Montclair Hospital Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 51828 This Condition is not met as evidenced by: Based on interview and record review, the Governing Body (GB-a group of people responsible for the overall direction and management of an organization) failed to provide adequate oversight to ensure quality of care and safety for 31 of 31 sampled patients when: The GB did not ensure an effective oversight of quality improvement measures and oversight of medication administration process including nursing assessment, reassessment, medication and order reconciliations (is a safety process that ensures your healthcare provider has the most accurate, up-to-date list of every medication you are taking and current order information), and notification to healthcare provider in regards to change in vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood)). (Refer to A-0049) The cumulative effect of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 51828 Based on interview, and record review, the facility failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI- is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for 31 of 31 sampled patients, as evidenced by: 1. The facility did not ensure an ongoing program to monitor, collect data and analyze the process of medication reconciliation (chart check of a patient’s current medication list with new orders during transitions of admission, transfer, and discharge), follow the physician orders, notification to the responsible physician of abnormal vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR- how fast the heart is beating every minute, respiratory rate (RR- how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood)), and obtaining an order prior to using Bilevel Positive Airway Pressure (BIPAP- a non-invasive breathing aid that uses a mask to deliver pressurized air to help patients breathe). (Refer to A-0273). 2. The facility did not maintain an effective and ongoing hospital wide, data driven QAPI program to identify opportunities from the collected data of the issues of restraints (any device, method, or medication used to intentionally restrict a patient’s freedom of movement, physical activity, or normal access to their body) assessment, and nursing pain assessment and reassessment. (Refer to A-0283). The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas in nursing services and patient assessments and ensure the provision of quality health care in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health).”

“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: 51269 Based on observation, interview and record review the facility failed to maintain effective and organized nursing services for 16 of 31 sampled patients (Patient 2, 4, 6, 8, 9, 10, 11, 13, 15,18, 22, 24, 25, 26, 28, and 31) when: 1. For one patient (Patient 8), the nursing staff did not document restraints (device used to stop a patient from moving freely to prevent them from hurting themselves or others) reassessment every two hours. (Refer to A-398) 2. For one patient (Patient 15), the nursing staff did not perform an electrocardiogram (EKG- a test that checks how the heart is beating by recording its electrical signals and determining if there is anything abnormal) for a patient being admitted with chest pain. (Refer to A-398) 3. For four patients (Patient 13, 18, 26, and 28), the nursing staff did not notify the responsible physician of abnormal vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood)). (Refer to A-398) 4. For one patient (Patient 24), the nursing staff did not notify patient’s family regarding restraint application. (Refer to A-398) 5. For one patient (Patient 22), the nursing staff did not document the intake (amount of feeding or fluid given) for gastrostomy tube (G-Tube- a small tube that goes directly through the stomach used to give foods, liquids, and medicine to someone who cannot eat enough by mouth) feeding. (Refer to A-398) 6. For one patient (Patient 31), the nursing staff did not obtain an order prior to using Bilevel Positive Airway Pressure (BIPAP- a device that helps someone breathe by delivering higher pressure when you breathe in and lower pressure when you breathe out). (Refer to A-398) 7. For five patients (Patient 4, 6, 8, 9, and 10), the nursing staff did not completely document pain assessment before and/or after pain medication administration. (Refer to A-405) 8. For three patients (Patient 2, 11, and 25), the nursing staff did not administer medications as ordered. (Refer to A-405) The cumulative effects of these systemic problems resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed supervision, monitoring, evaluation, and treatment which jeopardized the health and safety of the patients.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 51828 Based on interview and record review, the Governing Body (GB-a group of people responsible for the overall direction and management of an organization) failed to identify and ensure a safe environment and provide quality of care for 31 of 31 sampled patients when the GB did not have an effective oversight on medication administration process including nursing assessment, reassessment, medication and order reconciliations (is a safety process that ensures your healthcare provider has the most accurate, up-to-date list of every medication you are taking and current order information), and notification to healthcare provider in regards to change in vital signs (VS-basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood)). These failures resulted in the hospital’s inability in identifying the problem prone areas and had the potential for treatment errors with unsafe respiratory, and medication administration and can cause adverse health outcomes such as inadequate patient monitoring, and inadequate therapy for treatment, which could negatively affect patients’ health, safety, prolonged hospitalization, and/or lead up to death. Findings: A review of the facility’s document titled, “Governing Board Meeting Minutes February 4, 2026,” indicated there was no documented evidence of the Quality Assurance and Performance Improvement (QAPI-is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) notification to the GB regarding physician order, medication reconciliation, and notification to healthcare provide in change in VS. During an interview on April 3, 2026, at 1:10 PM, in the facility’s conference room, with members of the Governing Board (GB): Chief Executive Officer (CEO), and the Director of Medical Staff, the survey team’s findings were discussed including missing pain assessment and reassessments, not following the physician’s orders, not obtaining an order prior to using Bilevel Positive Airway Pressure (BIPAP- a non-invasive breathing aid that uses a mask to deliver pressurized air to help patients breathe), not completing medication reconciliations, and not notifying healthcare provider in regard to change in VS. The CEO stated, the Performance Improvement/Patient Safety Committee (PI/PSC) reports to the board each meeting, which is every three months as noted in the GB minutes. The CEO further stated, improvement opportunities and interventions are discussed at each GB meeting for each department presenting. The CEO stated that the GB was made aware of QAPI improvement projects but not for issues with medication reconciliation, pain assessment and reassessment, and notification to provider regarding change in vital signs. The CEO stated order reconciliation is not part of the field that the facility tracked. The CEO stated, it is the responsibility of the GB to provide oversight to the PI/PSC and ensure patient safety. A follow-up concurrent interview on April 3, 2026, at 1:15 PM, the CEO stated, the BIPAP order issue of not following the physician’s order and not obtaining an order prior to using BIPAP, and not notifying the provider for vital signs changes would have been caught if the nursing staff had conducted 24-hour chart check (a detailed review of patient’s chart to verify all current medications and orders as part of medication and order reconciliation) as required. The CEO further stated she was informed of these issues with pain assessment and reassessment, physician order, and medication and order reconciliation during this survey. During a review of the facility’s policy and procedure (P&P) titled, “Verbal and Telephone Orders,” revised December 2012, the P&P indicated, “...A concurrent 24-hour audit of charts will be done by the License Nurse on the 7pm-7am [7:00 PM to 7:00 AM] shift. Orders are to be checked for completion, that orders have been carried out for the previous 24 hours. If orders are not completed, they are to be completed, dated, and authenticated with the time that the order was completed...” During a review of the facility’s (P&P) titled, “2026 Performance Improvement Plan,” dated January 2009, the P&P indicated, “...A. Governing Board: The Governing Board of [Hospital Name] has the authority and responsibility for: 1. Determining priorities regarding which processes to monitor (indicators and frequency) with data collection and the subsequent development of planned improvement efforts. 2. Assuring patient safety and quality of patient care and services, including the reduction of medical errors through organization-wide mechanisms and related policies ...””

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 51828 Based on interview and record review, the facility did not ensure an effective and ongoing Quality Assessment and Performance Improvement (QAPI-is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for 31 of 31 sampled patients when the facility failed to monitor, collect data and analyze the process of medication reconciliation (comparing a patient’s current medication list with new orders during transitions of admission, transfer, and discharge), follow the physician orders, and notification to the responsible physician of abnormal vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure ( BP-how strongly blood is pushing through arteries), heart rate (HR- how fast the heart is beating every minute, respiratory rate (RR- how fast a person is breathing), oxygen level (SPO2- how much oxygen is in the blood)), and obtaining an order prior to using Bilevel Positive Airway Pressure (BIPAP- a non-invasive breathing aid that uses a mask to deliver pressurized air to help patients breathe). These failures had resulted in the missed opportunity to identify patient safety issues and changes to improve patients’ health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients’ health and safety. Findings: During an interview on April 3, 2026, at 12:30 PM, in the conference room, with three members of the QAPI including the Director of Quality (DQ), Chief Nursing Officer (CNO), and Chief Executive Officer (CEO), the DQ stated that each department manager is responsible for its own Performance Improvement (PI) project including collecting and bring all the collected data and significant issues to the QAPI meeting. A follow-up concurrent interview and record review on April 3, 2026, at 12:33 PM, with the QAPI team, the facility’s document titled, “2026 Performance Improvement Dashboard” (PI), undated, was reviewed. There was no data to indicate that the facility monitored daily medication reconciliation to ensure patients’ medications remain current, and staff followed physician orders and notified physicians as appropriate. The DQ stated that the facility did not monitor or track medication reconciliation every 24 hours, physician orders, or physicians’ notification of abnormal vital signs. A follow-up interview on April 3, 2026, at 12:40 PM, with the QAPI team, the survey team brought up some of the issues identified during survey as follows: The nursing staff did not administer medication as ordered. The nursing staff did not notify responsible physicians of abnormal vital signs. The nursing staff did not conduct medication reconciliation for pain medications and electrocardiogram (EKG- a test that checks how the heart is beating by recording its electrical signals and determining if there is anything abnormal) order. The facility staff did not obtain an order prior to using BIPAP. The DQ verified and confirmed that the survey team findings were not being tracked or monitored. The DQ stated that the facility needs to have better tracking of the issues identified. A follow-up concurrent interview on April 3, 2026, at 1:15 PM, the CEO stated, the BIPAP usage without a physician order, and the physician notification for vital changes would have been caught if the nursing staff had conducted a 24-hour chart check (a detailed review of patient’s chart to verify all current medications and orders as part of medication and order reconciliation) as required. During a review of the facility’s policy and procedure (P&P) titled, “2026 Performance Improvement Plan,” dated January 2009, the P&P indicated, “...[Hospital Name] Leadership and Medical Stall will set performance improvement priorities for [Hospital Name]-wide activities and patient health outcome, which is proportional to the scope and complexity of the [Hospital Name] program. The program will include but not be limited to indicators for which there is evidence of improved health outcomes, prevention and reduction of medical errors ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 51828 Based on interview and record review, the facility did not ensure an effective and ongoing Quality Assessment and Performance Improvement (QAPI-is a proactive, data-driven system used in healthcare to constantly improve patient care and safety) program for 31 of 31 sampled patients when the facility did not maintain an effective and ongoing hospital wide, data driven QAPI program to identify opportunities from the collected data of restraints (any device, method, or medication used to intentionally restrict a patient’s freedom of movement, physical activity, or normal access to their body) assessment, and nursing pain assessment and reassessment. These failures had resulted in the hospital inability to focus on problem prone areas to ensure the provision of quality nursing and patient safety and had the potential to cause adverse health outcomes which could interfere with patients’ medical care and jeopardize the health and safety of the patients. Findings: During an interview on April 3, 2026, at 12:30 PM, in the conference room, with three members of the QAPI including the Director of Quality (DQ), Chief Nursing Officer (CNO), and Chief Executive Officer (CEO), the DQ stated that each department manager is responsible for its own Performance Improvement (PI) project including collecting and bring all the collected data and significant issues to the QAPI meeting. A follow-up concurrent interview and record review on April 3, 2026, at 12:40 PM, with the QAPI team, the facility’s undated document titled, “2026 Performance Improvement Dashboard” (PI), was reviewed. The “PI” indicated, restraints tracking for 1st quarter of 2026 [January 2026, through March 2026] at 100 percent (%) meeting target benchmark, and nursing pain assessment and reassessment tracking also showed 100% meeting target benchmark. The DQ verified and confirmed the tracking numbers. A follow-up interview on April 3, 2026, at 12: 33 PM, with the QAPI team, the survey team brought up some of the issues identified during survey as follows: The nursing staff did not complete restraint assessments every two hours. The nursing staff did not complete pain assessment before and after pain medication administration. The DQ verified and confirmed the issues. The DQ stated that the facility did not seem to do enough tracking to identify restraint, and nursing assessment and reassessment documentation. During a review of the facility’s (P&P) titled, “2026 Performance Improvement Plan,” dated January 2009, the P&P indicated, “...[Hospital Name] Leadership and Medical Stall will set performance improvement priorities for [Hospital Name]-wide activities and patient health outcome, which is proportional to the scope and complexity of the [Hospital Name] program. The program will include but not be limited to indicators for which there is evidence of improved health outcomes, prevention and reduction of medical errors ...””

“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: 51269 Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to hospital policies and procedures (P&P), to provide adequate supervision and evaluation for 9 of 31 sampled patients (Patient 8, 13, 15, 18, 22, 24, 26, 28, and 31) when: 1. For one patient (Patient 8), the nursing staff did not document restraints (device used to stop a patient from moving freely to prevent them from hurting themselves or others) reassessment every two hours. 2. For one patient (Patient 15), the nursing staff did not perform an electrocardiogram (EKG- a test that checks how the heart is beating by recording its electrical signals and determining if there is anything abnormal) for a patient being admitted with chest pain. 3. For four patients (Patient 13, 18, 26, and 28), the nursing staff did not notify the responsible physician of abnormal vital signs (VS- basic measurements that show how well a person’s body is working that includes temperature, blood pressure (BP-how strongly blood is pushing through arteries), heart rate (HR-how fast the heart is beating every minute), respiratory rate (RR-how fast a person is breathing), and oxygen level (SPO2- how much oxygen is in the blood)). 4. For one patient (Patient 24), the nursing staff did not notify patient’s family regarding restraint application. 5. For one patient (Patient 22), the nursing staff did not document the intake (amount of feeding or fluid given) for gastrostomy tube (G-Tube- a small tube that goes directly through the stomach used to give foods, liquids, and medicine to someone who cannot eat enough by mouth) feeding. 6. For one patient (Patient 31), the nursing staff did not obtain an order prior to using Bilevel Positive Airway Pressure (BIPAP- a device that helps someone breathe by delivering higher pressure when you breathe in and lower pressure when you breathe out). These failures resulted in the hospital’s inability to provide consistent and adequate nursing services in a safe environment and potentially resulted in delayed monitoring, evaluation, treatment, deterioration of patient conditions, and unsafe patient care. Findings: 1. During a review of Patient 8’s “History and Physical” (H&P- a document containing demographic information), dated March 28, 2026, the H&P indicated Patient 8 was admitted on March 28, 2026, at 5:25 AM, for insomnia (inability to get quality sleep). Patient 8 had medical history including congestive heart failure (CHF- a condition where the heart muscle is unable to pump blood effectively enough to meet the body’s needs) and intellectual disability (limited intellectual functioning). During a concurrent observation and interview on April 2, 2026, at 9:50 AM, in the medical surgical unit (MS-patients with general health conditions or those with recent surgery)/ telemetry (Tele-patients with cardiac or heart monitoring), in Patient 8’s room, with Registered Nurse (RN 6), Patient 8 was observed with bilateral (both side) soft wrist restraints attached to the bed. RN 6 verified and confirmed Patient 8 had bilateral soft wrist restraints. During a concurrent interview and record review on April 3, 2026, at 8:45 AM, with RN 5, Patient 8’s “Order” dated March 31, 2026, through April 2, 2026, and the “Flowsheet” (FS-a part of the electronic health record used to track patients information over time such as pain), dated April 1, 2026, through April 2, 2026, were reviewed. The “Order” indicated “Restraint type: Soft restraint...bilateral wrist; restraint reason: inference with medical treatment ...” The FS indicated that the restraints were documented as follows: On April 1, 2026, at 10:00 PM: “Restraint status ... in place ...” On April 2, 2026, at 2:00 AM: “Restraint status ... in place ...” (4 hours without documentation/monitoring) On April 2, 2026, at 7:00 AM: left blank without documentation, (5 hours without documentation/monitoring) RN 5 stated the night shift nurse (7:00 PM to 7:30 AM) did not document every two hours on the restraints and should have before the end of the shift. RN 5 stated it is important to check every 2 hours for any change of condition, for the circulation, and to check for any injury. During a concurrent interview and record review on April 3, 2026, at 10:47 AM, with the Chief Nursing Officer (CNO), the facility’s P&P titled, “Restraint: NON-VIOLENT behavior,” dated September 2024, was reviewed. The P&P indicated, “ ...Monitoring and care- patient in Non-Violent Restraints 1. A patient in restraints is monitored at least every two (2) hours or more often as applicable to the patient ...” The CNO confirmed and verified that the policy was not followed and should have. The CNO stated it is important to monitor the patients on restraints every two hours to ensure circulation is not compromised. 2. During a review of Patient 15’s H&P, dated March 31, 2026, the H&P indicated Patient 15 was admitted on March 31, 2026, at 10:08 AM, for chest pain and shortness of breath. Patient 15 had a medical history including hypertension (HTN-high blood pressure), diabetes mellitus (DM -high blood sugar), atrial fibrillation (A-fib: irregular heartbeat), and CHF. During a concurrent interview and record review on April 2, 2026, at 3:00 PM, with RN 6, Patient 15’s “EKG 12 LEAD” (EKG 12 LEAD- a test that records the electrical activity of the heart from 12 different views and can identify heart rhythm problems),” dated March 31, 2026, was reviewed. RN 6 verified and stated that she was unable to provide documented evidence that EKG was completed on March 31, 2026. During an interview on April 3, 2026, at 9:38 AM, with RN 4, RN 4 stated that when a patient shows up to the facility with chest pain, the nursing staff should obtain an EKG to rule out (exclude) a ST elevation myocardial infarction (STEMI- one of the arteries that supplies blood to the heart becomes completely blocked, it is also known as a heart attack). During a concurrent interview and record review on April 3, 2026, at 9:43 AM, with the Intensive Care Unit/Emergency Department Director (ICUEDD), Patient 15’s “EKG 12 LEAD,” dated March 31, 2026, was reviewed. The ICUEDD verified and stated that she was unable to provide documented evidence that an EKG was completed on March 31, 2026. The ICUEDD further stated that there should be one. During a concurrent interview and record review on April 3, 2026, at 10:48 AM, with the CNO, the facility’s P&P titled, “Standardized procedure: Relief of Chest Pain- ICU [intensive care unit]/Tele/ ED [Emergency Department],” dated September 2024, was reviewed. The P&P indicated, “ ...I. The competent registered nurse may initiate the following to relieve chest pain: 1. Obtain a 12 lead EKG ...” The CNO stated that Patient 15 did not get an EKG and should have. The CNO also stated that it was important to obtain an EKG for patients with chest pain to assess patients and determine what the following steps in plan of care should be. 3a. During a review of Patient 13’s H&P, dated March 31, 2026, the H&P indicated Patient 13 was admitted on March 30, 2026, at 6:27 PM, for neck pain. Patient 13 had a medical history including HTN, DM, coronary artery disease (CAD-heart condition where the blood vessel that supply blood to the heart become narrow or blocked), and Bell’s palsy (a condition that causes sudden weakness or paralysis on one side of the face and can cause the face to droop.) During a concurrent interview and record review on April 3, 2026, at 8:48 AM, with RN 5, Patient 13’s “Flow sheet” (FS), dated April 1, 2026, to April 2, 2026, and “Nursing Notes,” dated April 2, 2026, at 12:30 AM, to April 2, 2026, at 7:45 AM, were reviewed. The FS indicated the following BPs: On April 1, 2026, at 7:19 PM: 148/78 (normal BP: 120/80: the top number measures the pressure in the arteries (blood vessels that carry blood away from the heart to the rest of the body) when the heart beats. The bottom number indicates the pressure in the arteries between heartbeats.) April 2, 2026, at 12:00 AM: 194/80 On April 2, 2026, at 4:22 AM: 200/94 On April 2, 2026, at 5:49 AM: 231/94 On April 2, 2026, at 8:00 AM: 214/89 The “Nursing Notes” indicated there was no physician notification of the abnormal BP. RN 5 verified and stated that the nursing staff are expected to notify the physician of any change in condition, including an increase in the patient’s blood pressure. RN 5 further stated it is important to notify the physician because there might be an underlying issue that can cause the increase in BP. During a concurrent interview and record review on April 3, 2026, at 10:49 AM, with the CNO, the facility’s P&P titled, “Vital Sign Parameters,” dated September 2024, was reviewed. The P&P indicated, “ ...Once values are obtained and assessed, the nurse will utilize clinical judgement to determine any necessary intervention and/or physician reporting based upon ...c. patient baseline and abnormal assessments. 4. All vital signs should be recorded in the EMR [Electronic Medical Record]. Any reporting or intervention that was deemed necessary should be documented.” The CNO stated that the policy was not followed for Patient 13 and should have. The CNO added that it is important to notify the physician of abnormal VS to get new orders if the current ones are not working. 47394 3b. During a review of Patient 18’s H&P, dated March 30, 2026, the H&P indicated that Patient 18 had complaint of abdominal pain. During a concurrent interview and record review on April 1, 2026, at 2:00 PM, with a Charge Nurse (CN1), Patient 18’s FS, dated March 31, 2026, through April 1, 2026, was reviewed. The FS indicated Patient 18’s BP as follows: On March 31, 2026, at 4:00 AM, BP was 162/87 On March 31, 2026, at 8:05 AM, BP was 163/77 On March 31, 2026, at 9:56 AM, BP was 162/82 On April 1, 2026, at 4:00 AM, BP was 176/91 On April 1,2026, at 4:14 AM, BP was 172/85 On April 1,2026, at 4:30 PM, BP was 166/88 CN 1 verified and confirmed Patient 18’s BP. A follow-up concurrent interview and record review on April 1, 2026, at 2:10 PM, with CN1, Patient 18’s “Order”, dated March 30, 2026, was reviewed. The “Order” indicated that the physician should be notified if the patient had systolic blood pressure [top number of the reading] greater than 140 or less than 90, or diastolic pressure [bottom number of the reading] is greater than 90 or less than 60. CN 1 acknowledged and verified the order. CN 1 stated that the nursing staff are expected to follow the physician order, and document in patient’s chart. During an interview on April 2, 2026, at 8:55 AM, with RN 7, RN 7 stated, when a patient has abnormal vital signs, the nurses are expected to call the physician by phone or text message system and inform the abnormal findings. RN 7 further stated, it is important as the vitals indicate the patient’s physical status and nurses are expected to document the provider notification. 3c. During a review of Patient 26’s H&P, dated March 31, 2026, the H&P indicated that Patient 26 had complaints of shortness of breath and asthma. During a concurrent interview and record review on April 2, 2026, at 10:50 AM, with CN1, Patient 26’s FS, dated March 31, 2026, through April 1, 2026, was reviewed. The FS indicated Patient 26’s HR as follows: On March 31, 2026, at 1:30 AM, heart rate (HR-normal adult hear rate is 60 to 100 beats per minute or bpm. Consistent high HR may indicate infection, or heart condition) was 151 bpm On March 31, 2026, at 5:00 AM, HR was 140 bpm On March 31, 2026, at 8:00 PM, HR was 138 bpm On April 1, 2026, at 8:00 PM, HR was 131 bpm CN 1 verified and confirmed Patient 26’s HR. During a concurrent interview and record review on April 2, 2026, at 10:55 AM, with CN 1, Patient 26’s “Order”, dated March 31, 2026, was reviewed. The “Order” indicated that the physician should be notified if the patient’s heart rate is greater than 120 bpm or less than 60 bpm. CN 1 acknowledged and verified the order. CN 1 stated that the nursing staff are expected to follow the physician order and document in patient’s chart. 3d. During a review of Patient 28’s H&P, dated March 31, 2026, the H&P indicated that Patient 28 had complaint of cerebrovascular accident (CVA- a condition in which the blood flow to a part of the brain was blocked). During a concurrent interview and record review on April 2, 2026, at 11:20 AM, with CN 1, Patient 28’s FS, dated April 1, 2026, was reviewed. The FS indicated Patient 28’s BP as follows: On April 1,2026, at 12:00 PM, BP was 81/48 On April 1,2026, at 4:00 PM, BP was 85/46 On April 1,2026, at 8:00 PM, BP was 90/47 CN 1 verified and confirmed Patient 28’s BP. During a concurrent interview and record review on April 2, 2026, at 11:25 AM, with CN 1, Patient 28’s “Order”, dated April 1, 2026, was reviewed. The “Order” indicated that the physician should be notified if the patient had systolic blood pressure greater than 140 or less than 90, or diastolic pressure is greater than 90 or less than 60. CN 1 acknowledged and verified the order. CN 1 stated that the nursing staff are expected to follow the physician order and document in patient’s chart. During a concurrent interview and record review on April 3, 2026, at 9:30 AM, with the CNO, the facility’s undated document titled, “Job description for Registered Nurse” (JD RN), was reviewed. The JD RN indicated, “ ...A. Knowledge of work 4. Documents evidence of nursing care on patients, record. Observed for reactions and/or complications and report to the physician in a timely manner”. The CNO stated, JD RN was followed. During a concurrent interview and record review on April 3, 2026, at 9:40 AM, with the CNO, the facility’s P&P titled, “Vital signs parameter”, dated September 2024, was reviewed. The P&P indicated, “Purpose: To provide guidelines for the assessment, monitoring, and documentation of vital signs. Procedure: 3. Standard parameters are general guidelines for healthy individuals. Fluctuations and/or deviation from established electronic medical record (EMR) Parameters may be expected in certain conditions and be clinically indicated by the physician or other licensed independent practitioners (LIP). Once values are obtained and assessed, the nurse will utilize critical judgment to determine any necessary interventions and/or physician reporting based upon: a. Physicians Order ...c. Patient baseline and abnormal assessments. 4. All vital signs should be recorded in the EMR. Any reporting or intervention that was deemed necessary should be documented.” The CNO stated, policy was not followed as we are missing documentation. The CNO further stated, changes in vital signs indicate the changes in patients’ health. 4. During a review of Patient 24’s H&P, dated March 31, 2026, Patient 24 had history including dementia (impaired ability to remember, think or make decisions), hypertension (high blood pressure), and dysphagia (difficulty in swallowing food). During an observation on April 1, 2026, at 10:10 AM, Patient 24 was observed to have soft restraints on both upper extremities. During a concurrent interview and record review on April 2, 2026, at 10:35 AM, with CN 1, Patient 24’s EMR, dated April 1, 2026, was reviewed. The EMR indicated that soft restraints were initiated on April 1, 2026, at 12:00 AM. CN 1 verified and was unable to provide any documented evidence to show Patient 24’s responsible party was notified before soft restraints were applied on Patient 24. CN1 stated, the nursing staff are expected to inform the family and document. During an interview on April 3, 2026, at 9:12 AM, with RN 5, RN 5 stated, the nursing staff are expected to inform the family regarding the initiation of the restraints and need to document in patient’s chart. During a concurrent interview and record review on April 3, 2026, at 9:50 AM, with the CNO, the facility’s P&P titled, “Restraints: Nonviolent behavior”, dated September 2024, was reviewed. The P&P indicated, “ ... Nonviolent or. Non-self-destructive restrained use: 4. The patient and the family are educated to the best extent possible. Education should include the purpose of restraint use, the criteria of termination and the monitoring/Care that will be provided ... Documentation 1.4. Physician/Family notifications”. The CNO stated that the policy was not followed as the facility was missing documentation for family notification. 5. During a review of Patient 22’s H&P, dated March 31 ,2026, the H&P indicated that Patient 22 had complaints of hypertension, diabetic mellitus (high blood sugar) and was a G tube dependent. During an observation on April 1, 2026, at 10:00 AM, Patient 22 was lying on her bed and G tube feeding bottle (a bottle containing the feeding solution) was observed disconnected from Patient 22. During a review of Patient 22’s “Order”, dated March 31, 2026, the “Order” indicated, G tube feeding of continuous rate at 40 milliliter per hour (ml/hr-a unit of measurement) of [Brand Name of Feeding Tube]. During a concurrent interview and record review on April 2,2026, at 10:25 AM, with CN 1, Patient 22’s EMR was reviewed. The EMR indicated that Patient 22 had no documentation of intake for G tube feeding. CN 1 verified the FS and confirmed that the G tube feeding documentation was missing. CN 1 stated, it was important to document the intake and output of G Tube feeding as it indicated the nutritional status of the patient. During a concurrent interview and record review on April 3, 2026, at 10:00 AM, with the CNO, the facility’s P&P titled, “Enteral Feeding Management”, dated September 2024, was reviewed. The P&P indicated, “ ...1. Maintain and record formula and water on intake and output record”. The CNO stated that the policy was not followed. 51828 6. During a review of Patient 31’s “Admission Record” (contains demographic and medical information), undated, the “Admission Record” indicated Patient 31 was admitted to the facility on January 5, 2026, to the Telemetry Unit on High Flow Nasal Cannula (a non-invasive respiratory support system delivering heated, humidified oxygen at high flow rates), with diagnoses that included chronic obstructive pulmonary disease (COPD- a progressive, long-term lung disease including emphysema and chronic bronchitis characterized by restricted airflow, chronic coughing, wheezing, and breathlessness), and atrial fibrillation (chronic arrhythmia causing a rapid, irregular heart rhythm, which occurs when the heart’s upper chambers (atria) beat out of sync with the lower chambers) During a concurrent interview and record review on April 2, 2026, at 12:00 PM, in the facility’s conference room, with RN 2, Patient 31’s “Physician Order List,” dated January 21, 2026, was reviewed. The “Physician Order” indicated, Patient 31 did not have physician order for a Bilevel Positive Airway Pressure (BIPAP- a device that helps someone breathe by delivering higher pressure when you breathe in and lower pressure when you breathe out). RN 2 acknowledged there were no orders for BIPAP prior to treatment with BIPAP on January 21, 2026. A continuous concurrent interview and record review with RN 2, Patient 31’s “Nursing Note,” dated January 21, 2026, was reviewed. The “Nursing Note” indicated that on January 21, 2026, at 12:29 PM, “Patient 31’s oxygen keeps desaturating [decreasing] Registered Respiratory Therapist (RRT 1) switched Patient 31 from High Flow Nasal Cannula to Mask BIPAP.” RN2 acknowledge there were no orders prior to switching from High Flow Nasal Cannula to Mask BIPAP. During a concurrent telephone interview and record review on April 2, 2026, at 3:07 PM, in the facility’s conference room, with RRT 1 on the Chief Nursing Office (CNO)’s phone, Patient 31’s “Physician Order List,” dated January 21, 2026, was reviewed. RRT 1 acknowledged there were no physician orders for BIPAP prior to providing oxygen treatment with BIPAP. RRT 1 stated there must be a physician order before medical treatment is provided. During a concurrent interview and record review on April 3, 2026, at 8:40 AM, in the facility’s conference room, with the CNO. Patient 31’s “Physician Order List,” dated January 21,2026, was reviewed. The CNO acknowledged there were no physician orders for BIPAP prior to the staff providing oxygen treatment with BIPAP. The CNO further stated that all patient treatment should have a physician order before initiating. During an interview on April 3, 2026, at 1:15 PM, with the Chief Executive Officer (CEO), the CEO stated, the BIPAP order issue of not following the physician order and not obtaining an order prior to using BIPAP, would have been caught if the nursing staff had conducted 24-hour chart check (a detailed review of patient’s chart to verify all current medication and orders as part of medication and order reconciliation). The CEO further stated she was informed of this issue with order reconciliation on during this survey. During a review of the Registered Respiratory Therapist job description title, “Respiratory Care Practitioner (RCP)-II” dated January 2010, indicated “ ...Job Summary: Under the direction and authorization of the medical director and cardiopulmonary director or manager, the Respiratory Care Practitioner (RCP II) is responsible for performing respiratory therapeutic and pulmonary diagnostic procedures as ordered by the ordering provider ...” During a concurrent interview and record review on April 3, 2026, at 8:50 AM, with the CNO, of the facility’s policy and procedure (P&P) titled, “Complete Order of Respiratory Therapy,” revised April 2024, was reviewed. The P&P indicated, “ ...Respiratory Care shall only be initiated by the Respiratory Care Practitioner upon the written order by a physician ...” The CNO further stated the policy was not followed and should have been.”

“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: 51269 Based on interview and record review, the facility failed to ensure that medications were administered in accordance with physician orders and accepted standards of practice for eight of 31 sampled patients (Patient 2, 4, 6, 8, 9, 10, 11, and 25) when: 1. For five patients (Patient 4, 6, 8, 9, and 10), the nursing staff did not completely document pain assessment before and/or after pain medication administration. 2. For three patients (Patient 2, 11, and 25), the nursing staff did not administer medications as ordered. These failures placed patients at risk for ineffective pain management and had the potential to result in patients’ safety from preventable medication errors with discrepancy and undetected adverse reactions which could negatively affect patients’ health, safety, prolonged hospitalization, and lead to actual harm or death. Findings: 1a. During a review of Patient 4’s “History and Physical” (H&P- a document containing demographic information), dated March 31, 2026, the H&P indicated, Patient 4 was admitted on March 30, 2026, at 3:59 PM, for abdominal (stomach) pain. During an interview on April 3, 2026, at 9:30 AM, with Registered Nurse (RN 4), RN 4 stated, the nursing staff are expected to assess pain one hour before a pain medication given to obtain a baseline and one hour after to determine if the medication is effective. During a concurrent interview and record review on April 3, 2026, at 9:50 AM, with the Intensive Care Unit/Emergency Department Director (ICUEDD), Patient 4’s “Order,” dated March 30, 2026, “Medication Administration” (MA- record of the medication given to a patient), dated March 30, 2026, at 6:22 PM, and “Flowsheet” (FS- part of the electronic health record used to tract patients information overtime such as pain, restraints, and medication), dated March 30, 2026, were reviewed. The “Order” indicated, “Morphine [medication to treat pain] injection 4 [milligram-unit of measurement] route: intravenous [IV- in vein] frequency: once ...” The MA indicated “Morphine injection 4 MG injection...given...Date: 3/30/2026 [March 30, 2026] Time: 1822 [6:22 PM] ...” The FS indicated the pain assessment was documented as follows: On March 30, 2026, at 4:15 PM: “Pain score [pain level to determine severity of pain from 0 to 10 where 0 is no pain and 10 is the worst pain] ...10...Abdomen ...” On March 30, 2026, at 9:31 PM: “Pain score ...8...Abdomen ...” (3 hours and 9 minutes after administration of pain medication). The ICUEDD verified the nursing staff did not reassess within an hour of the administration of pain medication and stated it is important to reassess to ensure the patient is comfortable. 1b. During a review of Patient 6’s H&P, dated March 28, 2026, the H&P indicated, Patient 6 was admitted on March 27, 2026, at 8:55 PM, for decreased appetite and weakness. Patient 6 had a medical history of testicular cancer (overproduction of cells in one or both testicles). During a concurrent interview and record review on April 3, 2026, at 8:39 AM, with RN 5, Patient 6’s “Order,” dated March 28, 2026, MA, dated April 2, 2026, at 5:08 AM, and FS dated April 2, 2026, were reviewed. The “Order” indicated, “acetaminophen (TYLENOL-medication to treat pain) tablet 650 MG route: oral [PO-by mouth] frequency: every 4 hours as needed ...for mild pain (1-3) ...” The MA indicated, “acetaminophen (TYLENOL) tablet 650 MG ...given ...Date: 4/2/2026 [April 2, 2026] Time: 0508 [5:08 AM] ...” The FS indicated the pain assessment was documented as follows: On April 2, 2026, at 5:08 AM: “Pain score: 3 ...” On April 2, 2026, at 8:00 AM: “Pain score: 0 ...” (2 hours and 52 minutes after administration of pain medication) RN 5 confirmed that the reassessment was not done within one hour of medication administration and stated that the nurses should reassess the effectiveness of a medication one hour after medication administration to ensure the medication worked. 1c. During a review of Patient 8’s H&P, dated March 28, 2026, the H&P indicated Patient 8 was admitted on March 28, 2026, at 5:25 AM, for insomnia (unable to or difficulty staying asleep). Patient 8 had medical history including congestive heart failure (CHF-a condition where the heart muscle is unable to pump blood effectively enough to meet the body’s needs) and intellectual disability (limited intellectual functioning). During a concurrent interview and record review on April 3, 2026, at 8:40 AM, with RN 5, Patient 8’s “Order,” dated March 28, 2026, MA, dated April 2, 2026, at 1:51 AM, and FS, dated April 2, 2026, were reviewed. The “Order” indicated, “oxyCODONE (ROXICODONE-medication to treat pain) immediate release tablet/ capsule 5 MG route: oral frequency: every 6 hours as needed ...for moderate pain (4-6) ...” The MA indicated, “oxycodone (ROXICODONE) ...5 MG ...given ...Date: 4/2/2026 [April 2, 2026] Time: 0151 [1:51 AM] ...” The FS indicated the pain assessment was documented as follows: On April 2, 2026, at 1:51 AM: “Pain score ...5 ...” On April 2, 2026, at 7:30 AM: no pain assessment documented (5 hours and 39 minutes, without pain reassessment documented) RN 5 confirmed that the reassessment was not done within one hour of medication administration and stated that the night shift nurse (7:00 PM to 7:30 AM) should reassess the effectiveness of a medication one hour after medication administration to ensure the medication worked. 1d. During a review of Patient 9’s H&P, dated March 30, 2026, the H&P indicated, Patient 9 was admitted on March 30, 2026, at 9:46 AM, for abdominal pain. Patient 9 had a medical history including cerebral vascular accident (CVA- blood flow to a part of the brain is blocked or burst also known as stroke), and severe rheumatoid arthritis (a disease that causes pain, swelling, stiffness in joints). During an interview on April 3, 2026, at 9:30 AM, with RN 4, RN 4 stated, the nursing staff are expected to assess pain one hour before a pain medication given to obtain a baseline and one hour after to determine if the medication is effective. During a concurrent interview and record review on April 3, 2026, at 9:51 AM, with the ICUEDD, Patient 9’s “Order,” dated March 30, 2026, MA, dated March 30, 2026, at 11:47 AM, and FS, dated March 30, 2026, were reviewed. The “Order” indicated, “Morphine injection 4 MG route: intravenous frequency: once ...” The MA indicated “Morphine injection 4 MG injection...given...Date: 3/30/2026 [March 30, 2026] Time: 1147 [11:47 AM] ...” The FS indicated the pain assessment was documented as follows: On March 30, 2026, at 11:47 AM: “Pain score ...10...” On March 30, 2026, at 4:21 PM: “Pain score ...9 ...” (4 hours and 34 minutes after administration of pain medication) The ICUEDD verified and stated that the nursing staff did not reassess within an hour of the administration of pain medication. The ICUEDD further stated it is important to reassess to ensure the patient is comfortable. 1e. During a review of Patient 10’s H&P, dated March 30, 2026, the H&P indicated, Patient 10 was admitted on March 29, 2026, at 10:52 PM, for abdominal pain. Patient 10 had a medical history of hypertension (HTN- high blood pressure). During a concurrent interview and record review on April 3, 2026, at 9:52 AM, with the ICUEDD, Patient 10’s “Order,” dated March 29, 2026, and March 30, 2026, MA, dated March 29, 2026, at 11:22 PM, and March 30, 2026, at 1:58 AM, and FS, dated March 29, 2026, to March 30, 2026, were reviewed. The “Order” for both dates indicated, “Morphine injection 4 MG route: intravenous frequency: once ...” The MA indicated “Morphine injection 4 MG injection...given...Date: 3/29/2026 [March 29, 2026] Time: 2322 [11:22 PM] ...” and “Morphine injection 4 MG injection...given...Date: 3/30/2026 [March 30, 2026] Time: 0158 [1:58 AM] ...” The FS indicated the pain assessment was documented as follows: On March 29, 2026, at 10:48 PM: “Pain score ...10...” On March 30, 2026, at 4:25 AM: “Pain score ...8 ...” (5 hours and 3 minutes after initial pain assessment) The ICUEDD verified and stated that the nursing staff did not assess Patient 10’s pain before given morphine at 1:58 AM and did not reassess within an hour of the administration of pain medication for administration on March 29, 2026, and March 30, 2026. The ICUEDD further stated it is important to reassess to ensure the patient is comfortable. During a concurrent interview and record review on April 3, 2026, at 10:43 AM with the Chief Nursing Officer (CNO), the facility’s Policy and Procedure (P&P) titled “Pain Management” dated September 2024 was reviewed. The P&P indicated, “ ...1. Assess for pain using a pain scale ... B. Before and after any pain-producing treatment of procedure E. After each pain management intervention once, sufficient time has elapsed (passed) for the treatment to reach peak effect (most effective), the goal is reassessment and documentation within 1 hour of intervention ...” The CNO stated that the policy was not followed and should have been for Patient 4, 6, 8, 9, and 10. The CNO stated it is important to follow the policy because the nursing staff should know the level of pain and treat accordingly. 2a. During a review of Patient 2’s H&P, dated March 27, 2026, the H&P indicated, Patient 2 was admitted on March 26, 2026, at 7:28 PM, for altered mental status (AMS- a person’s thinking, awareness, or alertness is not normal) and fatigue (very tired, weak, low energy). Patient 2 had a medical history including HTN and atrial fibrillation. During an interview on April 3, 2026, at 8:41 AM, with RN 5, RN 5 stated, the nursing staff are expected to follow a physician’s order for medication administration. RN 5 further stated, a responsible physician should be notified if medication needs to be given different from the order. During a concurrent interview and record review on April 3, 2026, at 9:54 AM, with the ICUEDD, Patient 2’s “Order,” dated March 26, 2026, MA, dated March 29, 2026, at 3:53 PM, and FS, dated March 29, 2026, were reviewed. The “Order” indicated, “oxycodone-acetaminophen (Percocet-a combination of medication to treat pain) 5-325 MG [5 mg of oxycodone and 325 mg of acetaminophen] ...frequency: every 4 hours as needed for moderate pain (4-6).” The MA indicated, “oxyCODONE-acetaminophen (Percocet) 5-325 MG ...Given ...3/29/2026 [March 29, 2026] ...Time: 1553 [3:53 PM] ...” The FS indicated the medication was administered as follows: On March 29, 2026, at 3:00 PM: “Pain ...FLACC [pain assessment tool used for patients who are unable to communicate verbally- score ranging from 0 (least pain) to 10 (highest pain)] score 0.” The ICUEDD verified and stated that the medication was not given as ordered. The ICUEDD further stated that the nursing staff should administer medication as indicated on the order. 2b. During a review of Patient 11’s H&P, dated April 1, 2026, the H&P indicated, Patient 11 was admitted on March 31, 2026, at 6:10 PM, for foot pain and had a medical history of HTN. During a concurrent interview and record review on April 3, 2026, at 8:43 AM, with RN 5, Patient 11’s “Order,” dated March 31, 2026, MA, dated April 1, 2026, at 12:20 AM, and FS, dated March 31, 2026, to April 1, 2026, were reviewed. The “Order” indicated, “HYDROcodone-acetaminophen (NORCO-a combination of medication to treat pain) 5-325 MG [hydrocodone 5 mg and acetaminophen 325 mg] ...frequency: every 4 hours as needed for moderate pain (4-6).” The MA indicated, “HYDROcodone-acetaminophen (NORCO) 5-325 MG ...Given ...Date 4/1/2026 [April 1, 2026] ... Time: 0020 [12:20 AM] ...” The FS indicated the medication was administered as follows: On March 31, 2026, at 11:46 PM: “Pain score ...9 ...” On April 1, 2026, at 12:13 AM: “Pain score ... 9 ...” RN 5 verified and stated, the medication was not given as indicated. RN 5 further stated, it is important for the nursing staff to follow a physician’s order. 47394 2c. During a review of Patient 25’s H&P, dated March 31, 2026, the H&P indicated that Patient 25 had complaints of HTN and hypoxic respiratory failure (a condition in which the normal function of lungs is affected). During a concurrent interview and record review on April 2, 2026, at 10:40 AM, with a Charge Nurse (CN1), Patient 25’s Electronic Medical Record (EMR), dated March 31, 2026, was reviewed. The EMR indicated that Patient 25 had temperature as follows: On March 31,2026, at 3:24 PM, temperature was 103-degree Fahrenheit (F- unit of measurement, normal range of 97 to 99 F) On March 31,2026, at 5:36 PM, temperature was 101.2 F On March 31,2026, at 8:46 PM, temperature was 101.4 F On March 31,2026, at 9:35 PM, temperature was 101.4 F CN 1 verified and confirmed Patient 25’s temperature readings. A follow-up concurrent interview and record review on April 2, 2026, at 10:45 AM, with CN 1, Patient 25’s “Order”, dated March 31, 2026, was reviewed. The “Order” indicated Tylenol 650 mg was ordered for mild pain for a scale of 1-3. CN1 verified and stated, Patient 25 had high temperature readings and Tylenol was ordered for pain. A follow-up concurrent interview and record review on April 2, 2026, at 10:50 AM, with CN1, Patient 25’s medication administration record (MAR), dated March 31, 2026, was reviewed. The MAR indicated that Patient 25 received Tylenol on March 31, 2026, at 9:35 PM for fever. CN1 acknowledged and verified the MAR and documentation. CN1 stated, the nurse should have requested the physician for the update of the order as Tylenol is ordered for pain not for fever. During a concurrent interview and record review on April 3, 2026, at 10:45 AM, with the Chief Nursing Officer (CNO), the facility’s P&P titled “Pain Management” dated September 2024 and “Medication administration” dated September 2024 were reviewed. The “Pain Management” indicated, “ ... 1. Assess for pain using a pain scale ... B. Before and after any pain-producing treatment of procedure ... 5. Pharmacologic pain management will be provided to patients by physician order. “ The “Medication Administration” indicated, “ ...10. Verify that the right medication is being given to right patient at right dose at right time by the right route ...” The CNO stated that the policies were not followed for Patients 2, 11 and 25 should have been. The CNO stated that it is important for the nursing staff to follow the physician order because they do not want to over or under medicate a patient with pain.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 47360 Based on interview and record review, the Governing Body (GB- a group of people or a committee that leads a health care organization’s compliance and quality oversight efforts) failed to ensure quality of care was provided for 30 of 30 patients when, the GB did not provide oversight of quality improvement measures implemented for Intravenous (IV- into a vein) drip continuous medication administration assessment and reassessment, or ensure an effective safety and quality improvement program of the Operating Room (OR) staff for surgical counts(checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient’s body) and electrocautery (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety. (Refer to A-0049) The cumulative effect of this systemic problem resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 47360 Based on interview and record review, the facility failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for a universe of 30 patients, when: 1. QAPI failed to monitor, collect and analyze quality data when a surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient’s body), are accurately counted and electrocautery (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety during surgery . Refer to A-273). 2. The facility failed to identify the collected data to utilize the opportunities for improvement to measure its success, and to ensure that the improvements are sustained when the issues regarding the continuous Intravenous (IV- into a vein) drip medication administration assessment and reassessment was not monitored. (Refer to A-283) The cumulative effects of these systemic problems resulted in the hospital’s inability to identify problem prone areas (likely to cause errors) and ensure the provision of quality health care and nursing services in a safe environment and had the potential to cause adverse health outcomes (undesirable and harmful effects on someone’s health) which could interfere with the patients’ medical care and may jeopardize the health and safety of other patients undergo the surgeries.”

“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: 47360 Based on interview, and record review, the facility failed to maintain an organized nursing services to patients for two of 30 sampled patients (Patient 1 and Patient 27), as evidenced by: 1a. For Patient 27, the nursing staff did not perform surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient’s body) are accurately counted per facility policy and procedure, which lead to a retained surgical laparotomy sponge (a surgical gauze that is accidentally left inside the body), a secondary surgery to remove the item and had acquired infection. (Refer to A-0395) 1b. For Patient 27, the nursing staff did not document the Electro surgical settings(a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety, including cautery settings (amount of electricity used to cut and seal tissue during surgery) and grounding pad (a pad placed on the body before the surgery to protect the person from the harmful effects of the electricity) during the surgery. (Refer to A-0395) 2. For Patient 1, the nursing staff did not document an assessment on a dexmedetomidine (Precedex -a sedative medication) drip (continuous Intravenous [IV-going into a vein] infusion) for 4 hours on June 2, 2025. (Refer to A-0410) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of safe and quality nursing care in a safe environment and potentially resulted inadequate patient monitoring prolonged discomfort, infection and delayed healing which significantly jeopardized the health and safety.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 47360 Based on interview and record review, the Governing Body (GB-a group of people or a committee that leads a health care organization’s compliance and quality oversight efforts) failed to identify and ensure a safe environment and provide quality of care for 30 of 30 sampled patients when the Quality Council Committee (QCC) did not have a tracking system for data collections and monitoring patients with a continuous sedative (a drug used to calm or induce sleep) intravenous (IV-into the vein) medication assessment and identifying surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient’s body) and electrocautery ( a surgical tool that uses a high temperature by a direct electrical current to cut and seal tissue) safety measures in the operating room. This failure resulted in the facility’s inability to identify and prevent a retained surgical item (objects left unintentionally inside patient’s body after surgery) and monitor patients with a continuous sedative IV medication which had the potential to cause adverse health outcome such as inadequate monitoring, infection, overdosing medication, and could negatively affect patients’ health, safety, and/or lead up to death. Findings: During a review of the facility document titled, “Governing Board Meeting Minutes” dated May 7, 2025, the meeting minutes under “1st Quarter 2025 PI [Performance Improvement] Dashboard Summary” indicated, “4. Departmental Performance Improvement Measures” was not monitoring IV medication drip assessments or surgical counts and surgical safety processes and documentation and were not identified as a problem prone area or focus by the GB. A further review of the record indicated the performance data that was collected and presented, did not identify what was discussed regarding the results or progress of the root cause analysis and further implementation to address patient care areas without meeting goal. The “Action/Comments/Follow-Up” section of the minutes indicated, “Report was accepted as presented.”, and did not include quality care measures discussed, improvement opportunities identified, or implementation of corrective actions. During an interview on June 5, 2025, at 11:55 AM, in the conference room, with three members of the GB: Board Member 1, Board Member 2 and Board Member 3, the survey team’s findings was discussed. The GB’s Board Member 3 stated, the GB is ultimately responsible for the Quality Council Committee (QCC) and the Medical Executive Committee (MEC). - Board Member 3 stated, IV drip medications and assessments were a focus after the previous survey, but after six months of focus on the dashboard (program used to track and analysis data) and meeting goal, that metric was no longer a focus. Board Member 3 stated, since it was identified (continuous sedative drip assessment and monitoring) during this survey, it needs to continue to be a focus. - Board Member 3 stated, the facility was blind-sided by the retained surgical item (RSI- something that is left in a patient’s body after surgery), as the facility was not made aware of the incident by the secondary hospital. Board Member 3 stated, there have been areas of improvement identified by the survey related to missed surgical counts and electrocautery safety not being documented or conducted as often as required per policy and these processes will now be monitored by the GB. During an interview and record review on June 5, 2025, at 12:10 PM, with the GB, the facility document titled, “Governing Board Meeting Minutes” dated May 7, 2025, was reviewed. The “Governing Board Meeting Minutes” indicated, the “Action/Comments/Follow-Up” section of the minutes indicated, “Report was accepted as presented.”, and did not include any quality care measures discussed, improvement opportunities identified, or implementation of corrective actions. Board Member 3 stated, data collected by the committee’s is present to the board and improvement opportunities and interventions are discussed at length and an action plan is developed. Board Member 2 reviewed the minutes and stated, the discussion held during the GB meeting was not reflected in the GB meeting minutes and needed to what was discussed during the meeting. During a review of the facility’s document titled, “ Performance Improvement Plan 2025” dated January 2025, the “Performance Improvement Plan 2025” indicated, “ ...A. Governing Board the Governing Board of [ Name of Facility] has the authority and responsibility for: 1. Determining priorities regarding which processes to monitor (indicators and frequency) with data collection and the subsequent development of planned improvement efforts. 2. Assuring patient safety and quality of patient care and services, including the reduction of medical errors through organization-wide mechanisms and related policies; 3. Systemic evaluation of the effectiveness of the organization-wide performance improvement function; 4. Appropriate delegation of adequate resources for measuring, assessing, improving and sustaining [Name of Hospital} performance and the reduction of risks to patients; 5. Delegation of responsibility for performance improvement functions to MEC and the Performance Improvement/Risk Management Committee ...”.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 47360 Based on interview and record review, the Quality Assessment and Performance Improvement (QAPI) program failed to monitor, collect and analyze quality data for 30 of 30 patients, when surgical nursing quality indicators including surgical counts(checking inventory throughout the surgery to make sure everything is accounted for and none are accidentally left inside the patient’s body), and electrocautery (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety were not part of the QAPI tracked performance measures. This failure resulted in the hospital’s inability to identify problem prone areas (likely to cause errors) and ensure the provision of quality health care and nursing services in a safe environment and one patient (Patient 27) suffering from infection and an avoidable secondary surgery to remove a retained surgical item (RSI- something that is left unintentionally in a patient’s body after surgery). Findings: During a concurrent interview and record review on June 5, 2025, at 11:00 AM, with the Performance Improvement Manager (PIM), the facility document titled, “2025 Performance Improvement Dashboard [the Name of Hospital]” was reviewed. The “2025 Performance Improvement Dashboard [the Name of Hospital]” indicated, the facility was monitoring surgical procedure, complications (0%), unplanned return to OR (if a patient had to go back to the OR due to an unexpected complication or error from the initial surgery was -0%), anesthesia complications (0%) and all informed consents (process of communication between patient and healthcare provider for the permission of treatment or services)completed prior to procedure (100%). The PIM stated, in the 3rd Quarter of 2024, the time frame for Patient 27’s Cesarean Section (C-Section- a surgery where a baby is delivered through incisions made in the mother’s abdomen and uterus, instead of through the birth canal) rate was being monitored, but no other additional surgical quality measures. The PIM stated surgical counts and electrocautery safety were not a performance measure being tracked by QAPI. The PIM stated, the facility was not made aware of the retained surgical item (RSI- something that is left in a patient’s body after surgery) by Patient 27 or the secondary hospital, this facility did implement interventions. The PIM stated, the facility became aware of the RSI upon entrance for this survey, approximately nine months after the closure of the labor and delivery unit. The PIM further stated, there was a lack of documentation in Patient 27’s “Surgical Case Record” to show surgical counts were not implemented per the policy and procedure and no documentation noted regarding electrocautery settings. During a review of the facility’s document titled, “Performance Improvement Plan 2025” dated January 2025, the “Performance Improvement Plan 2025” indicated, “C. Quality Council Committee (PI [Performance Improvement]/Risk management) ...3. The Performance Improvement/Risk Management Committee of [Name of Hospital] is responsible for: a. Recommending for approval of the MEC [Medical Executive Committee], plans for maintaining quality patient care within the [Name of Hospital]. These may include mechanisms to: 1) Establish systems to identify potential problems in patient care; 2) Set priorities for action on problem correction; 3) Refer priority problems for assessment and corrective action to appropriate departments or committees; 4) Monitor the results of quality improvement activities throughout the [Name of Hospital]; 5) Coordinate performance assessment activities. B. Document what quality projects are being conducted, the reasons for conducting these projects and measurable progress achieved on the projects ...”.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 47360 Based on interview and record review, the hospital failed to maintain an effective and ongoing hospital wide, Quality Assessment and Performance Improvement (QAPI) program for 30 of 30 patients, when a continuous Intravenous (IV- into a vein) drip medication administration assessment and reassessment was not identified as a focus area and the areas identified by QAPI did not include an action plan in the meeting minutes to measure it’s success, track performance and to ensure that improvements are sustained. This failure resulted in the hospital’s inability to focus the already identified problem prone areas and set priorities to improve quality nursing care and ensuring a safe environment for their patients. Findings: During a concurrent interview and record review on June 5, 2025, at 10:45 AM, with the Performance Improvement Manager (PIM), the facility document titled, “2025 Performance Improvement Dashboard [the Name of Hospital]” was reviewed. The “2025 Performance Improvement Dashboard [Name of the Hospital]” indicated, ICU performance measures did not include IV drip continuous medication administration assessment and reassessment. The PIM stated, the IV drip continuous medication administration assessment and reassessment was a focus after issues were found with the last survey. The PIM stated, the continuous IV drip was monitored for six months after nurses had been re-educated and then once compliance was observed, that metric was no longer a focus. The PIM stated, the issue has been identified again during this survey and will need to become a focus again with education and audits. During an interview and record review, on June 5, 2025, at 11:15 AM, with the PIM, the facility document titled, “Performance Improvement/Patient Safety Committee” dated September 20, 2024, was reviewed. The “Performance Improvement/Patient Safety Committee” included the meeting minutes and the quality measures discussed with data collected from department directors. The document further indicated, each of the quality measures the had a section titled “Comments/Follow/UP/Monitor/Track/Trend” with “Report accepted as presented.” The document did not include specific comments on the quality measures regarding action plans, trends, interventions, evaluations. The PIM stated, these discussions do take place during QAPI meetings and need to be included in the meeting minutes. The PIM stated, the meeting minutes do not reflect the process and interventions used to improve the quality measures identified and discussed. During a review of the facility’s document titled, “Performance Improvement Plan 2025” dated January 2025, the “Performance Improvement Plan 2025” indicated, “C. Quality Council Committee (PI [Performance Improvement]/Risk management) ... 3. The Performance Improvement/Risk Management Committee of [Name of Hospital] is responsible for: a. Recommending for approval of the MEC [Medical Executive Committee], plans for maintaining quality patient care within the [Name of Hospital]. These may include mechanisms to: 1) Establish systems to identify potential problems in patient care; 2) Set priorities for action on problem correction; 3) Refer priority problems for assessment and corrective action to appropriate departments or committees; 4) Monitor the results of quality improvement activities throughout the [Name of Hospital]; 5) Coordinate performance assessment activities. B. Document what quality projects are being conducted, the reasons for conducting these projects and measurable progress achieved on the projects ...”.”

“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: 47360 Based on interview and record review, the facility failed to ensure licensed nurses maintained and implemented acceptable standards of care per the facility’s policies and procedures (P&P) for one of 30 sampled patients (Patient 27) when: 1a.The surgical counts (checking inventory throughout the surgery to make sure everything is accounted for and none are left accidentally left inside the patient’s body) are accurately counted and was not documented and instead of the minimum of four counts, three counts were conducted during a Cesarean Section (C-Section - a type of surgery where a baby is delivered through a cut made in the mother’s belly and uterus) for one patient (Patient 27). This failure resulted in an avoidable, secondary surgery to remove a retained laparotom y sponge (a sterile, super-absorbent pad used in surgery, especially in operations on the abdomen) and treatment for an abdominal abscess and potentially contributed to a third surgical procedure to control bleeding prolonged discomfort, infection and delayed healing which significantly jeopardized the health and safety. 1b. There was no documentation of Electro Surgical (a surgical tool that uses electricity to cut and seal tissue, which flows through an electrical current, from one electrode, through the tissue to a grounding pad) safety, including cautery settings (amount of electricity used to cut and seal tissue during surgery) and grounding pad (a pad placed on the body before the surgery to protect the person from the harmful effects of the electricity) for one patient (Patient 27). This failure resulted in lack of documentation for Patient 27 was grounded and had ordered cautery settings and had the potential to cause burns to Patient 27 during the C-Section. Findings: 1a. During a review of Patient 27’s, “History and Physical” (H&P- a document containing patient history and current medical issues) from Facility A, dated July 2, 2024, the “H&P” indicated, Patient 27 was admitted to Facility A’s Labor and Delivery Unit on July 2, 2024, for a C-Section. During a review of Patient 27’s, “Complete Operation Note” from Facility B, dated December 11, 2024, the “Complete Operative Note” indicated, “ ...Post Operative Diagnosis: 1. Intra-abdominal abscess (a pocket of pus that forms in the body, usually as a result of an infection) associated with retained laparotomy sponge (lap sponge - a surgical sponge or gauze that is accidentally left inside a patient’s body after a surgical procedure) ...Indication (reason) for Operation ...found to have retained foreign object on CT [Computed Tomography- an X-ray machine that uses a computer to create detailed images of the inside of your body] imaging suspicious for retained laparotomy sponge from cesarean section 5 months ago at outside hospital ...”. During a review of Patient 27’s, “Surgical Case Record” from Facility A, dated July 2, 2024, the “Surgical Case Record” indicated, Patient 27 had a planned cesarean section. The “Surgical Case Record” indicated, there were a total of three counts performed during the surgery. The “Initial Count” for lap sponge was left blank, the “Second Count” for lap sponge was marked as correct, and the “Final Count” for lap sponge was marked as correct, no other counts were documented. During an interview on June 3, 2025, at 3:23 PM, with Surgical Technician 1 (ST 1), ST 1 stated, the Circulating Registered Nurse (CRN) and the Surgical Technician (ST) will conduct an initial count prior to the patient’s arrival to the Operating Room (OR - a sterile room where surgical procedures are performed)to establish a baseline count of lap sponges and instruments. ST 1 stated, all other counts are performed with the entire surgical team and each of the counts are documented by the CRN. ST 1 further stated, a C-Section requires at least four counts by the surgical team during the operation including the initial count, closure of the uterus count, closure of the abdominal cavity count, and Final count. During an interview on June 4, 2025, at 11:20 AM, with Circulating Registered Nurse 1 (CRN 1), CRN 1 stated, counts are performed by the surgical team before the beginning of the surgery and throughout the surgery to ensure no surgical devices are mistakenly left behind in the patient. CRN 1 stated, it is the nurse’s responsibility to communicate with the surgical team and to document the counts in the patient’s chart. CRN 1 stated, a retained surgical item could cause bleeding and infection. During a concurrent interview and record review on June 5, 2025, at 9:12 AM, with the Director of Operating Room (DOR), the facility’s policy and procedure (P&P) titled, “Counts: Surgical” dated October 2022, was reviewed. The P&P indicated, “Purpose: To provide accountability for sponges, sharps, instruments, miscellaneous and any other small items that have the potential for being retained in a surgical wound. Implementation of accurate count procedures helps perioperative patient safety by preventing retained surgical items (RSI) ...Counts shall coincide with the number per packages ...Count Boards and instrument count sheets shall be used to track counts ...Counting ...Initial count before the procedure to establish a baseline and identify manufacturing package errors ...at anytime during the procedure when an item (s) is opened, it shall be added to the count ...Closing count upon closure of a cavity or within a cavity ...Final count immediately before completion of the surgical incision ...Documentation: 7. All Sponge, needle, instrument and miscellaneous item counts are the responsibility of a registered nurse and shall be documented on the patient’s intra-operative record 8. Types of counts ...10 results of counts ...”. The DOR stated, the facility does not have a specific instrument count sheet. It may be a scrap paper or an instrument count sheet that comes with the surgical kit, but that these papers are thrown away after the procedure. The DOR stated, the circulating OR nurse is responsible for documentation of counts: either correct or incorrect, not a numerical entry. The DOR stated, counts are done initially, before the patient enters the OR to establish a baseline count. Subsequent counts are based on addition of sponges or instrument to count, closure of each cavity, closure and final count. The DOR stated, anyone can initiate a count at any time there is a concern. The DOR further stated, based on the facility P&P, a c-section would require a minimum of four counts during the operative procedure. During a concurrent interview and record review on June 5, 2025, at 9:20 AM, with the DOR, Patient 27’s “Surgical Case Record” dated July 2, 2024, was reviewed. The “Surgical Case Record” indicated, a Cesarean Section was performed. The initial count for lap sponge was left blank, the “Second count” was marked as correct, and the “Final Count” was marked as correct. There were no other counts documented. The DOR stated, there was no documented evidence of the “Initial Count”, and it was the CRN’s responsibility to document the “Initial Count” and compare all subsequent counts. The DOR further stated, there are only three “Counts” noted to the documentation and a Cesarean Section requires at the minimum four: initial, closure of uterus, closure of abdominal cavity and final count. The DOR stated, a retained surgical sponge would result in Patient 27 requiring a secondary surgery, to remove the sponge and would likely cause pain and infection. During a telephone interview on June 5, 2025, at 9:38 AM, with the [ Name of Managed Health Care] Quality Review Nurse (QRN), the QRN stated, she had verified per claims that Patient 27 did not have any other documented surgical procedures between July 2, 2024 (d ate of c-section) and December 12, 2024 (date of surgery to remove laparotomy sponge). During a review of the facility document titled, “Job Description: Registered Nurse OR” (JD), dated January 2014, the “JD” indicated, “ ...The Registered Nurse coordinates the care of the patient with the surgeon and anesthesiologist, directs and guides the OR Technician and other personnel while maintaining standards of professional nursing ...Responsible for adherence to regulation, standards and hospital or unit policies and procedures ...B. Duties and Responsibilities ...3. Detects, corrects and/or reports incorrect instrument, sponge or needle counts ...”. 1b. During a review of Patient 27’s, “Surgical Case Record” from Facility A, dated July 2, 2024, the “Surgical Case Record” indicated, Patient 27 had a planned cesarean section. The “Surgical Case Record” indicated, the electrocautery settings and grounding of the electrocautery unit were not documented. During an interview on June 4, 2025, at 11:25 AM, with Circulating Registered Nurse 1 (CRN 1), the CRN 1 stated, the electrocautery settings need to be verified by the nurse and the doctor and grounding of the patient needs to be documented by the circulating RN. CRN 1 stated, these checks are part of patient safety in the OR, verifying settings and grounding to ensure the patient does not get burned. During a concurrent interview and record review on June 5, 2025, at 8:45 AM, with the Chief Nursing Officer (CNO) the facility’s policy and procedure (P&P) titled, “Electrocautery Safety” dated October 2022, and Patient 27’s “Surgical Case Record” dated July 2, 2024, was reviewed. The P&P indicated, “The intent of this policy is to establish guidelines for safe use of electrocautery during surgical procedures ...All electrosurgical generators shall meet the performance and safety standards of the facility. It is extremely important to provide for safe operation of electrosurgical units, used for the purpose of cutting and coagulation of body tissue with a high frequency electrical current during surgical procedures ...Documentation in [Name of electronic health record] -Electrocautery unit number & settings. - Grounding Pad lot number. - Any reddened areas, burn, marks or no problems ...”. The CNO stated, the electro cautery settings need to be documented in the patient chart per the P&P. The CNO further verified and stated, she reviewed Patient 27’s “Surgical Case Record” dated July 2, 2024, and stated, the CRN did not document these settings in Patient 27’s chart. During a concurrent interview and record review on June 5, 2025, at 9:25 AM, with the DOR, Patient 27’s “Surgical Case Record” dated July 2, 2024, was reviewed and indicated, a Cesarean Section was performed. There was no documented evidence of Electrocautery Unit ID (surgical device identification), Grounding Pad # (ground pad identification) or coagulation settings in Patient 27’s chart. The DOR stated, the coagulation settings and grounding unit were not documented. The DOR stated, it is the CRN’s responsibility to document these settings in the patient’s chart. The DOR further stated, per P&P these should be documented to ensure all is connected and working properly to prevent the patient from being burned. During a review of the facility document titled, “Job Description: Registered Nurse OR” (JD), dated January 2014, the “JD” indicated, “ ...The Registered Nurse coordinates the care of the patient with the surgeon and anesthesiologist, directs and guides the OR Technician and other personnel while maintaining standards of professional nursing ...Responsible for adherence to regulation, standards and hospital or unit policies and procedures ...B. Duties and Responsibilities ...7. Monitors all patient care equipment during use, ...electrocautery ...ensuring they are set with the appropriate parameters for the patient and that any/all alarms are audible at all times ...”.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 46696 Based on interview and record review, the facility failed to ensure the nursing staff assessed and documented continuously for one of 30 sampled patients (Patient 1), when a dexmedetomidine (Precedex -a sedative medication) drip (continuous Intravenous [IV-going into a vein] infusion) for 4 hours in an acceptable standard of practices on June 2, 2025. This failure had the potential to leave the patient unmonitored and under sedated which would compromising patient safety and possibly lead to undo discomfort. Findings: During a review of Patient 1’s History and Physical (H&P) dated, May 21,2025, the H&P indicated, Patient 1 was admitted to the facility on May 21,2025, with history of Dementia (neurodegenerative diseases that cause a decline in mental abilities), Parkinsons(a progressive brain disorder that primarily affects movement, causing symptoms like tremors, slowness of movement), Schizophrenia(a chronic brain disorder characterized by a disconnection from reality, including hallucinations and delusions) and malnutrition transferred from a skilled nursing facility for failure to thrive and urinary tract infection. During an interview on June 2,2025, at 9:55 AM, with Registered Nurse (RN2), RN2 stated, “we need to document on our IV drips every 2 hours if we are not adjusting the dose.” During a concurrent interview and record review on June 2, 2025, at 2:02PM with Registered nurse (RN1), Patient 1’s “Medications Administration Record” (MAR) dated June 2, 2025, was reviewed. Patient 1’s MAR indicated, “dexmedetomidine (Precedex- a sedative medication) 400 microgram (mcg a unit of mass in the metric system) in 100 milliliter (mL- unit of measurement ) infusion, Initiated dexmedetomidine infusion at 0.2mcg/kg/hr, ( the amount of medication in micrograms that is administered per kilogram of patient weight per hour ), titrate(adjust medication dose) by 0.1mcg/kg/hr every 15 minutes to achieve desired level of sedation. Titrate for RASS (Richmond agitation and sedation scale- a scale to measure levels of sedation or agitation, -1 (drowsy), -2 (light sedation), -3 (moderate sedation), -4 (deep sedation), -5 (unarousable sedation)) of -2. Administration documentation on June 2,2025 indicated: 2:41AM rate: 0.3mcg/kg/hr. Rass -2 4:00AM rate: 0.3mcg/kg/hr. Rass-2 6:00AM rate: 0.3mcg/kg/hr. Rass-2 8:00AM rate: 0.3mcg/kg/hr. Rass-2 10:00AM rate: 0.3mcg/kg/hr. Rass-2 After 10:00 AM, there was no documentation of the continuous IV drip infusion RASS score could be identified. RN1 verified and stated, there is missing documentation, there should be documentations at 12:00PM and 2:00 PM by now. During a concurrent interview and record review on June 4,2025 at 10:10AM, with the Director of Intensive Care Unit (DICU), Patient 1’s MAR dated June 2,2025 was reviewed. Patient 1’s MAR indicated, there was no nursing documentation on the dexmedetomidine drip including the RASS score on June 2,2025 after 10:00AM till 2:00PM. The DICU stated, “Yes, the nurse responsible has been spoken too about it, and per facility policy the nurse should have documented at minimum of every two hours per the intensive care unit (ICU) charting policy.” During a review of the facility policy and procedure (P&P) titled, “Charting for ICU (24hr Critical Care)” dated February 2024, the P&P indicated, “Data shall be collected continuously on all critically ill patients wherever they may be located. It consists of a baseline full body system assessment each shift and the following: ...5. Nursing documentation ... G. Chart reassessment of affected system q2(every 2) hours.””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42004 Based on interview and record review, the Governing Body (GB) failed to provide adequate oversight to ensure safe and effective patient care for a universe of 34 patients admitted on January 22, 2024, as evidenced by: 1. The GB did not ensure an ongoing quality improvement program. (Refer to A-0049). 2. The GB did not ensure the medication administration observation was evaluated. (Refer to A-0049). The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42004 Based on observation, interview, and record review, the hospital failed to implement patient rights for 30 sampled patients, as evidenced by: 1. For Patient 9, the nursing staff delayed in starting the blood transfusion. (Refer to A-0129) 2. For Patient 14, the facility failed to ensure patient’s representative was informed and involved in the plan of care in a timely manner after an unwitnessed fall. (Refer to A-0131) 3. For a universe of three (3) patients admitted to the Intensive Care Unit (ICU) on January 22, 2024, the needle supply cart was left unlocked. (Refer to A-0144) 4. Licensed Nursing staff removed, two patient (Patient 15 and 16) medications from the medication room at the same time, taken into a contact precaution (actions to prevent spread of germs by direct or indirect contact) room, and left unattended at Patient 16’s room. (Refer to A-0144) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care in a safe environment.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 42004 Based on observation, interview, and record review, the hospital failed to maintain an effective and on-going hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 34 patients admitted on January 22, 2024, as evidenced by: 1. The hospital did not ensure an ongoing program to monitor, collecting data and analyze the process of the medication administration, implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and the utilization of Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs). (Refer to A-0273) 2. The hospital failed to maintain an effective and ongoing hospital wide, data driven QAPI program to identify the collected data of the issues regarding nursing assessment, documentation, medication administration, and infection control practices to improve patient outcomes. (Refer to A-0283) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of quality health care and nursing services 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: 42004 Based on observation, interview, and record review, the facility failed to maintain an organized Nursing Services to patients for 30 sampled patients, as evidenced by: 1. For Patient 2, the nursing staff did not follow up or clarify on the STAT (as soon as possible) order for the Electroencephalogram (EEG-a test that record the brain activities) to ensure it was completed as ordered and did not closely monitor Patient 2 in response with seizure (SZ-a condition that causes abnormalities in muscle tone or movements) activity. (Refer to A-0395) 2. For Patient 3, Enoxaparin (Lovenox-medication to treat or prevent blood clot) syringe was left on the patient’s side table. (Refer to A-0398) 3. For Patient 4, patient’s own medications (POM) were left on the patient’s side table. (Refer to A-0398) 4. For Patient 1, the nursing staff did not administer Colace (stool softener) appropriately. (Refer to A-0405) 5. For Patient 1, the nursing staff did not administer Fluoxetine (Prozac-medication to treat depression) appropriately. (Refer to A-0405) 6. For Patient 10, the nursing staff did not check blood pressure (BP) before Hydralazine (medication to treat high blood pressure) administration. (Refer to A-0405) 7. For Patient 12, the nursing staff did not check blood sugar (BS) as ordered. (Refer to A-0405) 8. For Patient 5, the nursing staff did not assess BP and titrate (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) Norepinephrine (Levophed-a medication to treat life-threatening low BP) appropriately. (Refer to A-0410) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure the provision of safe and quality nursing care in a safe environment.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 42004 Based on observation, interview, and record review, the facility failed to ensure the infection prevention control program demonstrate adherence and control the transmission of infectious diseases including Hospital Acquired Infections (HAIs) for 30 sampled patients, as evidenced by: 1. For Patient 2, the nursing staff cleaned the intravenous (IV-into the vein) port with a used alcohol wipe after the medication administration. (Refer to A-0749) 2. For Patient 1, 27, and 29, intravenous infusion tubing (tubing that administers fluids and medication onto a patients vien) was not labeled and dated. (Refer to A-0749) 3. For Patient 16, the nursing staff did not clean/disinfect the IV port during two medication administration opportunities. (Refer to A-0749) 4. For Patient 15, the nursing staff did not clean/disinfect the glucometer (a portable device used to measure blood sugar) properly after used. (Refer to A-0750) 5. For Patient 15 and 16, the nursing staff did not wear Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) appropriately. (Refer to A-0750) 6. For a universe of 34 patients admitted on January 22, 2024, the facility failed to have a system in place to audit implementation and interventions for transmission-based precautions (used to help stop the spread of germs from person to another). (Refer to A-0770) 7. For Patient 16, the nursing staff implemented an incorrect transmission-based precaution. (Refer to A-0772) 8. For Patient 1, the nursing staff did not wash her hands after the medication administration. (Refer to A-0776) The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure safe and quality infection control program.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 42004 Based on observation, interview and record review, the Governing Body (GB) failed to ensure the quality of care was provided to patients for a universe of 34 patients admitted on January 22, 2024, when, 1. The GB did not ensure an ongoing quality improvement program. 2. The GB did not ensure medication administration process was evaluated appropriately to improve the quality of care. This failure had resulted in the facility’s failure to deliver quality patient care with the GB oversight and failure to provide safe medication administrations for patients. Findings: 1.During an observation on January 23, 2023, at 9:50 AM, in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit, Patient 1 was lying in bed with a trach attached to a ventilator, Registered Nurse 3 (RN 3) was observed using a needle to puncture a capsule of Colace (stool softner) 100 milligrams (mg-unit dosing medication), squeezed out the clear gel substance inside the capsule onto Patient 1’s apple sauce, and administered to Patient 1. During an observation on January 23, 2023, at 9:50 AM, in the MST Unit, Patient 1 was lying in bed with a trach attached to a ventilator, RN 3 was observed opening a capsule of Prozac (anti depressant) 10 mg, poured the white powder inside the capsule onto Patient 1’s apple sauce, and administered to Patient 1. During an interview on January 26, 2024, at 8:55 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the department had not observed, tracked, or collected data regarding the “medication pass [med pass-a process of giving medication to patient].” A follow-up interview and record review on January 26, 2024, at 9:00 AM, with the DPD and Pharm 1, the facility’s document titled, “Performance Improvement Quality Council/Committee,” dated November 30, 2023, was reviewed. The “Performance Improvement Quality Council/Committee” indicated, the “medication administration” received 100 percent (%) with no issues identified. There was no documentation of data collection and analysis, description for mitigation plans or person responsible. The DPD verified and stated, the data did not come from the pharmacy department. The DPD further stated, there were no opportunities of med pass to observe in the year of 2023 from the pharmacy department. 2. During a concurrent interview and record review on January 26, 2024, at 9:45 AM, in the conference, with the Director of Quality Department (DQD), the facility’s document titled, “Performance Improvement Quality Council/Committee,” dated November 30, 2023, was reviewed. The “Performance Improvement Quality Council/Committee” indicated, the nursing assessment, documentation, and medication administration received 100% with no issues identified. The DQD verified and confirmed the results. The survey team brought up some issues identified during survey related to inappropriate medication administration observation during med pass in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit. The DQD stated, each service area would be responsible to conduct its own audit and his department would collect data. Based on the results, the DQD stated, there was no identification of issues. A follow-up interview on January 26, 2024, at 10:20 AM, with the DQD, the DQD stated, the medication administration data came from each nursing department combined since the pharmacy department has not conducted any med pass observation. During an interview on January 26, 2024, at 10:25 AM, in the conference room, with the DQD and Registered Nurse 6 (RN 6), RN 6 stated, she had some opportunities to observe med pass and identified issues from the nursing staff; however, she did not report to anyone. During an interview on January 26, 2024, at 11:10 AM, in the conference room, with the facility’s administration. The survey team brought up some issues identified during survey related to inappropriate medication administration observation during med pass and there was no data collection of medication administration audits. The Chief Executive Officer (CEO) confirmed and stated, the facility had stopped the pharmacy department to conduct the med pass observation, so the GB was not aware of the issues involving the med pass. A review of the facility’s document titled, “Amended & [and] Restated Governing Board Bylaw,” reviewed September 6, 2023, indicated, “ ...the primary purpose of the Hospital is to provide quality health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the Hospital ... supporting the Hospital’s Performance Improvement Programs and its initiatives and the Hospital’s Patient Safety Program ...””

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 42004 Based on interview and record review, the facility failed to ensure patient received a reasonable treatment requested for service for one of 30 sampled patients (Patient 9) when the nursing staff delayed in starting the blood transfusion in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit. This failure had resulted in delay of patient’s care which could potentially compromise and negatively affect Patient 9’s condition and lead to actual harm or death. Findings: A review of Patient 9’s “History and Physical” (H&P), dated January 20, 2024, the H&P indicated, Patient 9 was admitted into the facility for vaginal bleeding. A review of Patient 9’s “Hemoglobin [Hgb-cells that carry oxygen to body] - History,” dated January 20, 2024, from 3:00 AM through January 21, 2024, at 5:25 AM, indicated as follow: On January 20, 2024, at 3:35 AM: Hgb 7.2 grams per deciliter (g/dL-the amount of Hgb in blood with normal range for female is 12 to 16 g/dL) On January 20, 2024, at 3:35 AM: Hgb 8.0 g/dL On January 21, 2024, at 5:25 AM: Hgb 6.5 g/dL During an interview on January 25, 2024, at 2:40 PM, in the conference room, with Registered Nurse 6 (RN 6), RN 6 stated, the process of giving the blood transfusion included the nursing staff notified a physician to obtain an order with the critical level of Hgb. RN 6 stated, the nursing staff should attempt to start the blood transfusion within one (1) hour after received a call from the blood bank of the readiness of blood. A review of Patient 9’s “Critical Value Lab Reporting,” dated January 21, 2024, indicated, the critical value for Hgb of 6.5 was reported to a physician on January 21, 2024, at 8:35 AM. A follow-up concurrent interview and record review on January 25, 2024, at 3:15 PM, with RN 6, Patient 9’s “RBC [Red Blood Cell-blood components to help delivery oxygen to the body] - No Active Bleeding,” dated January 21, 2024, at 9:33 AM, was reviewed. The “RBC - No Active Bleeding” indicated, Patient 9 was ordered to receive the blood transfusion for Hgb less than 7 g/dL. RN 6 verified and confirmed the order date and time. During a concurrent interview and record review on January 25, 2024, at 3:20 PM, in the conference room, with Laboratory Manager 1 (LM 1), Patient 9’s laboratory report, dated January 21, 2024, was reviewed. LM 1 verified and stated, the laboratory staff notified the nursing staff on January 21, 2024, around 12:00 PM, that the blood was ready to be picked up. During an interview on January 25, 2024, at 3:30 PM, with RN 6, RN 6 stated, she was unable to provide any documented evidence to show the nursing staff notified a physician regarding the delayed in starting the blood transfusion on January 21, 2024. A follow-up concurrent interview and record review on January 25, 2024, at 3:35 PM, with RN 6, Patient 9’s “Blood or Blood Component Transfusion,” dated January 21, 2024, was reviewed. The “Blood or Blood Component Transfusion” indicated, the blood transfusion was started at 3:15 PM. RN 6 verified and confirmed, it took about six (6) hours after received a physician order before started the blood transfusion. RN 6 stated, it was a delayed of care. A review of the facility’s policies and procedures (P&P) titled, “Patient Rights and Responsibilities,” dated September 2023, indicated, “Policy: [Hospital Name] shall identify each and every patient’s Rights and Responsibilities by doing the following: ... 3. Developing and implementing hospital-wide policies and procedures that address the Patient Rights and Responsibilities ... Patient Bill of Rights. You have the right to: ... 9. Reasonable responses to any reasonable requests made for service ...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47360 Based on interview, and record review, the facility failed to ensure patient’s representative was informed and involved in the plan of care after an unwitnessed fall for one of 30 sampled patients (Patient 14). This failure resulted in Patient 14’s family not receiving the information needed to promptly participate in the plan of care, which caused Patient 14’s family to distrust the health care team and had the potential to interfere with Patient 14’s overall medical care. Findings: During a review of Patient 14’s “History and Physical” (H&P), dated December 6, 2023, the H&P indicated Patient 14 was admitted with diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI - heart attack), pneumonia (infection in the lung) and history of dementia (disease affecting the brain’s ability to think, remember and reason). During an interview on January 24, 2024, at 9:28 AM, with Patient 14’s daughter, Patient 14’s daughter stated, her father had been admitted to the facility in December 2023. Patient 14’s daughter stated, she had communicated with the facility staff that she was to be involved in all medical decisions and visited father daily during the hospitalization. Patient 14’s daughter stated she was not informed about her father’s fall or updated on his health status until the morning after the fall. During a review of Patient 14’s “Admission/Registration” dated December 12/05/2023, the “Admission/Registration” indicated, “ ...PERSON TO NOTIFY ... [name of Patient 14’s daughter] ... [Patient 14’s daughter’s phone number] ...”. During a review of Patient 14’s “Nurse Notes” dated December 7, 2023 at 12:30 AM, the “Nurses Note” indicated, “Patient had an unwitnessed fall. Pt found on floor, awake, and alert X 1. Pt placed back into bed. Bed alarm on. Pt agitated and confused. Vital signs stable post fall, no complaints of pain ...skin tear to L forearm noted ...”. A further review of the “Nurses Note” at 1:00 AM, indicated, “Patient further assessed. Equal strength to bilateral upper extremities and bilateral lower extremities. Patient denies pain upon movement of all limbs. Pt verbally responsive, denies pain at this time. No s/s [signs or symptoms] of distress.” During a concurrent interview and record review on January 24, 2024, at 2:30 PM, with the Chief Nursing Officer (CNO), Patient 14’s “electronic medical record” was reviewed. The CNO was unable to find any documented evidence indicating the of notification of family after Patient 14’s fall. The CNO stated, she was unable to find any documentation regarding family notification. During a concurrent interview and record review on January 25, 2024, at 9:45 AM, with Registered Nurse 9 (RN 9), the facility’s Policy and Procedure (P&P) titled, “Fall Reduction/Injury Prevention Policy”, dated June 2023, was reviewed. The P&P indicated, “ ...Policy ... to outline documentation and communication procedures ... Post Fall Management: ... 7.15 Notify the family ...”. RN 9 stated, she would follow the policy and procedure if a patient had a fall, even if the fall occurred in the middle of the night. RN 9 stated family should be notified immediately of the fall and would be notified of the current plan regarding injuries sustained and new interventions to prevent further falls. RN 9 further stated family could be offered to come to the facility to help sit with patient to prevent fall, especially if the patient is confused or has a history of dementia. During a review of Patient 14’s “Social Services Notes” dated December 7, 2023 at 2:53 PM, the “Social Services Notes” indicated, “ ...Patients daughter [name of daughter] provides all MDM [Medical Decision Making] ...”. During a review of the facility’s policy and procedure titled, “Patient Rights and Responsibilities” dated September 2023, the P&P indicated, “ ...Addendum A Patient Bill of Rights: You have a right to: ... 2. His or her representative has a right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment ...”.”

“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: 42004 Based on observation, interview, and record review, the facility failed to provide care in a safe setting when: 1. For a universe of three (3) patients admitted to the Intensive Care Unit (ICU) on January 22, 2024, the clean supply cart contained needles was not locked in the ICU. 2. For two patients of 30 sampled patients (Patient 15 and 16), two patient medications were removed from the medication room at the same time, taken into a contact precaution (actions to prevent spread of germs by direct or indirect contact) room, Patient 16’s room and left unattended. These failures had the potential to cause unsafe access from unauthorized personnel to needle supplies and medications which could potentially cause harms and injuries from unsafe handling of sharp objects and misused of medication. Findings: 1. During an observation on January 22, 2024, at 10:55 AM, in the ICU, observed an unlocked blue medical supply cart contained medication supplies including needles. During an interview on January 22, 2024, at 11:00 AM, in the ICU, with the Director of Medical Surgical Telemetry Unit (DMST), the DMST stated, needles or sharps items should be kept in a locked area for safety and unauthorized personnel should not be able to access them. The DMST stated, there was no specific policy regarding locking unused needle supplies. A follow-up concurrent observation and interview on January 22, 2024, at 11:05 AM, in the ICU, with the DMST and Registered Nurse 2 (RN 2), observed an unlocked blue cart contained needles. The DMST and RN 2 verified and confirmed an unlocked cart with needles. RN 2 stated, a cart should be locked, and the staff must have been too busy and forgot to lock it. A review of the facility’s Registered Nurse Job Description, undated, indicated, “The Registered Nurse is responsible for the delivery of safe patient care ... maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e., suction and oxygen immediately available at all ICU bedsides ...” A review of the facility’s policies and procedures (P&P) titled, “Patient Rights and Responsibilities,” dated September 2023, indicated, “Policy: [Hospital Name] shall identify each and every patient’s Rights and Responsibilities by doing the following: ... 3. Developing and implementing hospital-wide policies and procedures that address the Patient Rights and Responsibilities ... Patient Bill of Rights. You have the right to: ... 14. The right to receive care in a safe setting ...” 47360 2. During a review of Patient 15’s “History and Physical” (H&P), dated January 21, 2024, the H&P indicated, Patient 15 was admitted to the hospital with the diagnoses of sepsis (the body’s response to infection that can damage vital organs) secondary to lower extremity wound, diabetes with hyperglycemia (the body does not make enough insulin or use insulin [hormone produced by the body to use sugar for energy] to well resulting in high blood sugar), and hyponatremia (when the concentration of sodium in the blood is too low). During a review of Patient 16’s H&P, dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body’s response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system). During an observation on January 23, 2024, at 9:05 AM, in the hallway outside of Patient 16’s room, RN 8’s Workstation on Wheels (WOW) was observed with two paper cups with medicines, handwritten room numbers were left unattended. Patient 15’s cup contained the following medications: Lovenox (to treat or prevent blood clots in the vein) 40 Milli grams (mg - unit of measureent) injection syringe, Protonix (medicine to treat/ reduce acid in stomach) 40 mg tablet prednisone (steroid to treat inflammation) 20 mg x 3 tablets. Patient 16’s cup contained the following medications: Lovenox 40 mg injection syringe Protonix 40 mg tablet prednisone 20 mg x2 tablets Abilify (anti depressant) 10 mg tablet Lexapro (medicine to treat mood disorder) 20 mg tablet Buspar (anxiety medicine) 5 mg x3 tablets Lamictal (seizure [a condition that causes abnormalities in muscle tone or movements] medicine) 200 mg tablet Nicotine transdermal patch (medicine used to help quit smoking or to treat withdrawal from smoking) . During a concurrent observation and interview on January 23, 2024, at 9:10 AM, with RN 8, outside of Patient 16’s room, RN 8 stated he had already gotten the patient medications and his next patient medication for 9:00 AM, medication pass. RN 8 stated he had removed both Patient 15 and Patient 16’s medication from the medication room. During a concurrent observation and interview on January 23, 2024, at 9:40 AM, with RN 8, RN 8 donned (put on) gloves, mask, and gown prior to entering Patient 16’s room. RN 8 stated Patient 16 was on contact precautions because of pneumonia and pending laboratory test results. RN 8 entered into Patient 16’s room with Patient 15’s medications. During an observation on January 23, 2024, at 9:45 AM, in Patient 16’s room, RN 8 excused himself from the room to get requested pain medication and alcohol swabs for Patient 16. Both Patient 15 and Patient 16 medications were left on RN 8’s WOW in Patient 16’s room unattended by staff. During an interview on January 23, 2024, at 10:35 AM, with RN 8, RN 8 stated he removed both Patient 15 and Patient 16’s medications at the same time to save time and be more efficient with medication pass. RN 8 stated having both patient’s medications on the workstation at the same time could increase the chance of making an error and giving the wrong medication to the wrong patient. During a concurrent interview and record review on January 25, 2024, at 11:15 AM, with the Director of Pharmacy Department (DPD), the facility’s P&P titled, “Automated Dispensing Machines-Removing Medications”, dated March 2023, was reviewed. The P&P indicated, “Policy: Medications will be removed from the automated dispensing machine for only one patient at a time ...”. The DPD stated, nursing should only remove one patient medications for medication administration, removing multiple patients’ medications was not a safe medication practice and could lead to a medication error. During an interview on January 26, 2023, at 10:50 AM, with the Infection Control Preventionist (ICP), the ICP stated medications should not be taken into another patient’s room, especially if patient is on contact precautions. The ICP stated, this practice could spread infection. A review of the facility’s P&P titled, “Medication Administration”, dated March 2023, indicated, “ ...No medication will be left at the patient’s bedside except for the following: nitroglycerin, sublingual tabs, respiratory inhalers and external preps for topical application ...Personnel administering the medications must remain with the patient until all oral medication has been swallowed ...Medications will be prepared immediately prior to administration ...”. A review of the facility’s P&P titled, “Patient Rights and Responsibilities” dated September 2023. Indicated, “ ...Addendum A Patient Bill of Rights ...4. The right to receive care in a safe setting ...”.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) 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 improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 42004 Based on interview and record review, the hospital did not ensure an effective and ongoing hospital wide program for a universe of 34 patients admitted on January 22, 2024, when the facility failed to monitor, collecting data and analyze the process of the medication administration, implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and the utilization of Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs). This failure had resulted in the missed opportunities to identify issues and created changes to improve patients’ health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients’ health and safety. Findings: During an interview on January 26, 2024, at 8:55 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the department had not observed, tracked, or collected data regarding the “medication pass [med pass-a process of giving medication to patient].” A follow-up interview and record review on January 26, 2024, at 9:00 AM, with the DPD and Pharm 1, the facility’s document titled, “Performance Improvement Quality Council/Committee,” dated November 30, 2023, was reviewed. The “Performance Improvement Quality Council/Committee” indicated, the “medication administration” received 100 percent (%) with no issues identified. There was no documentation of data collection and analysis, description for mitigation plans or person responsible. The DPD verified and stated, the data did not come from the pharmacy department. The DPD further stated, there were no opportunities of med pass to observe in the year of 2023 from the pharmacy department. A follow-up interview and record review on January 26, 2024, at 9:20 AM, with the DPD, the facility’s document titled, “2023 Performance Improvement Dashboard [Hospital Name],” undated, was reviewed. The “2023 Performance Improvement Dashboard [Hospital Name]” indicated, “medication pass audits” goal was set at 95% and no opportunities were listed. The DPD stated, as discussed, there was no opportunities to identify issues. A review of the facility’s document titled, “2023 Performance Improvement Dashboard [Hospital Name],” undated, indicated, there was no indicators or data regarding the transmission-based precautions or PPE. During a concurrent interview and record review on January 26, 2024, at 10:05 AM, in the conference room, with the Infection Control Preventionist (ICP), the “Job Description” for “Infection Control Preventionist”, dated July 2021, was reviewed. The “Job Description” indicated, “ ...Job Summary: The Infection Control Preventionist is responsible for surveillance, prevention and control of infection ... Assists with policy and procedure development and implementation ...Acts as primary education consultant to hospital employees, physicians, Patients, volunteers and visitors in safe Infection Control/Prevention practices. Coordinates all hospital infection control activities with the infection control committee, Medical Staff and hospital employees...” The ICP stated, there was no system in place for monitoring the implementation of transmission-based precautions and PPE. During an interview on January 26, 2024, at 10:45 AM, in the conference, with the Director of Quality Department (DQD), the DQD stated, there was no data collection from the pharmacy or nursing department to show the appropriate medication administration practice such as the proper administration technique used. The DQD further stated, there was no data from the infection control regarding the monitoring or tracking of PPE usage. A review of the facility’s document titled, “Amended & [and] Restated Governing Board Bylaw,” reviewed September 6, 2023, indicated, “ ...the primary purpose of the Hospital is to provide quality health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the Hospital ... supporting the Hospital’s Performance Improvement Programs and its initiatives and the Hospital’s Patient Safety Program ...””

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 42004 Based on interview, and record review, the hospital failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 34 patients admitted on January 22, 2024, when the facility failed to identify the collected data of the issues regarding nursing assessment, documentation, medication administration, and infection control practices to improve patient outcomes. This failure resulted in the hospital inability to focus on problem prone areas to ensure the provision of quality nursing and patient safety and had the potential to cause adverse health outcomes which could interfere with patients’ medical care and jeopardize the health and safety of the patients. Findings: During an interview on January 26, 2024, at 8:55 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the department had not observed, tracked, or collected data regarding the “medication pass [med pass-a process of giving medication to patient]” observation. A follow-up interview and record review on January 26, 2024, at 9:00 AM, with the DPD and Pharm 1, the facility’s document titled, “Performance Improvement Quality Council/Committee,” dated November 30, 2023, was reviewed. The “Performance Improvement Quality Council/Committee” indicated, the “medication administration” received 100 percent (%) with no issues identified. The DPD verified and stated, the data did not come from the pharmacy department. The DPD further stated, there were no opportunities of med pass to observe in the year of 2023 from the pharmacy department. During a concurrent interview and record review on January 26, 2024, at 9:45 AM, in the conference, with the Director of Quality Department (DQD), the facility’s document titled, “Performance Improvement Quality Council/Committee,” dated November 30, 2023, was reviewed. The “Performance Improvement Quality Council/Committee” indicated, the nursing assessment, documentation, and medication administration received 100% with no issues identified. The DQD verified and confirmed the results. The survey team brought up some issues identified during survey such as missing nursing assessment and documentation for an Intensive Care Unit (ICU) patient who was on a titratable (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) medication, and the inappropriate medication administration observation during med pass in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit. The DQD stated, each service area would be responsible to conduct its own audit and his department would collect data. Based on the results, the DQD stated, there was no identification of issues. During an interview on January 26, 2024, at 9:50 AM, in the conference room, with the Infection Control Preventionist (ICP), the ICP stated, in December 2023, hand hygiene was identified with 90% compliance from the goal of 100%. The survey team brought up some issues identified during survey such as missing hand washing, wrong implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and not utilize Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) appropriately. The ICP stated, there was no tracking regarding the implementation of transmission-based precaution with the usage of at this facility, so the issues were not identified. A follow-up concurrent interview and record review on January 26, 2024, at 10:05 AM, with the DQD, the facility’s document titled, “Medical Record Review Abstraction Form,” undated, was reviewed. The “Medical Record Review Abstraction Form” did not include the nursing assessment or documentation for the titratable medication. The DQD confirmed and stated, the pharmacy department would track patients who were on the titratable medication. A follow-up concurrent interview and record review on January 26, 2024, at 10:15 AM, with the DQD and Pharm 1, the facility’s document titled, “Titratable Drips [Medication] Audit Tool,” dated from January 8, 2024, through January 16, 2024, was reviewed. The “Titratable Drips Audit Tool” indicated, there were 16 opportunities to review on the titratable medication with seven (7) incidents of the nursing staff missed the components for appropriate documentation. Pharm 1 verified and stated, he used this tool to check patients who were on the titratable medication; however, he only reviewed the administration of medication to ensure the nursing staff followed an order. Pharm 1 further stated, he did not check any nursing assessment or documentation to identify issues. A follow-up interview on January 26, 2024, at 10:20 AM, with the DQD, the DQD stated, the medication administration data came from each nursing department combined since the pharmacy department has not conducted any med pass observation. During an interview on January 26, 2024, at 10:25 AM, in the conference room, with the DQD and Registered Nurse 6 (RN 6), RN 6 stated, she had some opportunities to observe med pass and identified issues from the nursing staff; however, she did not report to anyone. RN 6 further stated, she discussed infection control practices with staff such as hand hygiene, the transmission-based precaution and PPE, but she did not observe the implementation or practices from the nursing staff. A follow-up interview on January 26, 2024, at 10:45 AM, with the DQD, the DQD confirmed, the collected data of nursing assessment and documentation did not capture some components of nursing services such as monitoring of titratable medication. The DQD stated, the medication administration data also did not provide the whole process of med pass from the pharmacy department. The DQD further stated, the hand hygiene has not met the set goal of 100% compliance, only achieved about 95%, so the facility still has to address this issue. The DQD confirmed, the facility had missed many opportunities to identify, plan and implement actions to improve patients care for many problems prone areas. A review of the facility’s document titled, “Amended & [and] Restated Governing Board Bylaw,” reviewed September 6, 2023, indicated, “ ...the primary purpose of the Hospital is to provide quality health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the Hospital ... supporting the Hospital’s Performance Improvement Programs and its initiatives and the Hospital’s Patient Safety Program ...””

“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: 42004 Based on observation, interview, and record review, the facility failed to ensure the nursing staff supervise and evaluate the plan of care for one of 30 sampled patients (Patient 2) when the nursing staff did not follow up or clarify on the STAT (as soon as possible) order for an Electroencephalogram (EEG-a test that record the brain activities) to ensure it was completed as ordered and did not closely monitor Patient 2 in response with seizure (SZ-a condition that causes abnormalities in muscle tone or movements) activity in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit. This failure had resulted in delay of providing an accurate medical diagnosis, creating disbelief from Patient 2’s family towards the healthcare team, and inadequate patient monitoring during SZ activity that could interfere with proper treatment plan and compromise Patient 2’s safety which could negatively affect Patient 2’s health, safety, and lead to actual harm or death. Findings: A review of Patient 2’s “History and Physical” (H&P), dated January 21, 2024, the H&P indicated, Patient 2 was admitted into the facility for SZ. During an observation on January 23, 2024, at 11:04 AM, in the MST Unit, Registered Nurse 3 (RN 3) was observed coming out of Patient 2’s room, rattling and cranking noise was heard from inside the room. RN 3 walked to the medication room and stated Patient 2 was having a SZ. Inside patient’s room, Patient 2 was observed lying in bed with SZ pad around the bed rails. Patient 2’s boyfriend was standing next to the bed. During an interview on January 23, 2024, at 11:05 AM, with Patient 2’s boyfriend, Patient 2’s boyfriend stated, Patient 2 was admitted for a witnessed SZ and had been having multiples SZ since admission. He further stated, the EEG was completed this morning which he expressed concern of the delayed in obtaining the EEG to give him information about Patient 2’s SZ. A follow-up observation on January 23, 2024, at 11:06 AM, RN 3 was observed back into Patient 2’s room with syringes. RN 3 informed Patient 2 and Patient 2’s boyfriend that she had an Ativan (a sedation medication that can be used to treat SZ) to give to Patient 2. Upon receiving permission, RN 3 administered medication to Patient 2 through an intravenous (IV-into the vein) catheter. A follow-up interview on January 23, 2024, at 11:20 AM, RN 3 stated, when she was in the room talking to Patient 2 and her boyfriend, she observed Patient 2’s whole body started to shake. RN 3 further stated, she came out of the room to get Ativan to give to patient and there was no other nursing staff in the room with Patient 2. During an interview on January 23, 2024, at 2:00 PM, in the conference room, with the Chief Nursing Officer (CNO), the CNO stated, there was no specific policy for SZ. During a concurrent interview and record review on January 23, 2024, at 3:45 PM, in the conference room, with RN 4, Patient 2’s “Order” for EEG, dated January 21, 2024, at 4:23 PM, was reviewed. The “Order” indicated, the EEG was ordered as a STAT order. RN 4 verified and confirmed the order status. RN 4 stated, the nursing staff should have called to arrange for the test to be completed as soon as possible. RN 4 further stated, she was unable to provide any documented evidence that the nursing staff followed up on the order to ensure its completion. RN 4 confirmed, an EEG was completed on January 23, 2023, more than 24 hours after the order was placed. During a concurrent interview and record review on January 24, 2024, at 10:20 AM, in the conference room, with the Director of MST Unit (DMST), Patient 2’s “Patient Notes,” dated January 23, 2024, at 11:07 AM, was reviewed. The “Patient Notes” indicated, Patient 2 had SZ activity. The DMST stated, there was no specific policy for SZ however, the nursing staff was expected and required to stay with patients during SZ activity. The DMST further stated, the nursing staff should not leave patients to ensure safety, however can request other nursing staff to obtain any necessary items such as medication to assist with the incident. A review of the facility’s Registered Nurse Job Description, undated, indicated, “The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation ... The Registered Nurse is directly responsible and accountable for the care given to their assigned patients ...””

“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: 42004 Based on interview and record review, the facility failed to ensure the nursing staff followed the policies and procedures (P&P) for medication administration and storage for two of 30 sampled patients (Patient 3 and 4) in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit when: 1. For Patient 3, Enoxaparin (Lovenox-medication to treat or prevent blood clot) syringe was left on the side table. 2. For Patient 4, patient’s own medications (POM) were left on the side table. These failures had the potential for unauthorized personnel to have access to medications and patients to misuse on medications which could negatively affect patients’ health, safety, and lead to actual harm or death. Findings: 1. A review of Patient 3’s “History and Physical” (H&P), dated January 18, 2024, the H&P indicated, Patient 3 was admitted into the facility for shortness of breath with past medical history of congestive heart failure (CHF-a condition that heart does not pump blood well to the body). During an observation on January 22, 2024, at 10:17 AM, in Patient 3’s room, Patient 3 was observed lying in bed with an unused syringe of Lovenox 30 milligrams (mg-unit dosing medication) on the side table. During an interview on January 22, 2024, at 10:23 AM, with Registered Nurse 1 (RN 1), RN 1 stated, he already administered Lovenox to Patient 3. A follow-up concurrent observation and interview on January 22, 2024, at 10:27 AM, with RN 1, an unused syringe of Lovenox 30 mg was observed on the side table. RN 1 verified and stated, he did not see this syringe when he was previously in the room. RN 1 further stated, he did not know how long this syringe was left here. RN 1 confirmed, medication should not be left unattended at the bedside. During an interview on January 26, 2024, at 9:05 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the nursing staff might accidentally pull extra doses of medication; however, the extra dose that was not administered to patient should either be wasted or returned. The DPD further stated, per policy, medication should not be left at the bedside. A review of the facility’s P&P titled, “Medication Administration,” dated March 2023, the P&P indicated, “Policy: Medications will be administered only upon the order of physicians ... No medication will be left at the patient’s bedside ...” 2. A review of Patient 4’s H&P, dated January 17, 2024, the H&P indicated, Patient 4 was admitted into the facility for altered mental status (AMS). During a concurrent observation and interview on January 22, 2024, at 9:35 AM, in Patient 4’s room, Patient 4 was observed lying in bed with a bag of medication bottles on the side table. Patient 4 stated, she did not know how or why the medications were there. The bag with medication bottles included as follow: Memantine (medication to treat memory loss) 5 mg. Gabapentin (medication to treat seizure [a condition that causes abnormalities in muscle tone or movements]) 300 mg. Folate (vitamin supplement) 666 micrograms (mcg-unit dosing medication). Amlodipine (medication to treat high blood pressure) 2.5 mg. Atorvastatin (medication to treat high cholesterol) 20 mg. Carvedilol (medication to treat high blood pressure) 12.5 mg. Levothyroxine (medication for thyroid) 100 mcg. Fluoxetine (medication to treat depression) 10 mg. Aspirin (medication to treat minor pain) 81 mg. Insulin pen (medication to control blood sugar). During an interview on January 22, 2024, at 9:45 AM, in Patient 4’s room, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, POM needed to be sent to the pharmacy department to check and would be given back to patients upon discharge. LVN 1 further stated, POM should not be kept at the bedside for anyone to be able to access. A follow-up concurrent observation and interview, on January 22, 2024, at 9:50 AM, with LVN 1, a bag of medication bottles was observed on the side table. LVN 1 verified and stated, she did not see this bag of medication bottles when she was previously in the room. LVN 1 confirmed, medication bottles should have been sent to the pharmacy department and should not be left on the side table. During an interview on January 26, 2024, at 9:10 AM, in the conference room, with the DPD and Pharm 1, the DPD stated, per policy, POM should not be kept at the bedside but sent to the pharmacy department. The DPD further stated, the nursing staff was responsible to ensure POM was not left inside patients’ room. A review of the facility’s P&P titled, “Patient’s Own Medications: Use, Storage, Destruction,” dated March 2023, the P&P indicated, “Policy: ... The contents of the containers have been examined, positively identified and the integrity evaluated by the hospital’s Pharmacist ... The patient will not be allowed to self-medicate or keep his/her own medication at the bedside, with exceptions made under special circumstances, see “Bedside Medication” policy. The medication will be kept in the pharmacy department and will be dispensed on a daily basis, stored in patient’s cassette ...””

“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: 42004 Based on observation, interview, and record review, the facility failed to ensure the nursing staff administered medications as ordered and followed the acceptable standards of practices during medication administration of 30 sampled patients when: 1. For Patient 1, the nursing staff did not administer Colace (stool softener) appropriately. 2. For Patient 1, the nursing staff did not administer Fluoxetine (Prozac-medication to treat depression) appropriately. 3. For Patient 10, the nursing staff did not check blood pressure (BP) before Hydralazine (medication to treat high blood pressure) administration. 4. For Patient 12, the nursing staff did not check blood sugar (BS) as ordered. These failures had resulted in preventable medication errors with unsafe medication administration and had the potential to cause adverse health outcomes such as inadequate therapy for treatment, inadequate patient monitoring of BP, and uncontrolled BS, which could negatively affect patients’ health, safety, prolonged hospitalization, and lead to actual harm or death. Findings: 1. A review of Patient 1’s “History and Physical” (H&P), dated January 18, 2024, the H&P indicated, Patient 1 was admitted into the facility for hypoxemia (low oxygen in blood) with medical histories including chronic respiratory failure (a condition when lungs cannot get enough oxygen) with tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing) and ventilator (a machine to assist in delivery of oxygen) dependent, and diabetes (a condition that body cannot control blood sugar). During an observation on January 23, 2023, at 9:50 AM, in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit, Patient 1 was lying in bed with a trach attached to a ventilator, Registered Nurse 3 (RN 3) was observed using a needle to puncture a capsule of Colace 100 milligrams (mg-unit dosing medication), squeezed out the clear gel substance inside the capsule onto Patient 1’s apple sauce, and administered to Patient 1. A follow-up interview on January 23, 2023, at 10:10 AM, RN 3 verified and confirmed of using needle to puncture a capsule of Colace, squeezed out the content inside onto Patient 1’s apple sauce, and administered to Patient 1. RN 3 stated, Patient 1 could not swallow capsules, so she gave the substance inside Colace to Patient 1. RN 3 further stated, she did not check with a pharmacist before she administered Colace. During an interview on January 23, 2023, at 2:05 PM, in the conference room, with Pharmacist 1 (Pharm 1), Pharm 1 stated, the department would provide Colace in liquid form for patients who could not swallow medication. However, the nursing staff needed to inform the pharmacy department and request to change from capsule to liquid form as appropriate. Pharm 1 stated, it was not appropriate to squeeze out the gel inside Colace’s capsule to give to patient. A review of the facility’s policies and procedures (P&P) titled, “Medication Administration,” dated June 2023, the P&P indicated, “Policy: To safely administer medication in the manner specified by the physician ... If there are any questions regarding the medication, contact the Pharmacist and/or refer to an appropriate medication reference ...” 2. A review of Patient 1’s H&P, dated January 18, 2024, the H&P indicated, Patient 1 was admitted into the facility for hypoxemia with medical histories including chronic respiratory failure with a trach and ventilator dependent, and diabetes. During an observation on January 23, 2023, at 9:50 AM, in the MST Unit, Patient 1 was lying in bed with a trach attached to a ventilator, RN 3 was observed opening a capsule of Prozac 10 mg, poured the white powder inside the capsule onto Patient 1’s apple sauce, and administered to Patient 1. A follow-up interview on January 23, 2023, at 10:10 AM, RN 3 verified and confirmed of opening a capsule of Prozac to get the powder inside, poured the white powder inside the capsule onto Patient 1’s apple sauce, and administered to Patient 1. RN 3 stated, she did not check with a pharmacist before she administered Prozac. During a concurrent interview and record review on January 23, 2023, at 2:55 PM, in the conference room, with Pharm 1, Patient 1’s “Medication Administration Record” (MAR) for Prozac, dated January 18, 2024, was reviewed. The MAR indicated, 10 mg or one capsule was ordered to be given. Pharm 1 verified and stated, there was no specific instruction to stop the nursing staff from opening the capsule. However, capsules should not be opened, and the nursing staff should check with the pharmacy department before giving medication outside of the original form. Pharm 1 stated, for Prozac, the nursing staff should not open the capsule since the medication would not be effective to patients. A review of the facility’s P&P titled, “Medication Administration,” dated June 2023, the P&P indicated, “Policy: To safely administer medication in the manner specified by the physician ... If there are any questions regarding the medication, contact the Pharmacist and/or refer to an appropriate medication reference ...” 3. A review of Patient 10’s H&P, dated January 20, 2024, the H&P indicated, Patient 10 was admitted into the facility for cough with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of disease that cause blockage in airflow) exacerbation on oxygen, and history of high blood pressure. A review of Patient 10’s “Medication Order” for Hydralazine, dated January 20, 2024, indicated, Hydralazine 50 mg was ordered to be given four times daily. During an interview on January 25, 2024, at 2:25 PM, in the conference room, with RN 6, RN 6 stated, patients’ blood pressure should be assessed and documented before any medication that will affect blood pressure was given. A follow-up concurrent interview and record review on January 25, 2024, at 2:30 PM, with RN 6, Patient 10’s MAR for Hydralazine, dated January 21, 2024, from 8:00 AM through 1:00 PM, was reviewed. The MAR indicated as follow: At 8:36 AM: 50 mg given. At 12:58 PM: 50 mg given. RN 6 verified and confirmed Hydralazine administration. RN 6 stated, Hydralazine would affect patients’ blood pressure so blood pressure should be assessed before the medication was given. A follow-up concurrent interview and record review on January 25, 2024, at 2:35 PM, with RN 6, Patient 10’s “Vital Signs [VS-a measurements of the body’s most basic function such as heart rate and BP],” dated January 21, 2024, from 8:00 AM through 1:00 PM, were reviewed. The VS indicated as follow: At 8:00 AM: BP 167/87 MAP 113 At 4:00 PM: BP 153/84 MAP 107 RN 6 verified and confirmed the blood pressure measurement. RN 6 stated, there was no blood pressure taken before 12:58 PM dose of Hydralazine given. RN 6 further stated, the nursing staff did not follow the P&P for medication administration. A review of the facility’s P&P titled, “Medication Administration,” dated June 2023, the P&P indicated, “Policy: To safely administer medication in the manner specified by the physician ... Prior to giving medications which will affect blood pressure or heart rate, check apical pulse rate and/or blood pressure. Hold medications if patient is bradycardic (less than 60), hypotensive or according to parameters ordered by physician and notify physician if medications held ...” 4. A review of Patient 12’s H&P, dated January 17, 2024, the H&P indicated, Patient 12 was admitted into the facility for COPD exacerbation with medical histories including high blood pressure and diabetes. A review of Patient 12’s “Orders” for Blood Glucose (blood sugar or BS) Monitoring, dated January 16, 2024, indicated, monitor of BS was ordered to be completed before meals and at bedtime. During a concurrent interview and record review on January 25, 2024, at 11:55 AM, in the conference room, with the Chief Nursing Officer (CNO), Patient 12’s “POC [Point of Care] Glucose - History” dated January 22, 2024, was reviewed. The “POC Glucose - History” indicated as follow: At 6:35 AM: BS 107 milligrams per deciliter (mg/dl-a unit measure of BS level with reference value between 70-105 mg/dl) At 10:03 PM: BS 163 mg/dl The CNO verified and confirmed BS testing was missing before lunch and dinner time. The CNO stated, she was unable to find any documented evidence to justify the missing BS testing. The CNO further stated, there was no specific policy regarding checking of BS; however, the nursing staff had to follow a physician’s order. During a concurrent interview and record review on January 25, 2024, at 4:15 PM, in the conference room, with RN 7, Patient 12’s “POC Glucose - History” dated January 22, 2024, was reviewed. The “POC Glucose - History” indicated, the BS testing was not completed before lunch and dinner time. RN 7 verified and confirmed, she did not check Patient 12’s BS since she was busy. RN 7 stated, she knew Patient 12 would refuse the test because Patient 12 refused in the morning; however, she did not ask Patient 12 again during lunch or dinner time. A review of the facility’s Registered Nurse Job Description, undated, indicated, “The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation ... The Registered Nurse is directly responsible and accountable for the care given to their assigned patients ...” A review of the facility’s P&P titled, “Medication Administration,” dated June 2023, indicated, “Policy: To safely administer medication in the manner specified by the physician ...””

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 42004 Based on interview and record review, the facility failed to ensure the nursing staff monitored patients appropriately and as ordered during the continuous intravenous (IV-Into the vein) infusion for one of 30 sampled patients (Patient 5) when the nursing staff did not assess Patient 5’s blood pressure (BP) and titrate (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) Norepinephrine (Levophed-a medication to treat life-threatening low BP) appropriately. This failure had resulted in an unsafe medication administration and monitoring of Patient 5 which could adversely affect Patient 5’s responses without proper dosing adjustment and monitoring and could jeopardize Patient 5’s health and safety, leading up to actual harm and possible death. Findings: A review of Patient 5’s “History and Physical” (H&P), dated January 18, 2024, the H&P indicated, Patient 5 was admitted into the facility for decreased responsiveness and seizure (SZ-a condition that causes abnormalities in muscle tone or movements). During an interview on January 24, 2024, at 1:30 PM, in the conference room, with Pharmacist 1 (Pharm 1), Pharm 1 stated, the nursing staff needed to monitor and assess patients’ blood pressure during the titration of medication based on the frequency ordered. Pharm 1 further stated, for example, Levophed was ordered to be titrated every five minutes to achieve BP goal. When the nursing staff needed to titrate Levophed, the nursing staff needed to monitor and document patients’ BP every five minutes. Once patients’ BP was stable, the nursing staff would follow the unit protocol to monitor BP every two hours. A review of Patient 5’s “Medication Order” for Levophed, dated January 18, 2024, indicated to start the medication at 0.1 microgram per kilogram per minute (mcg/kg/min-a unit dosing medication) and titrate by 0.03 mcg/kg/min every 5 mins to achieve goal of mean arteria pressure (MAP) above 65. During a concurrent interview and record review on January 25, 2024, at 2:00 PM, in the conference room, with Registered Nurse 5 (RN 5), Patient 5’s “Medication Administration Record” (MAR) for Levophed, dated January 18, 2024, from 11:00 AM through 3:00 PM was reviewed. The MAR indicated as follow: At 11:28 AM: the infusion rate set at 0.4 mcg/kg/min. At 2:00 PM: the infusion rate set at 0.37 mcg/kg/min (decrease 0.03 mcg/kg/min from previous). At 3:00 PM: the infusion rate set at 0.34 mcg/kg/min (decrease 0.03 mcg/kg/min from previous). RN 5 verified and confirmed the titration of Levophed. A follow-up concurrent interview and record review on January 25, 2024, at 2:05 PM, with RN 5, Patient 5’s “Vital Signs [VS-a measurements of the body’s most basic function such as heart rate and BP],” dated January 18, 2024, from 2:00 PM, through 7:58 PM, were reviewed. The VS indicated as follow: At 2:00 PM: BP 124/95 MAP 105 At 3:00 PM: BP 128/87 MAP 101 (60 mins from previous) At 3:36 PM: BP 141/75 (36 mins from previous) RN 5 verified and confirmed the nursing staff did not check Patient 5’s BP appropriately after the titrating of Levophed to ensure that Patient 5 was able to tolerate the adjustment of Levophed. During an interview on January 26, 2024, at 8:45 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharm 1, Pharm 1 stated, he reviewed Patient 5’s chart and confirmed Patient 5 was on 2 medications including Levophed and Neo-synephrine to control BP on January 18, 2024, at 5:00 PM. A follow-up concurrent interview and record review on January 26, 2024, at 8:50 PM, with the DPD and Pharm 1, Patient 5’s VS, dated January 18, 2024, at 4:00 PM through 7:58 PM, was reviewed. The VS indicated as follow: At 4:00 PM: BP 101/80 MAP 87 (24 mins from previous) At 4:13 PM: BP 124/87 (13 mins from previous) At 5:00 PM: BP 153/81 MAP 105 (57 mins from previous) At 7:58 PM: BP 114/74 (2 hours and 58 mins from previous) The DPD and Pharm 1 verified and stated, Patient 5’s BP at 5:00 PM, should be rechecked for accuracy or medication should be titrated down. The DPD further stated, it was unsafe to keep patients on medications when BP was high since patient could have negative effect from medication such as stroke (a condition of losing blood flow to the brain). A review of the facility’s policies and procedures (P&P) titled “Titrating Medications,” dated March 2023, the P&P indicated, “Policy: It is the policy of this institution to allow orders for medication titration, which is the progressive increase or decrease of the medication dose in response to the patient’s clinical status ... Clinical staff must assess the patient frequently when titrating medications to detect potential problems as early as possible ...””

“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: 42004 Based on observation, interview, and record review, the hospital failed to ensure the nursing staff implemented the prevention and control of infection for five (5) of 30 sampled patients (Patient 1, 2, 16, 27, and 29) when 1. For Patient 2, the nursing staff cleaned the intravenous injection (IV-a device that allows medication to be given through a vein) port with a used alcohol wipe after the medication administration. 2. For Patient 1, 27 and 29, the Intravenous infusion tubing (tubing that administers fluids and medication onto a patient’s vein) was not labeled and dated. 3. For Patient 16, Registered Nurse 8 (RN 8) did not clean/disinfect the IV port during two medication administration opportunities. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable bloodstream infection which can negatively affect patients’ health and prolonged hospitalization. Findings: 1. A review of Patient 2’s “History and Physical” (H&P), dated January 21, 2024, the H&P indicated, Patient 2 was admitted into the facility for seizures (SZ-a condition that causes abnormalities in muscle tone or movements). During an observation on January 23, 2024, at 11:04 AM, in the Medical/Surgical Unit, RN 3 was observed coming out of Patient 2’s room, rattling and cranking noise was heard from inside the room. RN 3 walked to the medication room and stated Patient 2 was having SZ. Inside patient’s room, Patient 2 was observed lying in bed with SZ pad around the bed rails. Patient 2’s boyfriend was standing next to the bed. During an interview on January 23, 2024, at 11:05 AM, with Patient 2’s boyfriend, Patient 2’s boyfriend stated, Patient 2 was admitted for a witnessed SZ and had been having multiples SZ since admission. He further stated, the Electroencephalogram (EEG-a test that record the brain activities) was completed this morning which he expressed concern of the delayed in obtaining the EEG to give him information about Patient 2’s SZ. A follow-up observation on January 23, 2024, at 11:06 AM, RN 3 was observed back into Patient 2’s room with syringes. RN 3 informed Patient 2 and Patient 2’s boyfriend that she had an Ativan (a sedation medication that can be used to treat SZ) to give to Patient 2. Upon receiving permission, RN 3 wiped or disinfected (kill germs) IV port with an alcohol wipe, placed a used alcohol wipe onto Patient 2’s bed, administered medication to Patient 2 through IV port, and picked up a previously used alcohol wipe left on Patient 2’s bed and wiped IV port. A follow-up interview on January 23, 2024, at 11:20 AM, with RN 3, RN 3 verified and confirmed using the same alcohol wipe to disinfect Patient 2’s IV port before and after medication administration. During a concurrent interview and record review on January 23, 2024, at 4:00 PM, in the conference room, with RN 4, Patient 2’s “Medication Administration Record” (MAR) for Ativan, dated January 23, 2024, at 11:06 AM, was reviewed. The MAR indicated, Patient 2 was given 1 milligrams (mg-unit dosing medication) of Ativan. RN 4 stated, the nursing staff should never use the same alcohol wipe to clean or disinfect IV port before and after the medication administration, it is a single use. RN 4 further stated, using the same alcohol wipe would increase the risk of introducing infection to Patient 2. A review of the facility’s policies and procedures (P&P) titled, “Standard and Transmission Based Precautions,” dated March 2023, the P&P indicated, “Policy: It is the policy of [Hospital Name] to provide an effective means of isolation, based on the Center for Disease Control and Prevention (CDC) Guidelines, for Standard and Transmission based precautions ... 7. Patient Care Equipment: ... ensure that single-use items are discarded properly ...” 47360 2a. During a review of Patient 1’s H&P, dated January 19, 2024, the H&P indicated, Patient 1 was admitted with diagnoses including pneumonia (an infection in the lung), Chronic Obstructive Pulmonary disease (COPD- a long-lasting disease where the airways in the lungs are damaged), and diabetes mellitus type 2 (the body does not make enough insulin or does not use insulin well). During an observation on January 22, 2024, at 10:54 AM, in Patient 1’s room, Patient 1 had Vancomycin (antibiotics) 1,000 mg in 250 milliliter (ml-unit of measurement) Dextrose (fluid used to give medications through IV) connected to her IV. The tubing was not labeled. 2b. During a review of Patient 27’s H&P, dated January 16, 2024, the H&P indicated, Patient 27 was admitted with diagnoses including small bowel obstruction (a blockage in the small intestine) and ileocecal mass (area of thickening in the in the large intestine). During an observation on January 22, 2023, at 11:03 AM, in Patient 27’s room, there was Total parenteral nutrition (TPN- a special formula given through a vein providing nutrients the body needs) infusing into patients IV. The IV tubing for the TPN was not labeled. During a concurrent observation and interview on January 22, 2024, at 11:20 AM, with RN 3, RN 3 stated Patient 27’s TPN tubing was not labeled but should be labeled because it needs to be changed every 24 hours to prevent infection. 2c. During a review of Patient 29’s H&P, dated January 8, 2024, the H&P indicated, Patient 29 was admitted with diagnoses including anemia (not enough red blood cells to transport nutrients and oxygen to organs), right pleural effusion (a buildup of fluids between the lungs and the chest cavity), and chronic kidney disease (progressive loss of kidney function). During an observation on January 22, 2024, at 10:40 AM, in Resident 29’s room, there were IV fluids and a secondary medication Mycamine (a medication used to treat fungal infection) hanging on IV pole and attached to Patient 29’s IV. The tubing was not labeled. During an interview on January 22, 2024, at 10:48 AM, with Chief Nursing Officer (CNO), the CNO stated all IV tubing should be dated and initialed because the tubing needs to be changed at least every four days. During a concurrent observation and interview on January 22, 2024 at 11:20 AM, with RN 3, RN 3 stated Resident 27’s TPN tubing was not labeled, but should be labeled because it needs to be changed every 24 hours to prevent infection. During a review of the facility’s P&P titled, “Intravenous Infusion: Peripheral Lines”, dated June 2023, the P&P indicated, “Policy: ... Primary, secondary and extension set tubing are changed every 4 days ... Exceptions: ...Replace tubing used to administer TPN within 24 hours of initiating the infusion ...Intermittent administration of Medication via Direct Line ...1. Prime and date secondary set ...”. 3. During a review of Patient 16’s H&P, dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body’s response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system). During an observation on January 23, 2024, at 10:06 AM, in Patient 16’s room, RN 8 accessed Patient 16’s IV port and administered Protonix (medication used to treat heartburn) 40 mg IVP without disinfecting the IV injection port. During an observation on January 23, 2024, at 10:21 AM, in Patient 16’s room, RN 8 accessed Patient 16’s IV port and administered Morphine (medication used to treat severe pain) 1 mg IVP without disinfecting the IV injection port. During an interview on January 23, 2024, at 10:30 AM, with RN 8, RN 8 stated, he had forgotten to wipe the IV injection port with alcohol wipes before administering both the Protonix and Morphine medications. RN 8 stated the IV injection port is to be cleansed every time medication is given in the IV line is flushed and not cleaning the IV injection port with alcohol could cause bacteria to enter Patient 16’s blood stream and cause an infection. During a review of the facility’s P&P titled, “Medication Administration”, dated June 2023, the P&P indicated, “ ...X. Injectables ...8. Choose appropriate injection site. 9. Cleanse injection site by wiping vigorously with alcohol wipe ...”.”

“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: 47360 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to prevent Hospital Acquired Infections (HAI - an infection acquired when receiving health care that was not present during the time of admission) when: 1) Registered Nurse 7 (RN 7) did not clean/disinfect the glucometer (a portable device used to measure blood sugar) properly after use with one of 30 sampled patients (Patient 15) who was on contact isolation precautions (preventative measure to prevent spread of germs from direct and indirect contact). 2) Staff did not wear Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) per policy and procedure for two of 30 sampled patients (Patient 15 and 16). These failures had the potential to expose all 32 patients on the Medical surgical/Telemetry (continuus heart montoring) floor which could lead to life threatening infections and prolonged hospitalizations. Findings: 1. During a review of Patient 15’s “History and Physical” (H&P), dated January 21, 2024, the H&P indicated, Patient 15 was admitted to the hospital with the diagnoses of sepsis (the body’s response to infection that can damage vital organs) secondary to lower extremity wound, diabetes with hyperglycemia (the body does not make enough insulin or use insulin [hormone produced by the body to use sugar for energy] to well resulting in high blood sugar), and hyponatremia (when the concentration of sodium in the blood is too low). During an observation on January 24, 2024, at 11:30 AM, outside of Patient 15’s room, Registered Nurse7 (RN 7) used the glucometer to obtain Patient 15’s blood sugar level. Upon completion of this task, RN 7 took the glucometer out of Patient 15’s room and set it on her work station. RN 7 rubbed a used alcohol swab over the top of glucometer and set the glucometer on her workstation outside of Patient 15’s room. During an interview on January 24, 2023, at 11:50 AM, with RN 7, RN 7 stated she was done using the glucometer. RN 7 stated the patient was on contact isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA- a germ that is resistant to most antibiotics). RN 7 stated the used alcohol swab was not sufficient to clean the glucometer and she should have used the chlorhexidine (chemical that kills most germs) or bleach wipe to clean the glucometer. RN 7 stated it was important to properly clean the glucometer between patients so infection will not spread from one patient to another. During an interview on January 25, 2024, at 3:00 PM, with Chief Nursing Officer (CNO), the CNO stated, the glucometer is to be disinfected before and after each patient use with the antiseptic wipes. During a review of the facility’s policy and procedure (P&P) titled, “Point of Care Test (Nursing)”, reviewed June 2023, the P&P indicated, “ ...Infection and Biohazard Precautions: 9. Cleaning/decontamination procedures should be followed ... 9.1 Meter disinfection for external surfaces should include the use of approved bleach wipes after each patient use, c. Thoroughly wipe the surface of the meter (top, bottom, front and back sides) ...”. 2a. During a review of Patient 16’s H&P, dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body’s response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system). During an observation on January 23, 2024, at 9:46 AM, RN 8 exited Patient 16’s room and continued to enter the medication supply room to get syringe and alcohol swabs without removing the used PPEs (including gloves and gown). During an interview on January 23, 2024, at 10:25 AM, RN 8 stated he had forgotten to remove his PPE when exiting the room to retrieve needed supplies for medication administration. RN 8 stated the facility’s policy was to remove PPE before exiting the room. RN 8 stated Patient 16 was on contact precautions for pneumonia pending lab results and contact precautions had been implemented. RN 8 further stated if PPE was not removed, it could spread infectious disease from one room to other rooms on the floor. 2b. During a review of Patient 15’s H&P, dated January 21, 2024, the H&P indicated, Patient 15 was admitted to the hospital with the diagnoses of sepsis (the body’s response to infection that can damage vital organs) secondary to lower extremity wound, diabetes with hyperglycemia (the body does not make enough insulin or use insulin well resulting in high blood sugar), and hyponatremia (when the concentration of sodium in the blood is too low). During an observation on January 24, 2024, at 11:30 AM, outside of Patient 15’s room, a Contact Precaution sign was posted outside the room and a cart with disposable masks, gowns, gloves and antiseptic wipes was located outside the door of the room. During an observation on January 24, 2024, at 11:31 AM, at patient 15’s room, RN 7 performed hand hygiene and donned gloves, she entered Patient 15’s room without putting on a gown. RN 7 obtained Patient 15’s blood glucose level with glucometer and then exited room. During an interview on January 24, 2024, at 11:45 AM, with RN 7, RN7 stated Patient 15 was on contact precautions and she should have put on a gown before entering in to Patient 15’s room. RN 7 stated the purpose of contact precautions was to prevent the spread of infection. During a review of the facility’s P&P titled, “Standard and Transmission Based Precautions”, dated March 2023, the P&P indicated “ ... 3. Contact Precautions ...use contact precautions for patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact ...or indirect contact ... c. Gown 1) Wear a gown (a clean, non-sterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient’s room ...”.”

“LEADERSHIP RESPONSIBILITIES CFR(s): Standard: Leadership responsibilities (1) The governing body must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 47360 Based on interview, and record review, the facility failed to ensure tracking of adherence to infection prevention policies and procedures (P&P) for a universe of 34 patients admitted on January 22, 2024, when the facility failed to have a system in place to audit implementation and interventions for transmission-based precautions (used to help stop the spread of germs from person to another). This failure had the potential to expose patients to highly contagious diseases (germs that cause illness) that could compromise the facility’s ability to ensure the quality of health care which may result in a life-threatening infection and prolong the hospitalization of the vulnerable patients. Findings: During an interview on January 26, 2024, at 10:40 AM, with the Infection Control Preventionist (ICP), the ICP stated, there was no tracking for the use of transmission-based precautions or Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) use at this facility. The ICP stated it was the expectation that the Registered Nurse (RN) and doctor placed the patient on the appropriate transmission-based precautions and all patient care staff wear the required PPEs per P&P. The ICP stated staff was educated on transmission-based precautions at new hire orientation and annually for patient care staff. During a concurrent interview and record review on January 26, 2024, at 10:05 AM, with the ICP, the “Job Description” for “Infection Control Preventionist”, revised on July 2021, was reviewed. The Job Description indicated, “ ...Job Summary: The Infection Control Preventionist is responsible for surveillance, prevention and control of infection ... Assists with policy and procedure development and implementation ...Acts as primary education consultant to hospital employees, physicians, Patients, volunteers and visitors in safe Infection Control/Prevention practices. Coordinates all hospital infection control activities with the infection control committee, Medical Staff and hospital employees...”. ICP stated there was no system in place for monitoring transmission-based precautions implemented and use of PPE.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 47360 Based on observation, interview and record review, the facility failed to ensure the correct infection prevention practice was implemented for one of 30 sampled patients (Patient 16) when an inadequate and inaccurate transmission-based precaution (used to help stop the spread of germs from person to another) was implemented. This failure had the potential to put all patients, visitors and staff on the medical surgical/telemetry (continuous heart monitoring) floor (area of hospital) at risk of being exposed to a contagious disease (illness caused by spread of germs). Findings: During a review of Patient 16’s “History and Physical” (H&P), dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body’s response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system). During a concurrent observation and interview on January 23, 2024, at 9:50 AM, with Registered Nurse 8 (RN 8), RN 8 donned gloves, mask, and gown prior to entering Patient 16’s room. No transmission-based precaution sign was displayed outside Patient 16’s room. RN 8 stated, there should be a contact precaution (actions to prevent spread of germs by direct or indirect contact) sign outside the room. RN 8 further stated, Patient 16 was on contact precautions because he has pneumonia and some of his tests are still pending. During a concurrent interview and record review, on January 23, 2024 at 11:45 AM, with RN 4, Patient 16’s pending laboratory tests was reviewed. The QuantiFERON-TB Gold Plus (a laboratory test that can detect tuberculosis [TB- a disease caused by bacteria usually affecting the lungs and can be spread through the air]) indicated, lab was ordered January 22, 2024, and results were currently pending. RN 4 stated, Patient 16 was on transmission-based precautions because of the QuantiFERON-TB Gold Plus test was pending, and he would remain on precautions until negative lab results were available. During a concurrent interview and record review, on January 26,2024, at 10:45 AM, with the Infection Control Preventionist (ICP) , the facility’s policy and procedure (P&P) titled, “Standard and Transmission Based Precautions”, dated March 2023 , was reviewed. The P&P indicated, “ ...While Standard precautions apply to all patients, Transmission Based Precautions apply to either a confirmed or suspected diagnosis ... Initiation of Transmission Based Precautions: a ... if a situation or diagnosis exists that requires “Transmission Based Precautions”, the nurse will implement the appropriate precaution and notify the physician ...2) The nurse is responsible for initiating the appropriate precaution as indicated by laboratory results or physician diagnosis and for notifying the primary physician if not already informed ...3. Identification of patient requiring Transmission Based Precautions: a. Post appropriate isolation sign outside patient’s room. B. Identify appropriate isolation precaution needed ... Procedure: 1. Airbourne Precautions (actions to prevent spread of germs by air) ...use Airborne precautions for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei ... such as tuberculosis ...”. The ICP stated, Patient 16’s Transmission based precaution should have been posted as airborne precautions and contact precaution was not appropriate for a patient pending a TB test result. Patient 16 should have been placed on Airborne Precautions. The ICP further stated every nurse was provided education at new hire orientation regarding transmission-based precautions, but states the nurses need further education. During a review of the facility’s document “Job Description” for “Infection Control Preventionist”, revised on July 2021, the “Job Description” indicated, “ ...Job Summary: The Infection Control Preventionist is responsible for surveillance, prevention and control of infection ... Assists with policy and procedure development and implementation ...Acts as primary education consultant to hospital employees, physicians, Patients, volunteers and visitors in safe Infection Control/Prevention practices. Coordinates all hospital infection control activities with the infection control committee, Medical Staff and hospital employees...”.”

“IC PROFESSIONAL ADHERENCE TO POLICIES CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. This Standard is not met as evidenced by: 42004 Based on observation, interview, and record review, the hospital failed to ensure the implementation of hand washing to prevent and control infection for one of 30 sampled patients (Patient 1) when the nursing staff did not wash her hands after the medication administration. This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) to other vulnerable patients from a preventable infection which can negatively affect patients’ health and prolonged hospitalization. Findings: A review of Patient 1’s “History and Physical” (H&P), dated January 18, 2024, the H&P indicated, Patient 1 was admitted into the facility for hypoxemia (low oxygen in blood) with medical histories including chronic respiratory failure (a condition when lungs cannot get enough oxygen) with tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing) and ventilator (a machine to assist in delivery of oxygen) dependent, and diabetes (a condition that body cannot control blood sugar). During an observation on January 23, 2023, at 9:50 AM, in the Medical/Surgical Unit, Patient 1 was lying in bed with a trach attached to a ventilator. Registered Nurse 3 (RN 3) was observed pouring crushed medications onto Patient 1’s apple sauce after received permission from Patient 1. Medications including: Aldactone (medication to treat fluid retention or blood pressure) 50 milligrams (mg-unit doing medication). Glucophage (medication to manage blood sugar) 500 mg. Eliquis (medication to prevent blood clot) 5 mg. Topamax (medication to prevent seizure or a condition that causes abnormalities in muscle tone or movements) 200 mg. RN 3 was also observed opening a capsule of Prozac (medication to treat depression disorder) 10 mg and poured the white powder inside the capsule onto Patient 1’s apple sauce. RN 3, then, used a needle to puncture a capsule of Colace (stool softener) 100 mg and squeezed out the clear gel substance inside the capsule onto Patient 1’s apple sauce. RN 3 gave all medication to Patient 1. A follow-up observation on January 23, 2023, at 10:05 AM, RN 3 was observed removing her gloves, isolation gown, and threw them into a trash bin. RN 3 wheeled out her computer on wheel (COW) to the hallway and continued to review Patient 1’s information without using alcohol based hand rub or performing a hand wash. A follow-up interview on January 23, 2023, at 10:10 AM, RN 3 verified and stated, she had not washed her hands after she finished Patient 1’s medication administration. RN 3 confirmed, she needed to perform hand washing after the medication administration and came out from patients’ room to prevent spreading of infection. RN 3 stated, she “forgot” and was “a little nervous.” A review of Patient 1’s “Report” for Methicillin-resistant Staphylococcus aureus (MRSA-a group of bacterial infection that become resistant to many medications), dated January 19, 2024, the “Report” indicated Patient 1 had a positive MRSA infection. A review of the facility’s policies and procedures (P&P) titled, “Standard and Transmission Based Precautions,” dated March 2023, the P&P indicated, “Policy: It is the policy of [Hospital Name] to provide an effective means of isolation, based on the Center for Disease Control and Prevention (CDC) Guidelines, for Standard and Transmission based precautions ... The following elements will be followed by ALL personnel at ALL times regardless of patient diagnosis: 1. Hands will be washed for a minimum of 15 seconds using soap and warm running water or use alcohol-based waterless hand rub for a minimum of 20-30 seconds (see Hand Washing/Hand Hygiene policy and procedure): before and after caring for each patient, after removing gloves, immediately after possible contact with blood or other body fluids ...””