Nurse (QAN), Patient 1’s medical chart was reviewed to locate the uploaded Homeless Waiver Form. The QAN stated that Patient 1’s medical chart contained no record of the Homeless Waiver Form completed and signed by Patient 1. During an interview on 11/14/2024 at 11:30 a.m. with the Director of Case Management (DCM) and Manager of Social Services (MSS) regarding the Homeless Waiver Form, both stated that the Homeless Waiver Form was only required when a homeless patient refuses the hospital’s proposed discharge plan. If the discharge plan was accepted, completion of the form was unnecessary. During a review of Patient 1’s HPI (History of Present Illness, a detailed account of the patient’s current medical issue and symptoms), dated 7/5/2024, at 6:05 p.m., the HPI indicated that Patient 1 was re-admitted to the facility’s emergency department (ED, a hospital unit specializing in the treatment of urgent and acute medical conditions) after being dropped off at a clinic (recuperative care facility). While walking to the “clinic?” [clinic was documented with a question mark, indicating uncertainty about the exact location], Patient 1 tripped and fell onto their left side. The HPI further indicated that Patient 1 had fractured (break in the bones) their left humerus (the long bone in the upper arm) with evidence of axillary nerve injury (damage to the nerve that runs through the armpit area, controlling the deltoid muscle and providing sensation to part of the shoulder) and had to be re-admitted to the facility on the same day (7/5/2024) for an Open Reduction and Internal Fixation (ORIF, is a surgical procedure used to repair and stabilize a broken bone) of the left humerus (the upper arm bone). During a review of the facility’s policy and procedure (P&P) titled, “Homeless Patient Discharge, Management of,” dated 7/2023, the P&P indicated the following requirements for treat-and-release homeless patients: 1. An identified discharge plan must be established to ensure that all necessary steps regarding follow-up clinical care, placement, transportation needs, available local resources, and medication dispensations (where appropriate and initiated by the physician) are addressed. 2. The patient must sign a completed Homeless Patient Waiver Form, and this endorsement must be witnessed by two staff members. The P&P also indicated that the facility’s discharge procedure for facilitating homeless patient discharge to any type of facility also requires the following information to be documented in the patient’s medical chart: a. The name of the receiving facility. b. The name of the intake staff at the receiving facility who accepted the homeless patient. c. Confirmation that the patient has agreed to go to the particular receiving facility. d. Documentation indicating that the patient completed and signed the Homeless Patient Waiver form or declined to do so. During a review of the facility’s policy and procedures (P&P) titled, “Discharge Planning,” dated 4/2023, the P&P indicated the following: “ ...Discharge planning begins at the time of admission. It is an interdisciplinary process through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. Discharge planning provides patients with a realistic, coordinated plan for hospital discharge that will ensure a smooth and timely transition from one level of care to another and meet the patient’s overall healthcare needs ... Objectives: ...2. Coordinate all patient care and support services consonant with the attending physician’s plan of care ... 7. Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated that patients have the right to be involved in the development and implementation of their discharge plan. 2. During a review of Patient 3’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient’s current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic encephalopathy (a sudden worsening of brain function). During further review of Patient 3’s H&P, dated 9/9/2024, the H&P indicated that Patient 3 was non-verbal (unable to communicate using spoken words) and that Patient 3’s dementia had been progressively worsening, causing significant weight loss. The H&P also indicated that Patient 3’s past medical history (PMH) was obtained from Patient 3’s caregiver, who stated that Patient 3 had been chewing on and swallowing parts of blankets. During a review of Patient 3’s medical record (MR) titled, “Patient Orders Detail (a section of the medical record that documents physician orders for tests, treatments, or interventions),” dated 9/9/2024, the MR indicated that on 9/9/2024 at 7:15 p.m., the physician placed an order for a Social Service consultation (a service provided to assess and address a patient’s social, emotional, and practical needs related to their medical condition and care). The consultation order included an evaluation and assessment for home safety (ensuring the patient’s living environment is free from hazards and supports their health and mobility) and home health services (medical and non-medical support provided at home, such as nursing care, therapy, or assistance with daily activities). During a review of Patient 3’s medical chart, no record of Social Services consultation was found in Patient 3’s chart. During a concurrent interview and record review on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), Patient 3’s medical record (MR) titled, “Admission Assessment (an initial evaluation conducted upon a patient’s admission to gather detailed information about their medical history, current condition, and immediate needs),” dated 9/10/2024, was reviewed. The MR indicated that Patient 3’s “Discharge Case Manager” score was 4 (a scoring system used to assess the complexity of a patient’s case and their need for case management services, with a score of 4 typically indicating a high level of need for support in planning post-discharge care). The QAN stated that when the discharge assessment score was assessed to be 4, a referral for case management (CM, a collaborative process in healthcare where a professional, typically a case manager, coordinates and oversees a patient’s care to ensure they receive the appropriate services and resources) and discharge planning evaluation (an assessment performed by healthcare professionals to determine a patient’s needs for a safe and effective transition from a hospital or healthcare facility to their next care setting or home) was automatically populated for case management to follow up and conduct the evaluation of the patient’s post-discharge needs. During a concurrent interview and record review on 11/15/2024 at 11:27 a.m. with the Quality Assurance Nurse (QAN), Patient 3’s discharge planning record (DPR, a section of the medical record that documents the assessment, planning, and coordination of services needed to ensure a safe and effective transition from the facility to the next care setting), dated 9/9/2024 through 9/13/2024, was reviewed. The QAN stated that Patient 3’s medical chart contained no documentation indicating that discharge planning had been conducted for Patient 3. During further review of Patient 3’s MR titled, “Case Manager Note,” dated 9/11/2024, the MR indicated that on 9/11/2024 at 4:27 p.m., a case manager (CM) documented in Patient 3’s chart that discharge planning was discussed with the attending physician (the primary doctor responsible for overseeing the patient’s care during their hospital stay and making key decisions about treatment and discharge). During further review of Patient 3’s MR titled, “Discharge Planner (DP)” Note, dated 9/13/2024, the MR indicated that the Discharge Planner (DP) (a healthcare professional responsible for coordinating the discharge process, including arranging post-hospital care, transportation, and necessary follow-up services to ensure a safe transition for the patient) documented that Patient 3 was to be discharged via ambulance (a medical transport vehicle equipped to provide emergency care or non-emergency transportation for patients who are unable to travel independently due to medical conditions). The MR further indicated that the DP found Patient 3’s caregiver at bedside and documented that Patient 3’s caregiver refused to allow Patient 3 to be discharged. However, the MR contained no record explaining why Patient 3’s caregiver refused to allow the discharge. During an interview on 11/15/2024 at 11:51 a.m. with the Director of Medical-Surgical Unit [a hospital department that provides care for a wide variety of patients recovering from surgery or managing other illnesses] (DMS), the DMS stated the following: “Discharge planning is a collaborative effort. We work alongside discharge planners and case managers. It starts at admission, where we determine the best plan for the patient. We have a team huddle every day to discuss the discharge plan for the patient. Case managers (CMs) are typically on the floors to assist with this process. The CM is responsible, along with their team and nursing staff, to ensure that, as a collaborative group, all of us are involved.” During an interview on 11/15/2024 at 1:39 p.m. regarding the lack of discharge planning documentation for Patient 3 during their admission at the facility [9/9/2024 through 9/13/2024], the Director of Case Management (DCM) stated the following: Discharge planning assessments must be completed as required (in accordance with the facility’s policies and federal regulation) and should include a comprehensive evaluation of the patient’s emotional status, living arrangements, prior level of functioning, social support, family involvement, and available resources to identify potential post-discharge needs. The DCM further stated that discharge planning was a collaborative process involving multiple healthcare team members, including the physician (MD) and, most importantly, the patient and/or the patient’s caregiver. The DCM stated that active patient participation in discharge planning was critical, and it should be clearly documented in the medical record that the discharge plan was discussed with the patient and that the agreement was obtained. During the same interview on 11/15/2024 at 1:39 p.m. with the Director of Case Management (DCM), the DCM stated, “I have identified many issues with discharge planning since I started working here about 7 months ago. Challenges I have identified include initial assessments not being completed, the patient’s involvement in discharge planning is lacking, and a lack of communication with the patient and the patient’s family.” The DCM further stated, “It took some time; I had to start by providing a lot of education and resources, as well as sharing contacts. I would bring staff into my office to offer counseling and guidance. I hired a new team of case managers and social workers, ensuring they were equipped with the necessary tools and resources to succeed. My plan is to continue focusing on education to strengthen the team. They had been without a director for a long time, which contributed to the challenges we’re now addressing.” During a review of the facility’s policy and procedures (P&P) titled, “Discharge Planning,” dated 4/2023, the P&P indicated the following: “ ...Discharge planning begins at the time of admission. It is an interdisciplinary process through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. Discharge planning provides patients with a realistic, coordinated plan for hospital discharge that will ensure a smooth and timely transition from one level of care to another and meet the patient’s overall healthcare needs ... Objectives: ...2. Coordinate all patient care and support services consonant with the attending physician’s plan of care ... 7. Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies ...” During a review of the facility’s policy and procedure (P&P) titled, “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated that patients have the right to be involved in the development and implementation of their discharge plan.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 48186 Based on interview and record review, the facility failed to ensure one of 34 sampled patients (Patient 4) received care coordination for cardiac follow-up care prior to discharge (the formal release of a hospitalized individual due to conclusion of the hospitalization stay, either by death, return home, or transfer to another institution), in accordance with the facility’s policy regarding Discharge Planning, when Patient 4 was discharged to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay). This deficient practice had the potential for Patient 4’s pacemaker device (a small, battery-powered device that prevents the heart from beating too slowly) failure, resulting in cardiac (heart) complications including death. Findings: During a concurrent record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), the CNS 3 verified the following in Patient 4’s medical record: Patient 4’s History and Physical (H&P, a physicians formal assessment of a patient’s medical history and current condition), dated 7/22/2024, indicated Cardiology (the branch of medicine concerned with the diagnosis and treatment of heart-related diseases and disorders) was consulted by Medical Doctor 3 (MD 3). Patient 4’s “(Cardiac Electrophysiology [the study of the heart’s electrical activity, including its function, performance, and mechanisms]) Consultation Report (a document that outlines a patient’s condition and the rationale for their treatment),” dated 7/25/2024, indicated Patient 4’s pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) remained in end of battery life since 2/8/2024 and needed battery replacement at [name of the facility]. Patient 4’s “Patient Orders (communicates the medical care that the patient is to receive) Detail,” dated 7/30/2024, indicated an order to discharge (the formal process of a patient leaving a hospital after receiving treatment or care) to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay) and did not indicate any follow-up care. Patient 4’s “Internal Progress Notes,” dated 7/30/2024, did not indicate Patient 4 was medically cleared (a physician, or another health care provider has determined that a person is medically stable) by Cardiology prior to discharge. Patient 4’s “Discharge Summary (a clinical document that summarizes a patient’s hospital stay and care plan so that the patient’s primary care provider can continue their care),” dated 7/30/2024, did not indicate Patient 4 was given follow-up care (the care a patient receives after finishing treatment for a disease or condition) for Cardiology at discharge. There was no documentation Patient 4 had a pacemaker interrogation (a procedure that allows a cardiologist to check the function of a pacemaker) prior to discharge. During a concurrent interview and record review on 11/14/2024 at 3:21 p.m. with the Director of Case Management (DCM) and the Quality Assurance Nurse (QAN), the DCM verified the following in Patient 4’s medical record: The discharge order, dated 7/30/2024 at 9:59 p.m., did not have written follow-up instructions (information relevant to a patient’s medical condition or behavioral health issue that is provided to the patient, the patient’s representative, or a health care institution). The QAN verified there was no follow-up instructions in the discharge summary, dated 7/30/2024, provided by nursing. The DCM stated the following: The case manager coordinated follow-up care for the patient. If a patient needed follow-up care, this would have been in the Physician’s discharge order and incorporated into the discharge instructions for the patient. It is the physician’s responsibility to coordinate the follow-up care and discuss this with the interdisciplinary team. The QAN stated it was important to include follow-up care in the discharge summary so the patient would know where to follow-up and how to manage their care after leaving the hospital. During an interview on 11/15/2024 2:41 p.m. with Medical Doctor 3 (MD 3), MD 3 stated the following: There should have been follow-up information given to Patient 4 at discharge because Patient 4’s safety and health was important. Any conversations with [MD 2] about Patient 4’s medical care should have been documented in the medical record. Follow-up information should have been documented in Patient 4’s discharge summary. During a review of Patient 4’s Face Sheet (gives information at a glance), the Face Sheet indicated Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar). The Face Sheet further indicated Patient 4 was discharged from the facility on 7/30/2024 at 11:30 p.m. During a review of Patient 4’s “History and Physical (H&P),” dated 7/22/2024 at 9:41 a.m., the H&P indicated the following: “Assessment and Plan Notes: ...Cardiology Consulted ...” During a review of Patient 4’s “Cardiology Progress Notes”, dated 7/22/2024; 7/23/2024; 7/24/2024; 7/25/2024; 7/26/2024/; 7/27/2024; 7/28/2024; 7/29/2024; and 7/30/2024, the progress note indicated Patient 4 was not stable for discharge. During a review of Patient 4’s “Internal Medicine Progress Notes,” dated 7/30/2024 at 4:33 p.m., the progress notes indicated the following: “ ...discharge planning to SNF ...” During a review of Patient 4’s “Patient Orders Detail,” dated 7/30/2024 at 9:59 p.m., the orders indicated the following: “Discharge patient to SNF ...” During a review of Patient 4’s “Nursing Discharge Note,” dated 7/30/2024 at 11:41 p.m., the discharge note indicated the following: Patient 4 was discharged from the facility on 7/30/2024 at 11:20 p.m. During a review of the facility’s policy and procedures (P&P) titled, “Discharge Planning,” dated 4/2023, the P&P indicated the following: “ ...Discharge planning begins at the time of admission. It is an interdisciplinary process through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. Discharge planning provides patients with a realistic, coordinated plan for hospital discharge that will ensure a smooth and timely transition from one level of care to another and meet the patient’s overall healthcare needs ... Objectives: ...2. Coordinate all patient care and support services consonant with the attending physician’s plan of care ... 7. Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies ...” During a review of the facility document “Medical Staff: General Rules and Regulations (section of the medical staff bylaws that describes more detailed operational policies for a hospital’s medical staff),” reviewed/revised 10/2024, the Rules and Regulations indicated the following: “ ... 1.8-10. Medical staff are responsible for collaborating with discharge planning personnel to ensure a smooth and effective transition of the patient to an appropriate post-hospital care setting.” During a review of the facility’s policy and procedure (P&P) titled “Patient Rights and Responsibilities,” dated 6/2022, the P&P indicated that “Patients have the right to be informed by the physician, or a delegate of the physician, about continuing healthcare requirements and options following discharge and/or transfer within or outside the hospital.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by: 1a. The facility failed to follow State and Federal regulatory standards regarding safe patient care assignments. Over 50 % of the patient care assignment in one of 3 sampled units (Unit 1) consisted of licensed vocational nurses (LVNs). One registered nurse (RN 5) and two LVNs (LVN 7 and 8) were assigned to perform direct patient care in the Medical Surgical unit (a unit that serves the general population hospitalized for various cases such as surgery, etc.) on 2/6/2024 from 7 a.m., to 7 p.m. This deficient practice had the potential to result in patient needs not being met. (Refer to A - 0392) 1b. The facility failed to ensure Charge Nurse 3 (CN 3) remained free of job duties that prevented CN 3 from fulfilling the functions of the Charge Nurse role for one of one telemetry nursing units (Unit 1, a floor in the hospital where patients receive continuous cardiac [heart] monitoring), when CN 3 was assigned as the Charge Nurse (CN, oversee the operations of their specific nursing unit during a set period while working alongside the team) and at the same time functioned as Monitor Technician (MT, a skilled professional who supports doctors and nurses in interpreting and diagnosing conditions related to the heart by using non-invasive monitor) on Unit 1. This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties, including the supervision of patient care, and operations of the assigned hospital unit. This deficient practice also had the potential to compromise the quality of medical care delivered to patients when the Charge Nurse is not readily available to assist the other nursing staff in case of medical emergencies on the unit. (Refer to A - 0392) 2. The facility failed to provide registered nurse’s oversight over licensed vocational nurses’ assessments for four of 34 sampled patients (Patients 4, 18, 21, 22), in accordance with the facility’s policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVNs without RN oversight and had the potential to result in an inaccurate assessment of patients’ condition and inappropriate provision and plan of care to patients. (Refer to A - 0395) 3a. The facility failed to ensure the call light (a means of communication for patients to their care providers that are outside the patients’ rooms was within reach for one of 34 sampled patients (Patient 3), in accordance with the Patient’s plan of care (provides a framework for evaluating and providing patient care needs related to the nursing process) and the facility’s policies and procedures regarding care plans. This deficient practice had the potential to result in a fall and immediate needs unattended for Patient 3. (Refer to A - 0396) 3b. The facility failed to develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest (the cessation of effective breathing and blood flow) specific to patient’s needs for one of 35 sampled patients (Patient 15). This deficient practice had the potential to result in Patient 15 not receiving the right level of care and not meeting the needs for the identified patient’s concerns. (Refer to A - 0396) 3c. The facility failed to Initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon admission for one of 34 sampled patients (Patient 18). This deficient practice had the potential to result in the delay of treatment by not identifying Patient 18’s needs and risks, which may result in worsening of Patient 18’s condition and prolonged hospitalization. (Refer to A - 0396) 4a. The facility failed to ensure two of six sampled nursing staff (Registered Nurse [RN] 9 and Licensed Vocational Nurse [LVN] 3) had annual skill competency evaluations (assessment of a clinician’s skills, abilities and knowledge to ensure provision of safe and effective care to patients) done. This deficient practice had the potential to result in patients receiving inadequate care and treatment from nursing staff whose competencies were not checked annually. (Refer to A - 0397) 4b. The facility failed to ensure three of three sampled staff (Registered Nurse (RN) 6, RN 7, and Charge Nurse (CN) 4) followed the facility Policy and Procedure regarding emergency termination procedure for hemodialysis machine and were competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) out of 34 sampled patients (Patient 6). This deficient practice had the potential to result in inadequate return of blood from the machine to Patient 6 causing harm or even death during hemodialysis treatment. (Refer to A - 0397) 5a. The facility failed to ensure one of one sampled registered nurse (Registered Nurse (RN) 5) followed the facility’s policy and procedure for putting on (donning) PPE (personal protective equipment, equipment worn to minimize exposure to illness, includes gown, gloves, mask etc.) and removing (doffing) personal protective equipment in taking care of one of 34 sampled patients (Patient 10), who was on contact precaution (interventions taken to prevent transmission of infectious agents). This deficient practice had the potential to spread infection to other Patients on the Unit due to improper donning and doffing of PPEs. (Refer to A - 0398) 5b. The facility failed to ensure one of one sampled staff (Licensed Vocational Nurse [LVN] 13) adhered to the facility’s policy and procedure on the LVN Scope of Practice when LVN 13 administered Methylprednisolone (Solu-Medrol, steroid injection provides relief of inflamed area of the body, lungs and breathing problem such as asthma) intravenously (given into the vein) for one of 34 sampled patients (Patient 22). This deficient practice had the potential for Patient 22 to develop a respiratory problem and reaction from an untrained staff’s improper administration of medication. (Refer to A - 0398) 5c. The facility failed to change enteral (a method of feeding that uses the gastrointestinal [GI, the digestive system consisting of the mouth, throat, stomach, small intestines, etc.] tract to deliver nutrition and calories) feeding container and feeding tube set (feeding tube inserted through an abdominal wall to deliver nutrients directly into the patient’s stomach) after 24 hours of use for one of 34 patients (Patient 15) in accordance with the facility’s policy and procedure regarding enteral feeding and feeding tube set replacement. This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems for Patient 15 such as diarrhea (loose stools), abdominal pain, vomiting, etc. (Refer to A - 0398) 5d. The facility failed to renew an order for restraints (a physical restraint is any manual method, material or equipment that is attached to patient’s body that cannot be easily removed and restricts freedom of movement) use for one of 34 patients (Patient 16) after 24 hours that the restraint was initially ordered. This deficient practice had the potential to violate Patient 16’s rights regarding restraint use, as nursing staff continued documenting the prolonged use of restraints without a physician’s renewal order for restraints. This deficient practice also had the potential to result in patient harm such as skin injury from prolonged and inappropriate use of restraints. (Refer to A - 0398) 5e. The facility failed to label a feeding tube container after initiating tube feeding (a way to provide nutrition for patients who are unable to eat or drink by mouth) to indicate the need for replacement after 24 hours of use and also did not indicate the date, time, and patient’s name when tube feeding container was hanged or initiated for one of 34 sampled patients (Patient 16) in accordance with the facility’s policy and procedure regarding labeling and replacing tube feeding containers after 24 hours from the time the feeding tube container was used. This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems for Patient 16 such as diarrhea, abdominal pain, vomiting, etc. (Refer to A - 0398) 5f. The facility failed to use translator services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when obtaining informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 34 sampled patients (Patient 14). This deficient practice had the potential for Patient 14 not receiving accurate and current information in the language Patient 14 could understand, which may result in Patient 14 not understanding information regarding her (Patient 14) health status and treatment and may delay recovery from illness. (Refer to A - 0398) 6. The facility failed to ensure its nursing staff documented properly and follow medication administration procedure on the electronic Medication Administration Record (eMAR, a record of medications given to patient) after a narcotic (opioids medication for pain relief) was given to one of 34 sampled patients (Patient 21) per facility Policy and Procedure. This deficient practice had the potential to put Patient 21 at risk for overdose on narcotics as it was not recorded on the electronic Medication Administration Record properly. (Refer to A - 0405) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care in a safe environment.”

“CARE OF PATIENTS CFR(s): 482.12(c) In accordance with hospital policy, the governing body must ensure that the following requirements are met: This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility’s Governing Body failed to ensure Nursing Services provided registered nurses (RN) oversight over licensed vocational nurses (LVNs) and conducting patient assessments for patients assigned to LVN. Four of 34 sampled patients (Patients 4, 18, 21, and 22) lacked assessments by a registered nurse, in accordance with policies and procedure and licensed vocational nurses’ scope of practice. This deficient practice had the potential to compromise patient care and safety due to lack of RN oversight on LVNs, to ensure that accurate patient assessments are conducted, and the plan of care/treatment are implemented to address patient care needs. Findings: 1. During a concurrent interview and record review on 2/7/2024 at 11:50 a.m., with the Quality Assurance Registered Nurse (QARN), Patient 4’s nursing assessment records were reviewed. The QARN stated the following: Patient 4 was admitted to the facility on 2/4/2024 for a gastrointestinal bleed (bleeding from the digestive tract). QARN reviewed Patient 4’s “Daily Shift Assessment,” dated 2/6/2024 at 8 a.m., and stated the assessment was documented by licensed vocational nurse (LVN) 6. The QARN verified that the assessment was not co-signed by a registered nurse (RN). In addition, the QARN verified that reassessments documented on 2/6/2024 at 12 p.m., and 4 p.m., were also documented by LVN 6 and not co-signed by a RN. In the same interview on 2/7/2024 at 11:50 a.m., the QARN stated there were no other signatures, from RNs, associated with the assessments performed and documented by LVNs. The QARN stated that a RN should oversee and validate and agree with the LVNs assessment, and it should be documented in the medical record. The QARN stated a RN should assess patients to ensure LVN’s documentation is accurate and fits the patient’s plan of care. During an interview on 2/6/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated the following: The RN oversees the LVN. RN performs the initial assessments and reassessments. RNs co-sign initial and shift assessments. During an interview on 2/9/2024 at 11:38 a.m., with the Clinical Educator Nursing Administration (CENA), the CENA stated the following: LVNs can collect data related to the patient. However, the RN was responsible for conducting a total assessment of patients’ conditions and to identify changes. During a review of Patient 4’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/4/2024 at 4:46 p.m., the H&P indicated the following: Patient 4’s chief complaint was gastrointestinal bleed (bleeding from the digestive tract). Patient 4 had a past medical history significant for hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), deep vein thrombosis (DVT, a blood clot forms in a deep vein), GI bleed, and diverticulosis (bulging pouches that develop in the digestive tract). Patient 4 presented to the facility from home because of bloody bowel movements. During a review of Patient 4’s “Med/Surg/Tele Flowsheet - Shift,” dated 2/6/2024, the flowsheet indicated it was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 8 a.m., the reassessment was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 12 p.m., the reassessment was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 4 p.m., the reassessment was documented by LVN 6. During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 2. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility’s Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone’s ability to think, move and speak) with left-sided deficits (weakness). During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18’s “Med/Surg/Tele Flowsheet Shift Assessment (nursing assessment, documentation of nursing assessment for patient)”, dated from 2/2/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVNs 5, 10, 11, and 12 recorded the nursing assessment on the following days: 2/3/2024 at 8 a.m. by LVN 10 2/4/2024 at 8 a.m. by LVN 11 2/5/2024 at 8 a.m. by LVN 11 2/6/2024 at 8 a.m. by LVN 5 2/6/2024 at 8 p.m. by LVN 12 2/7/2024 at 8 p.m. by LVN 12 QARN verified that there was no RN sign off on the nursing assessment recorded by the LVNs listed. QARN stated RN was required to perform assessment on patient and validate the data the LVN had collected to make sure assessment was done accurately, and to address any problems identified in the assessment. QARN further stated without proper assessment, it could potentially compromise patient care due to lack of RN oversight. During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 3. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility’s Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation). During a concurrent interview and record review on 2/8/2024 at 2:35 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 21’s “Critical care/Step down Shift Assessment (nursing assessment, documentation of nursing assessment for patient in DOU),” dated from 1/31/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVN 7 recorded the nursing assessment on 2/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 7. QARN stated RN was required to perform head to toe assessment once per shift to identify any abnormality or changes from the previous shift and to report to physician if there were any changes. QARN further stated without RN assessment, something could be missed and could result in inadequate care. During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and / or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 4. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility’s Telemetry (hospital unit where patients undergo continuous cardiac monitoring) with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body’s needs), and acute hypoxemic (lack of oxygen) respiratory distress. During a concurrent interview and record review on 2/8/2024 at 3:16 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 22’s “Critical care/Step down Shift Assessment (nursing assessment),” dated from 1/6/2024 to 1/7/2024, was reviewed. The nursing assessment indicated LVN 6 and LVN 13 recorded the nursing assessment on 1/6/2024 at 8 a.m. and 1/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 6 and LVN 13. During a concurrent interview and record review on 2/8/2024 at 3:30 p.m. with QARN, Patient 22’s nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 1/7/2024, was reviewed. The nurse notes indicated, at 3:30 a.m., Patient 22 bit bottom of his (Patient 22) tongue and resulted in tongue bleeding. QARN verified that there was no documentation that LVN 13 reported it to a RN or Patient 22’s physician. QARN stated that it was a change of condition and LVN 13 should have reported it to the RN who oversaw Patient 22 so the RN could perform assessment and address the problem. QARN stated there was no RN oversight over LVN 13. During a concurrent interview and record review on 2/9/2024 at 12:03 p.m. with the Director of Nursing (DON), Patient 22’s nursing assignment, dated 1/6/2024, was reviewed. The nursing assignment indicated LVN 13 was assigned to Patient 22 on 1/6/2024 night shift. DON verified that there was no documentation indicating a RN was assigned to oversee LVN 13’s patients including Patient 22. During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 36206 Based on interview and record review, the facility’s Governing Body failed to ensure Nursing Services provided registered nurses (RN) oversight over licensed vocational nurses (LVNs) and conducting patient assessments for patients assigned to LVN. Four of 34 sampled patients (Patients 4, 18, 21, and 22) lacked assessments by a registered nurse, in accordance with policies and procedure and licensed vocational nurses’ scope of practice. This deficient practice had the potential to compromise patient care and safety due to lack of RN oversight on LVNs, to ensure that accurate patient assessments are conducted, and the plan of care/treatment are implemented to address patient care needs. Findings: 1. During a concurrent interview and record review on 2/7/2024 at 11:50 a.m., with the Quality Assurance Registered Nurse (QARN), Patient 4’s nursing assessment records were reviewed. The QARN stated the following: Patient 4 was admitted to the facility on 2/4/2024 for a gastrointestinal bleed (bleeding from the digestive tract). QARN reviewed Patient 4’s “Daily Shift Assessment,” dated 2/6/2024 at 8 a.m., and stated the assessment was documented by licensed vocational nurse (LVN) 6. The QARN verified that the assessment was not co-signed by a registered nurse (RN). In addition, the QARN verified that reassessments documented on 2/6/2024 at 12 p.m., and 4 p.m., were also documented by LVN 6 and not co-signed by a RN. The QARN stated there were no other signatures, from RNs, associated with the assessments performed and documented by LVNs. The QARN stated that a RN should oversee and validate and agree with the LVNs assessment, and it should be documented in the medical record. The QARN stated a RN should assess patients to ensure LVN’s documentation is accurate and fits the patient’s plan of care. During an interview on 2/6/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated the following: The RN oversees the LVN. RN performs the initial assessments and reassessments. RNs co-sign initial and shift assessments. During an interview on 2/9/2024 at 11:38 a.m., with the Clinical Educator Nursing Administration (CENA), the CENA stated the following: LVNs can collect data related to the patient. However, the RN was responsible for conducting a total assessment of patients’ conditions and to identify changes. During a review of Patient 4’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/4/2024 at 4:46 p.m., the H&P indicated the following: Patient 4’s chief complaint was gastrointestinal bleed (bleeding from the digestive tract). Patient 4 had a past medical history significant for hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), deep vein thrombosis (DVT, a blood clot forms in a deep vein), GI bleed, and diverticulosis (bulging pouches that develop in the digestive tract). Patient 4 presented to the facility from home because of bloody bowel movements. During a review of Patient 4’s “Med/Surg/Tele Flowsheet - Shift,” dated 2/6/2024, the flowsheet indicated it was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 8 a.m., the reassessment was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 12 p.m., the reassessment was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 4 p.m., the reassessment was documented by LVN 6. During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During the review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 2. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility’s Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone’s ability to think, move and speak) with left-sided deficits (weakness). During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18’s “Med/Surg/Tele Flowsheet Shift Assessment (nursing assessment, documentation of nursing assessment for patient)”, dated from 2/2/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVNs 5, 10, 11, and 12 recorded the nursing assessment on the following days: 2/3/2024 at 8 a.m. by LVN 10 2/4/2024 at 8 a.m. by LVN 11 2/5/2024 at 8 a.m. by LVN 11 2/6/2024 at 8 a.m. by LVN 5 2/6/2024 at 8 p.m. by LVN 12 2/7/2024 at 8 p.m. by LVN 12 QARN verified that there was no RN sign off on the nursing assessment recorded by the LVNs listed. QARN stated RN was required to perform assessment on patient and validate the data the LVN had collected to make sure assessment was done accurately, and to address any problems identified in the assessment. QARN further stated without proper assessment, it could potentially compromise patient care due to lack of RN oversight. During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 3. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility’s Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation). During a concurrent interview and record review on 2/8/2024 at 2:35 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 21’s “Critical care/Step down Shift Assessment (nursing assessment, documentation of nursing assessment for patient in DOU),” dated from 1/31/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVN 7 recorded the nursing assessment on 2/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 7. QARN stated RN was required to perform head to toe assessment once per shift to identify any abnormality or changes from the previous shift and to report to physician if there were any changes. QARN further stated without RN assessment, something could be missed and could result in inadequate care. During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and / or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure (P&P) titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 4. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility’s Telemetry (hospital unit where patients undergo continuous cardiac monitoring) with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body’s needs), and acute hypoxemic (lack of oxygen) respiratory distress. During a concurrent interview and record review on 2/8/2024 at 3:16 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 22’s “Critical care/Step down Shift Assessment (nursing assessment),” dated from 1/6/2024 to 1/7/2024, was reviewed. The nursing assessment indicated LVN 6 and LVN 13 recorded the nursing assessment on 1/6/2024 at 8 a.m. and 1/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 6 and LVN 13. During a concurrent interview and record review on 2/8/2024 at 3:30 p.m. with QARN, Patient 22’s nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 1/7/2024, was reviewed. The nurse notes indicated, at 3:30 a.m., Patient 22 bit bottom of his (Patient 22) tongue and resulted in tongue bleeding. QARN verified that there was no documentation that LVN 13 reported it to a RN or Patient 22’s physician. QARN stated that it was a change of condition and LVN 13 should have reported it to the RN who oversaw Patient 22 so the RN could perform assessment and address the problem. QARN stated there was no RN oversight over LVN 13. During a concurrent interview and record review on 2/9/2024 at 12:03 p.m. with the Director of Nursing (DON), Patient 22’s nursing assignment, dated 1/6/2024, was reviewed. The nursing assignment indicated LVN 13 was assigned to Patient 22 on 1/6/2024 night shift. DON verified that there was no documentation indicating a RN was assigned to oversee LVN 13’s patients including Patient 22. During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs. During a review of the facility’s “Governing Board Minutes,” dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse’s oversight over the licensed vocational nurses. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 36206 Based on observation, interview, and record review, the facility failed to ensure two of five sampled crash carts (crash cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Telemetry Units (a unit in a hospital where patients undergo continuous heart monitoring) were stocked completely with all necessary equipment, and readily available, to be used in the event of a medical emergency according to the crash cart checklist. This deficient practice had the potential for emergency medical equipment to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by a patient, which may lead to patient harm and/or death. Findings: During an observation on 2/6/2024 at 10:15 a.m., in the West Telemetry Unit on the 8th floor, the crash cart # 129, was missing a backboard (a rigid plastic backboard that is placed under a person’s back to perform chest compressions during CPR [cardiopulmonary resuscitation, an emergency life-saving procedure performed when the heart stops beating]). There was only one crash cart on the unit. Concurrently, on 2/6/2024, at 10:15 a.m., during an interview with Charge Nurse (CN) 4, CN 4 verified the backboard was missing and should be located in front of the crash cart. CN 4 stated the back board was located in the dirty utility room because the backboard had been used earlier in the day and needed to be disinfected. CN 4 stated there was only one crash cart on the unit. CN 4 stated emergency equipment, including back boards, should be readily available on crash carts to be used in case of an emergency. Concurrently, on 2/6/2024, at 10: 15 a.m., during an interview with the Director of Telemetry (DOT), the DOT stated that back boards were used in an event of an emergency and were placed under a person’s back during CPR, to create a hard surface during chest compressions. The DOT verified the backboard was missing. During an observation on 2/6/2024 at 10:43 a.m., in the West Telemetry Unit on the 7th floor, two crash carts were observed, crash carts # 118 and 119. Crash cart #118 was missing the suction machine (a pump used for removing obstructions, such as saliva, mucus, and blood) and canister (a container used to collect body fluids, such as mucus or blood). Concurrently, on 2/6/2024 at 10:43 a.m., during an interview with Charge Nurse (CN) 5, CN 5 stated the suction machine and canister were not present on the crash cart because the items had been used and were taken to Central Supply Department (an area of a hospital responsible for receiving, storing, and distributing medical equipment) to be cleaned on 2/3/2024. CN 5 stated she (CN 5) ordered a suction machine however, none were available. CN 5 stated the suction machine and canister should be available on the crash cart to be used to clear a person’s airway in the event of an emergency. A review of a document titled, “Crash Cart Checklist,” dated 2/2024, for West Telemetry Unit on the 8th floor, indicated the high suction machine was not present from 2/3/2024 to 2/6/2024. On 2/4/2024, day shift, the Crash Cart Checklist indicated the suction machine was ordered, however, “none available.” During a review of the facility’s policy and procedure (P&P) titled, “Crash Cart Checks,” dated 10/2023, the P&P indicated the following: Purpose Statement, to ensure that all crash carts are complete, equipment functions properly and supplies are current ...A licensed staff member will use the crash cart checklist daily to verify that the cart is locked and all unsecured equipment is present and ready for use. After a Code Blue (a patient with unexpected cardiac or respiratory arrest, requiring resuscitation) or emergency situation requiring use of crash cart, the licensed staff will: ...Close cart drawers and bins, replace cardiac board in its housing on front of the cart ... Check high suction machine located on the side of the crash cart: The electric outlet is plugged, verify proper functioning, and check for the present of canister/lining.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 31993 Based on interview and record review of Medical Staff ongoing evaluations of approved privileges (authorizes medical practitioners for a specific practice of patient care in a specified healthcare facility) for two of nine sampled physicians’ credential files (MD 6 and MD 7), Credential file did not have current ongoing evaluation and monitoring of approved privileges per the facility Policy and procedure. This deficient practice had the potential to result in the delivery of unsafe patient care from unevaluated for credentialing physicians. Findings: During a concurrent interview and record review on 2/8/2024 at 2 p.m. with the Director of Medical Staff (MSD) and the Director of Data Quality (DDQ), the Medical Staff Credential files for physicians MD 6 and MD 7 provided ongoing evaluation and monitoring of approved privileges were evaluated from 4/2021 to 11/2021. The MSD stated the Ongoing Physician Performance Evaluation (OPPE) is ongoing and completed yearly over an 8-month period. However, the reviewed credential files for MD 6 and MD 7 did not have current ongoing performance evaluation included for review. During a review of the facility’s policy and procedure (P&) titled” Bylaws of the Medical Staff.” dated 9/2/2020, under the Section for Reappointment, the P&P indicated, “Current Competency: objective evidence of the individual’s clinical performance” and “included such evidence includes evaluation of applicants ongoing practice review including data comparison to peers during the prior period of appointment.” During a review of the facility’s undated policy and procedure (P&P) titled “Department of Surgery Rules and Regulations”, the P&P indicated “There will be an evaluation of practitioner performance when privileges are initially granted and on an ongoing basis thereafter. The ongoing process will allow for identification of any potential problems with a practitioner’s performance along with an efficient evidence-based privilege renewal process.””

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 48186 Based on observation, interview, and record review, the facility failed to: 1. Follow State and Federal regulatory standards regarding safe patient care assignments. Over 50% of the patient care assignment in one of 3 sampled units (Unit 1) consisted of licensed vocational nurses (LVNs). One registered nurse (RN 5) and two LVNs (LVN 7 and 8) were assigned to perform direct patient care in the Medical Surgical unit (a unit that serves the general population hospitalized for various cases such as surgery, etc.), for 13 of 13 sampled patients, on 2/6/2024 from 7 a.m., to 7 p.m. This deficient practice had the potential to result in patient needs not being met. 2. Ensure Charge Nurse 3 (CN 3) remained free of job duties that prevented CN 3 from fulfilling the functions of the Charge Nurse role for one of one telemetry nursing units (Unit 1, a floor in the hospital where patients receive continuous cardiac [heart] monitoring), when CN 3 was assigned as the Charge Nurse (CN, oversee the operations of their specific nursing unit during a set period while working alongside the team) and at the same time functioned as Monitor Technician (MT, a skilled professional who supports doctors and nurses in interpreting and diagnosing conditions related to the heart by using non-invasive monitor) on Unit 1. This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties, including the supervision of patient care, and operations of the assigned hospital unit. This deficient practice also had the potential to compromise the quality of medical care delivered to patients when the Charge Nurse is not readily available to assist the other nursing staff in case of medical emergencies on the unit. Findings: 1. During an observation on 2/6/2024 at 11:29 a.m., in the Medical Surgical Unit, CN 2, RN 5, LVN 8 and LVN 9 were observed on the unit. There were 13 patients on the unit. During a concurrent interview on 2/6/2024 at 11:29 a.m. with CN 2, CN 2 stated the following: There were 2 RNs (CN 2 and RN 5) and two LVNs (LVN 8 and 9) on the unit. She (CN 2) was the Charge Nurse, and not assigned patient care duties. RN 5, LVN 8 and LVN 9 were assigned to perform patient care. CN 2 stated since there were two RNs (including herself as the CN) and two LVNs on the unit, she (CN 2) interpreted that assignment as meeting mandatory State and Federal staffing ratios. CN 2 verified that over 50% of the licensed nurses assigned to patient care were licensed vocational nurses (LVNs). In this case, there was only 1 RN with her own patients and there were 2 LVNs who had 5 patients each. The CN 2 had oversight over both LVNs who had 5 patients each. CN 2, in addition to her charge nurse tasks, had to perform all patient care tasks such as IV medication administration, assessment and reassessment, etc., which were not within the LVNs ’ scope of practice. During an interview, on 2/6/2024 at 1:50 p.m., with the Director of Cardiac Services (DCS), the DCS stated the following: Nursing ratios should be 50% or less of LVNs to RNs assigned to patient care. Charge nurses were not included in the LVN to RN ratio of the patient care assignment. During an interview on 2/7/2024 at 9:24 a.m., with the Director of the Medical Surgical (DMS) Unit and the Director of Nursing (DON), the DMS and the DON verified that the patient care assignment on the Medical Surgical Unit on 2/6/2024 consisted of one RN (RN 5) and two LVNs (8 & 9), which was over 50 % of LVNs to RNs. The DMS and DON stated the assignment might impact patient care. During an interview on 2/9/2024 at 12 p.m., with the DON, the DON verified that the facility’s policy and procedure indicated that only nurses (RN and LVNs) assigned to perform direct patient care should be included in the staffing ratio excluding the charge nurse. During a review of a patient care assignment titled, “6-West Med/Surg Daily Assignment Sheet,” dated 2/6/2024, day shift 7 a.m. - 7 p.m., the assignment indicated the following: Charge Nurse (CN) 2 was assigned to be the Charge Nurse. Registered Nurse (RN) 5, LVN 8, and LVN 9 were assigned to perform patient care. Census 13. During a review of the facility’s policy and procedure (P&P) titled, “Staffing Plan,” dated 10/2023, the P&P indicated the following: The facility shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII (a set of rules and regulations established by the California Department of Social Services that governs community care facilities, from licensing requirements to staffing ratios to safety standards, and resident rights), California Licensing and Certification of Health Facilities in the General Acute Hospitals ...In no case shall the staffing level for licensed nurses fall below the requirements ...Only licensed nurses providing direct patient care shall be included in the ratios. 2. During a concurrent observation and interview on 2/26/2024 at 11:25 a.m. with Charge Nurse 3 (CN 3), CN 3 was observed on the unit at the telemetry monitoring screen (shows real-time monitoring of a patient’s heart rhythm). Furthermore, CN 3’s name was observed on the daily assignment board assigned as the Charge Nurse (CN, oversees the operations of their specific nursing unit and patient care during a set period of time while working alongside the team) and Monitor Technician (MT, a skilled professional who supports doctors and nurses in interpreting and diagnosing conditions related to the heart by using non-invasive monitor). CN 3 said that the MT called in sick for the day. CN 3 verified that CN 3 was assigned and working both roles (CN and MT roles) concurrently. CN 3 stated that due to staffing, CN 3 was the only available staff to work as a MT, in addition to the role as a CN. During an interview on 2/26/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated that the assigned Charge Nurse should be relieved of their job duties if they were assigned as the Monitor Technician. DCS stated that it was the responsibility of the DCS to cover the Charge Nurse when the Charge Nurse was doing the Monitor Technician role. During an interview on 2/7/2024 at 9:25 a.m. with Director of Nursing (DON), DON stated that if there was no MT, the CN can work as a MT per facility policy. However, DON said that if CN 3 was assigned the MT role, CN 3 should be relieved of the CN duties. DON stated that when CN 3 was working concurrently as the CN and MT, DCS should have taken over the CN role. During an interview on 2/8/2024 at 11:32 a.m. with the Clinical Supervisor of Telemetry (CST), CST stated that the MT role required to maintain line of sight on the telemetry monitoring screen always and that the MT should not take eyes off the telemetry monitoring screen. CST further stated that the CN cannot perform the MT role and the CN role at the same time. During a review of a patient care assignment titled, “3-West Cardiac Telemetry Report Sheet,” dated 2/6/2024, day shift 7 a.m. - 7 p.m., the assignment indicated the following: CN 3 was assigned as the Charge Nurse and Monitor Technician. During a review of a document titled “Job Description,” dated 1/2023, the document indicated: “Position Title: Charge Nurse, Department: Med/Surg ... Job Summary: The Med/Surg Charge Nurse is responsible and accountable for the quality of staff and functions during their shift. Assists the Department Director in the daily operations of the unit, directing, supervising, and evaluating personnel, ensuring the proper use of time, equipment and resources. Ensures the efficient functions of the department. Performs direct patient care, only as needed, within the scope of practice. Continually assesses patient care and directs staff to make necessary changes in the plan of care. Effectively communicates with physician and staff to ensure positive patient outcomes ... B. Duties and Responsibilities 1. When in charge: ... b) Serves as a resource to staff in area of expertise ...” During a review of the facility’s policy and procedure (P&P) dated 9/2023 titled “Telemetry Monitoring (Central Monitoring Unit),” the P&P indicated: “Section 1. Purpose: To establish guidelines for hospital personnel to ensure safe and consistent care of the patients requiring continuous telemetry monitoring and SP02 monitoring, Section 2. Policy: Continuous telemetry monitoring will be provided by trained hospital staff that have demonstrated competency in basic arrythmia monitoring and can safely utilize monitor alarm setting and protocols set by the hospital as described in this policy, Section 3. Applicability & Scope: This policy applies to: Monitor Technicians and Licensed Nurses (LN’s) who have demonstrated competency in basic arrythmia monitoring. Patients in the telemetry units who require telemetry monitoring shall be provided accurate, safe, and competent telemetry monitoring and nursing care, Section 4. Procedure: General Management of Telemetry Patients’. Remote Telemetry Monitoring: Remote telemetry monitoring stations are located on the 3rd floor (Central Monitoring Unit- CMU) and provide electrocardiographic (ECG, records the electrical signal from the heart to check for different heart conditions) monitoring for patients admitted to telemetry beds on telemetry floors. Telemetry monitoring stations are manned continuously ...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48212 Based on interview and record review, the registered nurses failed to: 1. Provide registered nurses’ oversight over licensed vocational nurses’ assessments for four of 34 sampled patients (Patients 4, 18, 21, 22), in accordance with the facility’s policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient’s current physical, mental and emotional state) and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVNs without RN oversight and had the potential to result in an inaccurate assessment of patients’ condition and inappropriate provision and plan of care to patients. Findings: 1. During a concurrent interview and record review on 2/7/2024 at 11:50 a.m., with the Quality Assurance Registered Nurse (QARN), Patient 4’s nursing assessments record, was reviewed. The QARN stated the following: Patient 4 was admitted to the facility on 2/4/2024 for a gastrointestinal bleed (bleeding from the digestive tract). QARN reviewed Patient 4’s “Daily Shift Assessment,” dated 2/6/2024 at 8 a.m., and stated the assessment was documented by licensed vocational nurse (LVN) 6. The QARN verified that the assessment was not co-signed by a registered nurse (RN). In addition, the QARN verified that reassessments documented on 2/6/2024 at 12 p.m., and 4 p.m., were also documented by LVN 6 and not co-signed by a RN. The QARN stated there were no other signatures, from RNs, associated with the assessments. The QARN stated that a RN should oversee and validate and agree with the LVNs assessment, and it should be documented in the medical record. The QARN stated a RN should assess patients to ensure LVN’s documentation was accurate and fits the patient’s plan of care. During an interview on 2/6/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated the following: The RN oversees the LVN. RN performs the initial assessments and reassessments. RNs co-sign initial and shift assessments. During an interview on 2/9/2024 at 11:38 a.m. with the Clinical Educator Nursing Administration (CENA), the CENA stated the following: LVNs can collect data related to the patient. The RN was responsible for conducting a total assessment of patients’ conditions and to identify changes. During a review of Patient 4’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/4/2024 at 4:46 p.m., the H&P indicated the following: Patient 4’s chief complaint was gastrointestinal bleed (bleeding from the digestive tract). Patient 4 had a past medical history significant for hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), deep vein thrombosis (DVT, a blood clot forms in a deep vein), GI bleed, and diverticulosis (bulging pouches that develop in the digestive tract). Patient 4 presented to the facility from home because of bloody bowel movements. During a review of Patient 4’s “Med/Surg/Tele Flowsheet - Shift,” dated 2/6/2024, the flowsheet indicated it was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 8 a.m., the reassessment was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 12 p.m., the reassessment was documented by LVN 6. During a review of Patient 4’s “Reassessments,” dated 2/6/2024 at 4 p.m., the reassessment was documented by LVN 6. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and / or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During the review of the facility’s policy and procedure titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 2. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility’s Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone’s ability to think, move and speak) with left-sided deficits (weakness). During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18’s “Med/Surg/Tele Flowsheet Shift Assessment (nursing assessment, documentation of nursing assessment for patient),” dated from 2/2/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVNs 5, 10, 11, and 12 recorded the nursing assessment on the following days: 2/3/2024 at 8 a.m. by LVN 10 2/4/2024 at 8 a.m. by LVN 11 2/5/2024 at 8 a.m. by LVN 11 2/6/2024 at 8 a.m. by LVN 5 2/6/2024 at 8 p.m. by LVN 12 2/7/2024 at 8 p.m. by LVN 12 QARN verified that there was no RN sign off on the nursing assessment recorded by the LVNs listed. QARN stated RN was required to perform assessment on patient and validate the data the LVN had collected to make sure assessment was done accurately, and to address any problems identified in the assessment. QARN further stated without proper assessment, it could potentially compromise patient care due to lack of RN oversight. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure (P&P) titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 3. During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility’s Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation). During a concurrent interview and record review on 2/8/2024 at 2:35 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 21’s “Critical care/Step down Shift Assessment (nursing assessment, documentation of nursing assessment for patient in DOU),” dated from 1/31/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVN 7 recorded the nursing assessment on 2/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 7. QARN stated RN was required to perform head to toe assessment once per shift to identify any abnormality or changes from the previous shift and to report to physician if there were any changes. QARN further stated without RN assessment, something could be missed and could result in inadequate care. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure (P&P) titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN. 4. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility’s Telemetry (hospital unit where patients undergo continuous cardiac monitoring) unit with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body’s needs), and acute hypoxemic (lack of oxygen) respiratory distress. During a concurrent interview and record review on 2/8/2024 at 3:16 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 22’s “Critical care/Step down Shift Assessment (nursing assessment),” dated from 1/6/2024 to 1/7/2024, was reviewed. The nursing assessment indicated LVN 6 and LVN 13 recorded the nursing assessment on 1/6/2024 at 8 a.m. and 1/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 6 and LVN 13. During a concurrent interview and record review on 2/8/2024 at 3:30 p.m. with QARN, Patient 22’s nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 1/7/2024, was reviewed, the nurse notes indicated, at 3:30 a.m., Patient 22 bit bottom of tongue and resulted in tongue bleeding. QARN verified that there was no documentation that LVN 13 reported it to a RN or Patient 22’s physician. QARN stated that it was a change of condition and LVN 13 should have reported it to the RN who oversaw Patient 22 so the RN could perform assessment and address the problem. QARN stated there was no RN oversight over LVN 13. During a concurrent interview and record review on 2/9/2024 at 12:03 p.m. with the Director of Nursing (DON), Patient 22’s nursing assignment record, dated 1/6/2024, was reviewed, the nursing assignment indicated LVN 13 was assigned to Patient 22 on 1/6/2024 night shift. DON verified that there was no documentation indicating a RN was assigned to oversee LVN 13’s patients including Patient 22. During a review of the facility’s policy and procedure (P&P) titled, “Assessment and Reassessment of the Patient,” dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient’s health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient’s plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters. During a review of the facility’s policy and procedure (P&P) titled, “Licensed Vocational Nurse, Scope of Practice,” dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.”

“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: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure the call light (a means of communication for patients to their care providers that are outside the patients’ rooms) was within reach for one of 34 sampled patients (Patient 3), in accordance with the Patient’s plan of care (provides a framework for evaluating and providing patient care needs related to the nursing process) and the facility’s policies and procedures regarding care plans. This deficient practice had the potential to result in a fall and immediate needs unattended for Patient 3. 2. Develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest (the cessation of effective breathing and blood flow) specific to patient’s needs for one of 35 sampled patients (Patient 15). This deficient practice had the potential to result in Patient 15 not receiving the right level of care and not meeting the needs for the identified patient’s concerns. 3. Initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon admission for one of 34 sampled patients (Patient 18). This deficient practice had the potential to result in the delay of treatment by not identifying Patient 18’s needs and risks, which may result in worsening of Patient 18’s condition and prolonged hospitalization. Findings: 1. During a concurrent observation and interview on 2/6/2024 at 10:20 a.m., in the Telemetry Unit (a unit in a hospital where patients undergo continuous heart monitoring), Patient 3 was awake and alert in bed, and sitting up on the bed. Bed rails on each side of the bed were up. Patient 3 was leaning towards the left side of the bed against the bed rail. The call light was placed on top of the nightstand against the back wall. The call light was not within Patient 3’s reach. Patient 3 stated (Patient 3) she did not know where the call light was. Patient 3 was asked how she (Patient 3) calls for help. Patient 3 stated “I just tell them,” when the staff passes by. Concurrently during an interview, on 2/6/2024 at 10:20 a.m., with the Discharge Planner (DCP), the DCP verified that the call light was not within Patient 3’s reach and should be within reach to prevent falls (an unplanned descent to the floor with or without injury to the patient). Concurrently during an interview, on 2/6/2024 at 10:20 a.m., with the Director of Telemetry (DOT), the DOT stated that the call light should be with Patient 3’s reach. DOT stated Patient 3 may fall if Patient 3 tried reaching for the call light on the nightstand. During a review of Patient 3’s “History & Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/5/2024 at 1:47 p.m., the H&P indicated the following: Patient 3 had a past medical history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), on nasal cannula (a device that delivers supplemental oxygen) 2 Liters (L, a unit of measurement) of oxygen, presented to the emergency department for shortness of breath. During a review of Patient 3’s “Admission Initial Assessment,” dated 2/5/2024 at 1:01 p.m., the assessment indicated the following: Patient 3’s Fall Risk Score was 60 (over 45 indicates high risk for fall). Patient is a high risk for fall: Yes ...Call light within reach: Yes, Patient instructed to call for assistance: Yes. During a review of Patient 3’s care plan titled, “Risk Injury/Fall,” initiated on 2/5/2024 at 12:13 p.m., the care plan indicated interventions, including having the call light within Patient 3’s reach. During a review of the facility’s policy and procedure (P&P) titled, “Fall Reduction,” dated 7/2023, the P&P indicated the following: All patients identified as high risk for falls will have the following measures initiated ...The patient and family will be educated. Educational interventions may include ...using brochures, pictures and signage as reminders about using the call bell system ...General strategies for patients at moderate or high risk for falls may include ...Call light within patient reach ... During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care: Patient, Interdisciplinary,” dated 7/2023, the P&P indicated the following: The plan of care shall consist of problems, measurable expected outcomes and interventions that reflect acceptable standards of care ...Formulation the Plan of Care: Identify the problem ... Establish an expected outcome for the problem ...Choose the interventions. Interventions reflect the course of actions that will be taken to move the patient towards the expected outcomes that have been established. 2. During a review of Patient 15’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/6/2024, the H&P indicated, Patient 15 was admitted on 1/31/2024 due to pneumonia (PNA, lung inflammation caused by bacterial or viral infection), acute (sudden) on chronic (long-lasting) respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or body requirements of the patient), and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). The H&P further indicated, Patient 15 had past medical history (PMH, a record of information about a patient’s health) of recent (1/19/2024) anoxic brain injury (a complete lack of oxygen to the brain, which results in the death of brain cells) due to prolonged seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest ( the cessation of effective breathing and blood flow) resulting in chronic ventilator dependence (long term mechanical support for breathing) with tracheostomy (surgical opening created to insert a tube through the neck into the windpipe to allow air to fill the lungs and remove secretions) and percutaneous endoscopic gastrostomy feeding tube (PEG, a tube inserted through the wall of the abdomen directly into the stomach) placement. During a review of Patient 15’s medical record (MR) titled, “Nutrition Assessment,” dated 2/1/2024, the MR indicated, Patient 15 required enteral (any method of feeding that uses the gastrointestinal [GI, includes the mouth, the throat, the stomach, etc.] tract to deliver nutrition and calories) nutrition infusion via PEG feeding tube with a recommendation to monitor for signs and symptoms of tube feeding (TF) intolerance (indicated by symptoms of vomiting, abdominal pain, etc. that diminishes the nutrient being delivered via tube feeding) and for aspiration (accidental breathing in of food or fluid into the lungs). During a review of Patient 15’s medical record (MR) titled, “Pulmonary Progress Note,” dated 2/6/2024, the MR indicated, Patient 15’s treatment plan consisted of, but not limited to, monitoring and treatment for seizures. During a review of Patient 15’s medical record (MR) titled, “Care Activity-Plan of Care,” dated 2/7/2024, the MR indicated, Patient 15 did not have a nursing care plan developed for seizures and aspiration precautions. During a concurrent interview and record review on 2/8/2024 at 2:45 p.m. with house supervisor (HS), Patient 15’s medical record (MR) titled, “Care Activity-Plan of Care,” dated 2/7/2024, was reviewed. The MR indicated, no Plan of Care was developed and kept for Patient 15’s potential risk for seizures and risk for aspiration related to TF was done. The HS stated, nursing must develop a care plan for all actual or potential patient’s needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not. During a review of the facility’s policy and procedure (P&P) titled, “Plan of Care: Patient Interdisciplinary,” last reviewed 4/2023, the P&P indicated, “A plan of care is developed to ensure each patients received individualized plan of care meeting the patients’ needs. The plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. The plan of care shall be developed within 24 hours of admission and shall be developed based on identified through assessment data actual or potential problems and should reflect the course of action that will be taken to move the patient toward the expected outcomes that have been established. The Plan of Care is a permanent part of the Medical Record.” 3. During a review of Patient 18’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility’s Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) on 2/2/2024 with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone’s ability to think, move and speak) with left-sided deficits (weakness). During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18’s care plan was reviewed. QARN verified that there was no nursing care plan initiated for Patient 18 regarding Patient 18’s diagnosis of failure to thrive and hypertension. QARN further stated care plan should have been initiated upon admission by a Registered Nurse (RN) to set plan and goals for the patient and to determine what interventions were needed in order to achieve the goals to reach the optimal level. During a concurrent interview and record review on 2/8/2024 at 11:05 a.m. with QARN, the facility’s policy and procedure (P&P) titled, “Plan of Care: Patient, Interdisciplinary,” dated 4/2023, was reviewed. The P&P indicated, “a Plan of Care is developed for each patient that is individualized to meet the patient’s unique needs ...within 24 hours of admission, an RN will initiate the care plan, document and review age related and other factors ... all disciplines involved in patient care will document on the Interdisciplinary Plan of Care. The LVN can implement care that is planned by the RN.” QARN verified that the RN did not develop care plan for Patient 18 at all. QARN further stated LVN needed to follow the care plan to provide intervention outlined by RN, without the care plan, Patient 18 could not receive optimal care needed, and the LVN would not have directions of what nursing care to provide for Patient 18.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 31993 Based on observation, interview and record review the facility failed to ensure: 1. Two of six sampled nursing staff (Registered Nurse [RN] 9 and Licensed Vocational Nurse [LVN] 3) had annual skill competency evaluations (assessment of a clinician’s skills, abilities and knowledge to ensure provision of safe and effective care to patients) done. This deficient practice had the potential to result in patients receiving inadequate care and treatment from nursing staff whose competencies were not checked annually. 2. Three of three sampled staff (Registered Nurse (RN) 6, RN 7, and Charge Nurse (CN) 4) followed the facility Policy and Procedure regarding emergency termination procedure for hemodialysis machine and were competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) of 34 sampled patients (Patient 6). This deficient practice had the potential to result in inadequate return of blood from the machine to Patient 6 causing harm or even death during hemodialysis treatment. Findings: 1. During a concurrent interview and record review of Registered Nurse (RN) 9 and Licensed Vocational Nurse (LVN) 3’s personnel file, on 2/8/2024 at 3 p.m., with the Director of Human Resources (DHR) and the Manager of Human Resources (MHR), the DHR and the MHR stated the following: RN 9 was hired on 10/15/2012. RN 9’s last annual skills competency evaluation was conducted on 6/21/2022. In addition, the DHR and MHR stated LVN 3 was hired on 1/20/2023. LVN 3 did not have an annual skills competency evaluation in the personnel file from the date LVN 3 was hired until present. The DHR and MHR stated the skills competency evaluation should be performed annually and upon hire and was overdue for RN 9 and LVN 3. The DHR stated the that the skills competency evaluations should be performed upon hire and annually to validate that the staff was capable of doing what they (staff) were supposed to do. During a review of the facility’s policy and procedure (P&P) titled, “Competency Assessment,” dated 1/2024, the P&P indicated the following: Competency assessment begins upon employment and continues with ongoing evaluation of competency-based performance ...Competencies will be assessed on a continuum throughout the employment of an individual. This continuum will include assessment during the hire process, initial competencies during the orientation period and ongoing annual competency assessment. 2. During a review of Patient 6’s, History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 2/6/2024, the H&P indicated Patient 6 was admitted to the facility to restart Hemodialysis (a treatment to filter wastes and water from your blood). During a concurrent observation and interview on 2/6/2024 at 10:15 a.m. with the House Supervisor (HS) and the Director of Data Quality (DDQ), observed a sign posted in the dialysis machine regarding how to shut off the Hemodialysis machine safely in case of an emergency. The DDQ stated hemodialysis services at the facility was a contracted service and was provided hospital wide. Likewise, Dialysis RN (RN10) confirmed there was a sign posted in the dialysis machine regarding instructions on how to shut off the Hemodialysis machine safely in case of an emergency. Concurrently, during an interview on 2/6/2024 at 10:15 a.m., Registered Nurse (RN) 6 (who was taking care of Patient 6 being dialyzed) was asked if she (RN 6) was trained on how to turn off the dialysis machine in case of an emergency. RN 6 stated she (RN6) was not trained. RN 7 was asked if she (RN7) was trained on how to turn off the dialysis machine in case of emergency, she stated she (RN7) did not know how to turn off the dialysis machine in case of an emergency. In addition, Charge Nurse (CN) 4 stated that an in-service on how to turn off the dialysis in case of emergency was provided but she (CN 4) was not sure of the procedure. During an interview and record review on 2/9/2024 at 11:30 a.m., with the Clinical Educator Nursing Administration (CENA) and the Clinical Educator (CED), the CENA and CED stated RN 6 and RN 7 did not have yearly competency on how to turn off the dialysis machine in case of emergency. CENA and CED stated hospital wide Inservice on how to turn off the dialysis machine in case of emergency was provided in 2023. During a review of the Facility’s policy and procedure (P&P) titled” Care for the Patient needing STAT (immediately) Hemodialysis,” dated 4/20/2023, indicated under Section 2, “If the Hemodialysis Nurse (HD) nurse becomes incapacitated during a treatment, hospital nursing staff must immediately attend to the patient safety.” Instructions on how to safely discontinue hemodialysis and temporary disconnection procedure was also included.”

“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: 46238 Based on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled registered nurse (Registered Nurse (RN) 5) followed the facility’s policy and procedure for putting on (donning) PPE (personal protective equipment, equipment worn to minimize exposure to illness, includes gown, gloves, mask etc. ) and removing (doffing) personal protective equipment while taking care of one of 34 sampled patients (Patient 10), who was on contact precaution (interventions taken to prevent transmission of infectious agents). This deficient practice had the potential to spread infection to other Patients on the Unit due to improper donning and doffing of PPEs. 2. Ensure one of one sampled staff (Licensed Vocational Nurse [LVN] 13) adhered to the facility’s policy and procedure on the LVN Scope of Practice when LVN 13 administered Methylprednisolone (Solu-Medrol, steroid injection provides relief of inflamed area of the body, lungs and breathing problem such as asthma) intravenously (given into the vein) for one of 34 sampled patients (Patient 22). This deficient practice had the potential for Patient 22 to develop respiratory problem and reaction from an untrained staff’s improper administration of medication. 3a. Change enteral (a method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) feeding container and feeding tube set (feeding tube inserted through an abdominal wall to deliver nutrients directly into the patient’s stomach) after 24 hours of use for one of 34 patients (Patient 15) in accordance with the facility’s policy and procedure regarding enteral feeding and feeding tube set replacement. This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems such as diarrhea, abdominal pain, vomiting, etc. for Patient 15. 3b. Renew an order for restraints (a physical restraint is any manual method, material or equipment that is attached to patient’s body that cannot be easily removed and restricts freedom of movement) use for one of 34 patients (Patient 16) after 24 hours that the restraint was initially ordered. This deficient practice had the potential to violate Patient 16’s rights regarding restraint use, as nursing staff continued documenting the prolonged use of restraints without a physician’s renewal order for restraints. This deficient practice also had the potential to result in patient harm such as skin injury from prolonged and inappropriate use of restraints. 3c. Label a feeding tube container after initiating tube feeding (a way to provide nutrition for patients who are unable to eat or drink by mouth) to indicate the need for replacement after 24 hours of use and did not indicate the date, time, and patient’s name when initiated for one of 34 sampled patients (Patient 16) in accordance with the facility’s policy and procedure regarding labeling and replacing tube feeding containers after 24 hours from the time the feeding tube container was used. This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems such as diarrhea, abdominal pain, vomiting, etc. for Patient 16. 3d. Use translator services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when obtaining informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 34 sampled patients (Patient 14). This deficient practice had the potential for Patient 14 not receiving accurate and current information in the language Patient 14 could understand which may result in Patient 14 not understanding information regarding her (Patient 14) health status and treatment and may delay recovery from illness. Findings: 1. During a concurrent observation and interview on 2/6/2024 at 11:40 a.m. on 6 West (Medical Unit) with the Infection Preventionist (IP) and the Director of Data Quality (DDQ), RN5 was observed exiting a contact precaution room (used for patients with infections, diseases, or germs that are spread by touching the patients or items in the room) with shoe covers, a hair cover, N95 mask (a respiratory protective device that is designed to provide very efficient filtration of airborne particles) and underneath the N95 mask was a surgical mask. RN 5 stated her assignment included two contact precautions Patients. RN 5 said she does not change her hair-cover, shoe covers and her N95 mask when leaving the Contact precaution rooms. The IP stated daily rounds are done hospital wide to conduct surveillance for compliance with Infection prevention practices. During an interview on 2/7/2024 at 10 a.m. with IP, the IP stated all PPE must be removed when leaving a contact precaution room. Shoe cover and hair cover should not be worn on the unit and should be removed when leaving a Contact Precaution room. IP stated there were daily rounds to conduct surveillance for compliance with policy and procedure including for Contact precautions and donning (putting on) and doffing (removing) of personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask etc.) During a concurrent interview and record review on 2/9/2024 at 11 a.m. with the Clinical Educator Nursing Administration (CENA) and the Clinical Educator (CED), CENA and CED stated all registered nurses have yearly competency for Infection prevention including contact precaution and donning and doffing of PPE. During a review of the facility’s policy and procedure (P&P) titled, “Standard and Isolation Precautions,” dated 7/20/23, the P&P indicated, “standard precautions prevent the spread of infectious organisms and include the use of barriers including gloves gowns masks and protective eyewear precautions” and the P&P also indicated to remove all PPE prior to leaving the contact precautions patient room. 2. During a review of Patient 22’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body’s needs), and acute hypoxemic (lack of oxygen) respiratory distress. During a concurrent interview and record review on 2/9/2024 at 10:59 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 22’s “electronic Medication Administration Record (eMAR, a record of medications given to patient),” dated from 1/5/2024 to 1/7/2024, was reviewed. The MAR indicated IV (intravenous, into the vein) Solu-Medrol (steroid injection provides relief of inflamed area of the body, lungs and breathing problem such as asthma) 20 mg (milligram, unit of measurement) was given by LVN 13 on the following days: 1/5/2024 at 11:16 p.m. 1/6/2024 at 5:44 a.m. 1/6/2024 at 10 p.m. 1/7/2024 at 6 a.m. QARN stated that LVN 13 was not allowed to give any IV medications because it was out of her (LVN 13) scope of practice. During an interview on 2/9/2024 at 11:38 a.m. with the Clinical Educator Nursing Administration (CENA), CENA stated per facility’s policy, LVN was not allowed to give any medication administration intravenously. CENA further stated LVN 13 should not have given the Solu-Medrol to Patient 22 because it was not under her (LVN 13) scope of practice, she (LVN 13) was not trained to give IV medication and could not perform assessment and assess the possible side effects after the IV medication was given. CENA stated Patient 22 might develop respiratory problem if Solu-Medrol was given too fast or too slow. During a review of the facility’s policy and procedure (P&P) titled, “Licensed Vocational Nurse, Scope of Practice,” dated 10/2023, the P&P indicated, “LVN’s may not: mix or administer IV medications (this includes IVP [intravenous push, medication is administered into the bloodstream very quickly], IVPB [Intravenous Piggy Back, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time. Example: antibiotic solutions] and IV drips) ... may not implement any actions or activities not in their scope of practice ... it is the LVN’s responsibility to always perform within their Scope of Practice and the must comply with current Standards of Care.” During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications,” dated 08/2023, the P&P indicated, “All medications shall be administered only by individuals licensed by local state and are authorized to administer medication. These routinely include Licensed Vocational Nurse, Administration by the parental route is limited to non-intravenous dosage forms and intravenous solutions without added medications.” 3a. During a review of Patient 15’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/6/2024, the H&P indicated, Patient 15 was admitted on 1/31/2024 due to pneumonia (PNA, lung inflammation caused by bacterial or viral infection), acute (sudden) on chronic (long-lasting) respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or body requirements of the patient), and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body’s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). The H&P further indicated, Patient 15 had a past medical history (PMH, a record of information about a patient’s health) of recent (1/19/2024) anoxic brain injury (a complete lack of oxygen to the brain, which results in the death of brain cells) due to prolonged seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest ( the cessation of effective breathing and blood flow) resulting in chronic ventilator dependence (long term mechanical support for breathing) with tracheostomy (surgical opening created to insert a tube through the neck into the windpipe to allow air to fill the lungs and remove secretions) and percutaneous endoscopic gastrostomy feeding tube (PEG, a tube inserted through the wall of the abdomen directly into the stomach) placement. During a review of Patient 15’s medical record ( MR) titled, “Nutrition Assessment,” dated 2/1/2024, the MR indicated, Patient 15 required enteral (any method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) nutrition infusion via PEG feeding tube with a recommendation to provide continuous enteral feeding at a rate of 45 milliliters an hour (ml, a unit of measurement) to meet Patient 15’s necessary body caloric (the number of calories your body needs to support your body’s basic functions, such as breathing, digestion, circulation, and regulating your body temperature) requirements. During an observation on 2/7/2024, at 11:23 a.m., in Patient 15’s room in a Direct Observation Unit (DOU), Patient 15 was observed in bed, receiving an enteral feeding nutrition via feeding pump, running at 45 milliliters an hour (ml/h, a unit of measurement). The tube feeding container label indicated, the feeding was initiated on 2/6/2024, at 6:30 a.m. During an interview on 2/7/2024, at 11:23 a.m., with Director of Nursing (DON) and Patient 15’s primary nurse (RN 12), the DON stated, the feeding bottle and the infusion set must be changed every 24 hours or as soon as the feeding runs out because of the risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption). The RN 10 stated, the feeding container and feeding set had to be changed on 2/7/2024 at/or before 6:30 a.m. as per the facility’s policy, but the primary nurses forgot to change it. During a review of the facility’s policy and procedure (P&P) titled, “Enteral Feeding Protocol,” last reviewed on 6/2023, the P&P indicated, “Enteral feeding is used to provide nutrients directly into the stomach, duodenum (the first part of the small intestine), and jejunum (one of the three sections that make up the small intestine) by tube for those patients with a minimally functioning gastrointestinal (GI) tract who cannot take adequate nutrition by mouth. Enteral feeding container and spike set are to be changed every 24 hours or sooner as the formula runs out. Each container must be labeled with the date and time when initiated and the patient’s name and initialed.” 3b. During a review of Patient 16’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 01/27/2024, the H&P indicated, Patient 16 was admitted on 1/27/2024 due to abdominal pain, nausea (feeling the urge to vomit) and weight loss. The H&P further indicated, Patient 16’s past medical history (PMH) included hypertension (a condition in which the blood vessels have persistently raised pressure). During a review of Patient 16’s medical record (MR) titled, “Nutrition Notes,” dated 2/1/2024, the MR indicated, Patient 16 required nasogastric tube (NGT) feeding (a narrow feeding tube is placed through your nose down into your stomach) due to being too lethargic (a state of fatigue and low energy) to eat. The MR further indicated; Patient 16 was started on continuous NG tube feeding. During an interview and concurrent record review on 2/8/2024, at 2:04 p.m., with house supervisor (HS), Patient 16’s medical record (MR) titled, “Care Activity-Assessments: Acute Medical Restraint Flowsheet,” dated 2/5/2024- 2/6/2024, was reviewed. The MR indicated, nursing documented that Patient 16 required bilateral (applied to both sides) soft wrist restraints (a physical restraint is any manual method, material or equipment that is attached to patient’s body that cannot be easily removed and restricts freedom of movement) due to behavior (pulling on lines [attempts to remove necessary medical equipment such as NGT or intravenous (IV) lines and was confused) interfering with patient care. The HS stated, the MR documentation indicated, Patient 16 was in restraints on 2/5/2024 and 2/6/2024. The HS further stated, nursing documentation in Patient 16’s MR indicated, on 2/6/2024, Patient 16 was restrained from 12:00 a.m. to 6:00 p.m. The HS stated, per the facility’s policies and procedures and federal regulation, nursing must have a physician’s order to use restraints when a clinical justification for use of restraints is present. During a concurrent interview and record review on 2/8/2024, at 2:04 p.m., with house supervisor (HS), Patient 16’s medical record (MR) titled “Physician’s Orders,” dated 2/5/2024-2/6/2024, was reviewed. The MR indicated, an order for soft bilateral wrist restraints was placed by the physician on 2/5/2024 to prevent Patient 16 from pulling on lines and interfering with care. The HS stated, the MR contained no order for soft bilateral wrist restraints on 2/6/2024.The HS further stated, nursing can initiate restraints, but the order for restraints must be renewed/rewritten every 24 hours if there was a clinical justification for its use. During a review of the facility’s policy and procedure (P&P) titled, “Restraints,” last reviewed on 12/2023, the P&P indicated, “All patients have the right to be free from restraint of any form. Restraints are only used in an emergency, when less restrictive interventions are ineffective, only when it can be clinically justified or warranted by patient behavior. Initiation of restrain by a qualified, competent RN in the absence of a licensed independent practitioner is permitted, but the order must be obtained as soon as possible, but no longer than one hour after initiation. All restraint orders must be renewed/rewritten based on the direction of the physician if there is clinical justification, for up to 24 hours. The attending physician must be consulted as soon as possible if the restrain is not ordered by the patient’s attending physician.” 3c. During a review of Patient 16’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 01/27/2024, the H&P indicated, Patient 16 was admitted on 1/27/2024 due to abdominal pain, nausea and weight loss. The H&P further indicated, Patient 16’s past medical history (PMH) included hypertension (a condition in which the blood vessels have persistently raised pressure). During a review of Patient 16’s medical record (MR) titled, “Nutrition Notes,” dated 2/1/2024, the MR indicated, Patient 16 required nasogastric tube (NGT, a nasogastric (NG) tube is a thin, soft tube that goes in through the nose, down the throat, and into the stomach and is used to feed formula when a person is unable to get nutrition by mouth) feeding due to being too lethargic (A person experiencing lethargy may not have the energy or motivation to do the tasks they need to each day) to eat. The MR further indicated Patient 16 was started on continuous NGT tube feeding (TF). During a review of Patient 16’s medical record (MR) titled, “Nutrition Notes,” dated 2/7/2024, the MR indicated, Patient 16 had severe malnutrition (lack of proper nutrition caused by not having enough to eat) related, difficulty swallowing related to mentation, and required administration of continuous NGT feeding formula. During an observation on 2/7/2024, at 11:34 a.m., Patient 16 was observed in bed, in Patient 16’s room. Patient 16 had NG Tube attached to an enteral feeding pump (Enteral feeding pumps use feeding tubes to deliver nutrition to patients who cannot obtain such by swallowing) with a spiked enteral feeding container (a sterile feeding container is spiked with a feeding set) attached to the tubing set. The enteral feeding container was not labeled with the date and time initiated and the patient’s name. During an interview on 2/7/2024 at 11:36 a.m. with director of nursing (DON), the DON stated, nursing must label newly spiked feeding container with the date and time initiated, the patient’s name and initialed by the administering nurse. The DON further stated enteral feeding bottle and spike set are to be changed every 24 hours or sooner to prevent bacterial contamination as per the facility’s policy. During a review of the facility’s policy and procedure (P&P) titled, “Enteral Feeding Protocol,” last reviewed on 6/2023, the P&P indicated, “Enteral feeding is used to provide nutrients directly into the stomach or small intestine by tube for those patients with a minimally functioning gastrointestinal (GI) tract (digestive tract) who cannot take adequate nutrition by mouth. Enteral feeding container and spike set are to be changed every 24 hours or sooner as the formula runs out. Each container must be labeled with the date and time when initiated and the patient’s name and initialed.” 3d. During a review of Patient 14’s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/23/2024, the H&P indicated, Patient 14 had a past medical history (PMH) of epidural abscess (an infection that forms in the space between your skull bones and your brain lining), diabetes (a disease in which the body’s ability to produce or respond to the hormone insulin resulting in elevated levels of glucose [sugar] in the blood) and laminectomy (surgery that creates space by removing bone spurs and tissues associated with arthritis of the spine) and was admitted with a chief complaint of bilateral (relating to two sides) flank pain (the area on either side of the lower back, between the pelvis and the ribs). During a review of Patient 14’s medical record (MR) titled, “Admission Initial Assessment,” dated 1/23/2024, the MR indicated, Patient 14’s preferred spoken and written language was Spanish. During a review of Patient 14’s medical record (MR) titled, “Blood Transfusion Consent,” dated 1/24/2024, the MR indicated, Patient 14 signed the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for blood transfusion (a process in which blood or blood components are administered to the patient through an intravenous [into the vein] line) on 1/24/2024, but nursing did not document using translator services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when obtaining the informed consent. During a review of Patient 14’s medical record (MR) titled, “Consent for Peripherally Inserted Central Catheter (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period),” dated, 2/1/2024, the MR indicated, Patient 14 signed the Informed Consent on 2/1/2024, but nursing did not document using the translator services that was supposed to be used when obtaining the informed consent for a patient whose preferred language was not English. During a concurrent interview and record review on 2/8/2024 at 1:57 p.m. with house supervisor (HS), Patient 14’s medical records (MR) titled, “Blood Transfusion Consent,” dated 1/24/2024 and “Consent for Peripherally Inserted Central Catheter,” dated 2/1/2024, were reviewed. The MR indicated, nursing did not document using translator services on both Informed Consents. The HS stated nursing should provide a qualified translator for non-English speaking patients and document in the patient’s medical record the name or the interpreter identification (ID) number of the person who acted as a translator, but nursing did not. During a review of the facility’s policy and procedure (P&P) titled, “Translation/Interpretation Services for Patients,” last reviewed, 7/2022, the P&P indicated, “non-English speaking patients must be provided with translators/interpreters to provide quality health care services and allowed patients to feel comfortable in the healthcare environment. Hospital staff shall make appropriate arrangements if the patient is identified as needing interpreter services/ Once a translator was provided to a patient, documentation should be placed in the patient’s medical record indicating the name or the Interpreter ID # of the person who acted as the interpreter.” During a review of the facility’s policy and procedure (P&P) titled, Patient Rights and Responsibilities, “last revised 6/2022, the P&P indicated, “The patient’s rights include being informed of his/her health status, being involved in care planning and treatment. The patient has the right to receive accurate and current information regarding the health status in terms they can understand and have the interpreter to assist language needs.””

“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: 48212 Based on interview and record review, the facility failed to ensure its nursing staff documented properly and follow medication administration procedure on the electronic Medication Administration Record (eMAR, a record of medications given to patient) after a narcotic (opioids medication for pain relief) was given to one of 34 sampled patients (Patient 21) per facility Policy and Procedure. This deficient practice had the potential to put Patient 21 at risk for overdose on narcotics as it was not recorded on the electronic Medication Administration Record properly. Findings: During a review of Patient 21’s “History and Physical (H&P, a formal and complete assessment of the patient and the problem),” dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility’s Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation). The H&P also indicated Patient 21 was awake and alert. During a concurrent interview and record view on 2/8/2024 at 2:40 p.m. with QARN, Patient 21’s nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 2/7/2024 at 7:28 a.m., was reviewed. The Nurse notes indicated Patient 21 complained of 9/10 (pain scale of 0 - 10 utilized to rate the severity of pain with 10 being the most severe) foot pain and Norco (narcotics, type of opioid medication for pain relief) was given by LVN 7. QARN verified that LVN 7 did not record Norco administration on Patient 21’s electronic Medication Administration Record. During an interview on 2/9/2024 at 2:05 p.m. with the Charge Nurse (CN 6) of DOU, CN 6 stated narcotics should be scanned and recorded on the eMAR upon medication administration. CN 6 stated if it was not recorded on the MAR, there would be risk for overdosing the patient as the nurse might not know the narcotics was given previously. During a review of the facility’s policy and procedure (P&P) titled, “Administration of Medications,” dated 08/2023, the P&P indicated, “the administration of each dose of medication shall be accurately recorded in the patient’s electronic medication administration record (eMAR) via barcode scanning (verifies patient identity as well as insuring that the patient receives the right medication, in the right dose, via the right route, at the right time) during administration ... the electronic medication administration record shall include the name and dose of the medication, the route of administration, the date and time of administration, and the initial of the person administering the dose.””