Loma Linda University Medical Center-Murrieta

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure privacy was maintained for one of 21 sampled patients (Patient 7), when Patient 7 was given a bed in the emergency department surge (ED surge, a unit within the ED which acts as an overflow area until a patient can move to a more permanent location) hallway, while having active bloody bowel movements (movement of feces) and hemoptysis (vomiting blood). This failure had the potential to result in an increased lack of privacy and consideration for Patient 7. Findings: On April 14, 2026, at 9 a.m., a review of Patient 7’s medical record was conducted with the regulatory specialist (RS) 2. A facility document titled, “H [history] & [and] P [physical],” dated March 2, 2026, at 8:36 p.m., was reviewed. The document indicated Patient 7 was admitted to the facility on March 2, 2026, and presented to the emergency department (ED, a specialized hospital unit providing 24/7, immediate care for acute, life-threatening injuries and illnesses) with a chief complaint of dizziness (a sensation of being unsteady, woozy, or lightheaded, often accompanied by a feeling of faintness) along with a witnessed syncopal (fainting or passing out) episode. The document indicated after Patient 7 regained consciousness, he began to vomit blood (hemoptysis) and his blood pressure (BP, the force of your blood pushing against the walls of your arteries as the heart pumps it around the body) was 70/38 (critically low blood pressure. Normal rage is typically around 120/80) in route to the ED. The document indicated Patient 7 had a past medical history of gastric (stomach) and duodenal (the first and shortest section of the small intestine located immediately below the stomach) ulcers (an open, painful sore on the skin or a mucous membrane, often characterized by the loss of surface tissue and inflammation) and adrenal insufficiency (a disorder where the adrenal glands fail to produce enough hormones which support bodily functions). The document indicated Patient 7’s symptoms were consistent with an acute upper gastrointestinal (GI, relating to the stomach and intestines) bleed and hemorrhagic shock (a life-threatening condition resulting from severe blood loss, causing inadequate oxygen delivery to tissues and organ failure). The document indicated Patient 7 had bloody bowel movements in the ED with a plan to manage acute blood loss, monitor for ongoing bleeding, and to transfuse blood products (the intravenous administration of concentrated red blood cells to increase the body’s oxygen-carrying capacity) as indicated. The document further indicated, “...He [Patient 7] is being admitted for management of acute upper GI bleed with hemodynamic instability [an insufficient blood flow within the body]...The Admission Plan: Admit to monitored setting with continuous telemetry...” A facility document titled “Event Management,” was reviewed. The document indicated, “3/2/26 [March 2, 2026]...2127 [9:27 p.m.]...MUR [Murrieta] EMERGENCY...MUREDS...S-15 [bed located in the hallway]...” A facility document titled, “RAPID RESPONSE NOTE,” dated March 3, 2026, at 1:21 p.m., was reviewed. The document indicated, “...I was called to the bedside for a medical rapid response event...I assessed the patient [Patient 7]. Patient [Patient 7] was found to be lethargic [slow to movement, sluggish]. Was able to answer basic questions by mental status changed. Pt. [Patient 7] pale and clammy [being damp, soft, sticky, and unusually cool]...[Patient 7] continuing to have hemoptysis and bloody stools [blood in the feces]...” Code called...13:57 [1:57 p.m.]...Code start...For intubation...14:45 [2:45 p.m.]...Code End Pt [Patient 7] transferred to ICU [intensive care unit, a specialized hospital department for patients with life-threatening illnesses or injuries]...” On April 14, 2026, at 10:55 a.m., an interview was conducted with the ED surge manager (EDSM). The EDSM stated surge 15 is in the hallway. The EDSM further stated it is in a high traffic area right next to the nurse’s station. On April 14, 2026, at 2:44 p.m., an interview was conducted with the ED surge registered nurse (EDSRN). The EDSRN stated Patient 7 was in the hallway during most part of her shift. EDSRN stated Patient 7 was actively having bloody and foul (offensive) smelling bowel movements. The EDSRN stated it was difficult to try and maintain his privacy because he was unable to walk to the bathroom and therefore had to use a bedside commode (a portable, chair-like medical device with a toilet seat and a removable collection bucket, designed to be placed near the bedside) multiple times. The EDSRN stated she tried to use privacy barriers however, it was difficult since the hallway is small. The EDSRN further stated, “I don’t feel like the hallway was appropriate for this patient and his privacy was compromised.” A review of the facility’s policy and procedure titled, “PATIENTS’ RIGHTS” dated December 2025, indicated, “...[name of facility] is committed to protecting and promoting each patient’s rights...[name of facility] patients shall have certain rights as stated below...Considerate and respectful care...””

“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: 50454 Based on interview and record review, the facility failed to ensure safety measures were implemented for one of 21 sampled patients (Patient 7), when a continuous telemetry monitoring (a wearable medical device which wirelessly transmits a patient’s heart rate and rhythm to a central screen to be monitored) order was not placed when it should have been. This failure had the potential to result in an increased risk of harm for Patient 7 with a possible delay in care. Findings: On April 14, 2026, at 9 a.m., a review of Patient 7’s medical record was conducted with the regulatory specialist (RS) 2. A facility document titled, “H [history] & [and] P [physical],” dated March 2, 2026, at 8:36 p.m., authored by the nurse practitioner (NP, a registered nurse with advanced graduate education who provides high-quality primary, acute, and specialty care) (NP) was reviewed. The document indicated Patient 7 was admitted to the facility on March 2, 2026, and presented to the emergency department (ED, a specialized hospital unit providing 24/7, immediate care for acute, life-threatening injuries and illnesses) with a chief complaint of dizziness (a sensation of being unsteady, woozy, or lightheaded, often accompanied by a feeling of faintness) along with a witnessed syncopal (fainting or passing out) episode. The document indicated after Patient 7 regained consciousness, he began to vomit blood (hemoptysis) and his blood pressure (BP, the force of your blood pushing against the walls of your arteries as the heart pumps it around the body) was 70/38 (critically low blood pressure. Normal rage is typically around 120/80) in route to the ED. The document indicated Patient 7 had a past medical history of gastric (stomach) and duodenal (the first and shortest section of the small intestine located immediately below the stomach) ulcers (an open, painful sore on the skin or a mucous membrane) and adrenal insufficiency (a disorder where the adrenal glands fail to produce enough hormones which support bodily functions). The document indicated Patient 7’s symptoms were consistent with acute upper gastrointestinal (GI, relating to the stomach and intestines) bleed and hemorrhagic shock (a life-threatening condition resulting from severe blood loss, causing inadequate oxygen delivery to tissues and organ failure). The document indicated Patient 7 had bloody bowel movements (movement of feces) in the ED with a plan to manage acute blood loss, monitor for ongoing bleeding, and to transfuse blood products (the intravenous administration of concentrated red blood cells to increase the body’s oxygen-carrying capacity) as indicated. The document indicated, “...He [Patient 7] is being admitted for management of acute upper GI bleed with hemodynamic instability [an insufficient blood flow within the body]...The Admission Plan: Admit to monitored setting with continuous telemetry...” A facility document titled, “RAPID RESPONSE NOTE,” dated March 3, 2026, at 3:48 a.m., was reviewed. The document indicated, “...I was called to the bedside for a medical rapid response event in ED Surge 15 for a case of a 33 y/o [year old] male with PHMX [past medical history] of adrenal insufficiency, duodenal ulcer, gastric ulcer, GI bleed...BIBA [brought in by ambulance] to the ED c/o [complaint of] dizziness. RRT [rapid response team, a specialized group of healthcare professionals called when a patient shows early signs of decline] was activated d/t [due to] pallor [loss of color from the skin, pale], dizziness, and borderline BP...Plan of Care; Repeat labs and keep in view blood transfusions...Location of rapid response: MEDEDSURGE 14-S-15...” A facility document titled, “RAPID RESPONSE NOTE,” dated March 3, 2026, at 1:21 p.m., was reviewed. The document indicated, “...I was called to the bedside for a medical rapid response event...I assessed the patient [Patient 7]. Patient [Patient 7] was found to be lethargic [slow to movement, sluggish]. Was able to answer basic questions by mental status changed. Pt. [Patient 7] pale and clammy [being damp, soft, sticky, and unusually cool]...[Patient 7] continuing to have hemoptysis and bloody stools [blood in the feces]...” Code called...13:57 [1:57 p.m.]...Code start...For intubation...14:45 [2:45 p.m.] Code End Pt [Patient 7] transferred to ICU [intensive care unit, a specialized hospital department for patients with life-threatening illnesses or injuries]...” No documented evidence of a continuous telemetry monitoring order in place for Patient 7 while in the ED surge area (a unit within the ED which acts as an overflow area until a patient can move to a more permanate location). On April 14, 2026, at 9:26 a.m., an interview was conducted with RS 2. RS 2 stated there was no evidence of an official telemetry monitor order in place. On April 14, 2026, at 1:13 p.m., an interview was conducted with the Director of Quality and Patient Safety (DQPS). The DQPS stated the NP should have put in an official telemetry monitor not just dictate it in the H&P. On April 14, 2026, at 2:59 p.m., an interview was conducted with the attending MD (MD). The MD stated if a provider dictates in their H&P they want a patient to be on a continuous telemetry monitor, they must place a separate order. The MD stated an order stating a telemetry level of care is not the same as an actual telemetry order. The MD further stated, “The telemetry order is a separate order, and the NP should have placed one, per policy.” A review of the facility’s policy and procedure titled, “CLINICAL MANAGEMENT,” dated July 2025, indicated, “...Routine authorized practitioner- initiated order shall be written/entered in the patient record by the authorized provider...” A review of the facility’s policy and procedure titled, “PATIENTS’ RIGHTS” dated December 2025, indicated, “...[name of facility] is committed to protecting and promoting each patient’s rights...[name of facility] patients shall have certain rights as stated below...Receive care in a safe setting...” A facility’s document titled, “[name of facility] GENERAL RULES AND REGULATIONS,” dated December 6, 2025, was reviewed. The bylaws indicated, “...ORDERS...TREATMENT ORDERS: All orders for treatment shall be in writing...””

“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: 50454 Based on interview and record review, the facility failed to ensure care was implemented in accordance with the facility’s policy and procedure (P&P) for three of 21 sampled patients (Patient 7, 15, and 21), when: 1. For Patient 7, telemetry monitoring (a wearable medical device which wirelessly transmits a patient’s heart rate and rhythm to a central screen to be monitored) was placed without a telemetry monitoring order. 2. For Patients 15, and 21, abuse and neglect screenings were not completed when seen in the ED (Emergency Department - a specialized unit in a hospital designed to address various urgent and critical medical conditions). These failures had the potential to put patients at risk for unnecessary treatments and unidentified abuse or neglect. Findings: 1. On April 14, 2026, at 9 a.m., a review of Patient 7’s medical record was conducted with the regulatory specialist (RS) 2. A facility document titled, “H [history] & [and] P [physical],” dated March 2, 2026, at 8:36 p.m., authored by the nurse practitioner (NP, a registered nurse with advanced graduate education who provides high-quality primary, acute, and specialty care) (NP) was reviewed. The document indicated Patient 7 was admitted to the facility on March 2, 2026, and presented to the ED, with a chief complaint of dizziness (a sensation of being unsteady, woozy, or lightheaded, often accompanied by a feeling of faintness) along with a witnessed syncopal (fainting or passing out) episode. The document indicated after Patient 7 regained consciousness, he began to vomit blood (hemoptysis) and his blood pressure (BP, the force of your blood pushing against the walls of your arteries as the heart pumps it around the body) was 70/38 (critically low blood pressure. Normal rage is typically around 120/80) in route to the ED. The document indicated Patient 7 had a past medical history of gastric (stomach) and duodenal (the first and shortest section of the small intestine located immediately below the stomach) ulcers (an open, painful sore on the skin or a mucous membrane, often characterized by the loss of surface tissue and inflammation) and adrenal insufficiency (a disorder where the adrenal glands fail to produce enough hormones which support bodily functions). The document indicated Patient 7’s symptoms were consistent with acute upper gastrointestinal (GI, relating to the stomach and intestines) bleed and hemorrhagic shock (a life-threatening condition resulting from severe blood loss, causing inadequate oxygen delivery to tissues and organ failure). The document indicated Patient 7 had bloody bowel movements (movement of feces) in the ED with a plan to manage acute blood loss, monitor for ongoing bleeding, and to transfuse blood products (the intravenous administration of concentrated red blood cells to increase the body’s oxygen-carrying capacity) as indicated. The document indicated, “...He [Patient 7] is being admitted for management of acute upper GI bleed with hemodynamic instability [an insufficient blood flow within the body]...The Admission Plan: Admit to monitored setting with continuous telemetry...” An untitled facility document dated March 2, 2026, authored by the NP, was reviewed. The document indicated, “...Order Date: Mar [March] 2, 2026...Order Time: 8:31 PM...Level of Care: MUR [murrieta]-Telemetry...Diagnosis: GIB (gastrointestinal bleeding, bleeding within the stomach area)...” An untitled facility document dated March 3, 2026, authored by the ED surge registered nurse (EDSRN), was reviewed. The document indicated, “...3/3/26 [March 3, 2026] at 0730 [7:30 a.m.]...Vitals Signs...Heart Rate Source...Monitor [telemetry monitor]...Cardiac [heart] Rhythm Extended...NSR [normal sinus rhythm, normal heart rate and rhythm]...” No documented evidence of a continuous telemetry monitoring order in place for Patient 7 while in ED surge (a unit within the ED which acts as an overflow area until a patient can move to a more permanent location). On April 14, 2026, at 9:26 a.m., an interview was conducted with RS 2. RS 2 stated there was no evidence of an official telemetry monitor order in place despite the NP stating the intention is for Patient 7 to be on continuous monitoring while in ED surge. On April 14, 2026, at 1:13 p.m., an interview was conducted with the Director of Quality and Patient Safety (DQPS). The DQPS stated Patient 7 was placed on a telemetry monitor when there was not an actual telemetry order. The DQPS further stated the EDSRN was practicing outside of her scope by placing Patient 7 on a telemetry monitor. On April 14, 2026, at 2:44 p.m., an interview was conducted with the EDSRN. The EDSRN stated when she looked through the managed orders, she saw the level of care listed as telemetry. The EDSRN stated she did not look for a separate or official telemetry monitoring order. The EDSRN stated, “I assumed the NP wanted Patient 7 to be on telemetry based on her inpatient order”. A review of the facility P&P titled, “CLINICAL MANAGEMENT,” dated July 2025, indicated, “...An RN shall “acknowledge” CPOE [computerized provider order entry orders]...” 2 a. A concurrent interview and record review was conducted on April 13, 2026, at 9:36 a.m.,with Registered Nurse (RN 1).The facility document titled,”Domestic Abuse Assessment,” was reviewed on the facility’s electronic health records. RN 1 stated abuse screening is part of the assessment documentation in the ED. A review of Patient 15’s medical record was conducted on April 13, 2026, at 2:33 p.m.,with the Regulatory Specialist (RS 2). A facility document titled, “ED Provider Notes,” dated April 12, 2026, was reviewed. The document indicated Patient 15 was seen in the ED on April 12, 2026, with a chief complaint of abdominal pain. There was no evidence of documentation found in Patient 15’s medical record that abuse screening was conducted. 2 b. A review of Patient 21’s medical record was conducted on April 14, 2026, at 9:10 a.m., with RS 3. A facility document titled, “ED Triage Notes,” dated April 10, 2026, was reviewed. The document indicated Patient 21 was seen in the ED on April 10, 2026, with a chief complaint of decreased fetal (unborn offspring) movement. There was no documented evidence in Patient 21’s medical record that an abuse screening was conducted. A concurrent interview and policy review were conducted on April 14, 2026, at 10:10 a.m., with the Quality and Patient Safety Specialist (QPSS). The policy titled, “ED Nursing Assessment/Reassessment,” dated March 29, 2023, was reviewed and indicated, “ ...The triage assessment will address the body system presented by the patient’s complaint and include duration severity associated factors mental status ambulatory status and ordering of clinical tests as appropriate. A complete triage assessment includes ...signs of abuse ...” The QPSS stated the policy was not followed.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50454 Based on interview and record review, the facility failed to ensure the patient’s right to safe and appropriate care, for two of 21 sampled patients (Patients 3 and 21), when: 1. For Patient 3, the patient was not informed of a worsening chest x-ray prior to discharge from the facility (A0130); and 2. For Patient 21, safety measures were not implemented when a radiology transporter (RTP, a staff member responsible for the safe and efficient movement of patients, medical equipment, and supplies throughout a facility) placed Patient 21 in a wheelchair without the leg rests (equipment on a wheelchair designed to support the patient’s feet and lower legs), resulting in a fall. (A0144) The cumulative effects of these systemic failures had the potential to result in delayed medical care, readmission, and could result in death for Patient 3 and Patient 21.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to allow one of 21 sampled patients (Patient 3) to participate in his treatment and discharge plan when a worsening chest x-ray was not reviewed with the patient prior to his discharge from the facility. This failure had the potential to result in delayed medical care, readmission, and could result in death. Findings: On February 10, 2026, at 10:45 a.m., a review of Patient 3’s medical record was conducted with the Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated November 12, 2023, was reviewed. The document indicated Patient 3 was admitted to the facility on November 12, 2023, with a diagnosis of congestive heart failure (a chronic condition where the heart cannot pump blood efficiently, often causing fluid buildup in the lungs and body) exacerbation (a sudden worsening of heart failure symptoms). A facility document titled, “Radiology Result,” dated November 20, 2023, was reviewed. The document indicated, “X-ray...Chest...Comparison: November 16, 2023...Findings:...Lungs: Increased airspace disease throughout the right chest...Impression: Worsening airspace disease throughout the right chest...” A facility document titled, “Physician Discharge Summary,” dated November 20, 2023, was reviewed. There was no documented evidence Patient 3’s worsening chest x-ray was acknowledged or addressed by a physician. A facility document titled, “Physician Discharge Summary,” dated November 21, 2023, was reviewed. The document indicated Patient 3 was discharged home on November 21, 2023. There was no documented evidence Patient 3’s worsening chest x-ray had been acknowledged or addressed by a physician prior to his discharge on November 21, 2023. During the review of Patient 3’s medical record with RS 1, there was no documented evidence Patient 3 was informed of his worsening chest x-ray prior to discharge. On February 12, 2026, at 10:09 a.m., an interview and record review was conducted with Medical Doctor (MD) 1. MD 1 stated Patient 3’s chest x-ray on November 20, 2023, looked worse compared to the prior chest x-ray. MD 1 stated he did not see where in the medical record Patient 3’s worsening chest x-ray had been addressed by the attending physician. MD 1 stated “the change in the chest x-ray not being addressed in the physician notes is a problem.” MD 1 further stated he would not have discharged Patient 3. A facility document titled, “General Rules and Regulations,” dated December 6, 2025, was reviewed. The document indicated, “A discharge clinical summary shall...include...significant findings...and treatment rendered...All final diagnoses, any complications, and operative reports should be recorded in full at the time of discharge...” A facility policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated December 2025, was reviewed. The document indicated, “...[Name of the facility] is committed to protecting and promoting each patient’s rights...patients shall have certain rights as stated below...Receive information about health status, diagnosis, prognosis, prospects for recovery and outcomes of care...The patient has the right to effective communication and to participate in the development and implementation of the plan of care...””

“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: 50454 Based on interview and record review, the facility failed to ensure safety measures were implemented, for one of 21 sampled patients (Patient 21), in accordance with the facilities policy and procedure (P&P), when a radiology transporter (RTP, a staff member responsible for the safe and efficient movement of patients, medical equipment, and supplies throughout a facility) placed Patient 21 in a wheelchair without the leg rests (equipment on a wheelchair designed to support the patient’s feet and lower legs) attached. This failure resulted in harm for Patient 21 and had the potential for an increased risk for Patient 21 to be readmitted. Findings: On February 10, 2026, at 1:20 p.m., a review of Patient 21’s medical record was conducted with the Regulatory Specialist (RS) 2. A facility document titled, “ED [Emergency Department, a specialized unit providing immediate, unscheduled care for acute, life-threatening, or severe injuries and illnesses] provider notes,” dated December 3, 2025, was reviewed. The document indicated Patient 21 presented to the ED for an unwitnessed fall in the bathroom at a senior living facility (a residential setting specifically designed for older adults, offering varying levels of support), and now experiencing pain and redness to her right hand. This document further indicated, “...While being taken to CT [computed tomography, a type of imaging which uses X-ray techniques to create detailed images of the body], patient [Patient 21] got her foot stuck, causing her to fall face forward from her wheelchair, hitting her head...Moderate distress...There is a contusion [an injury to the soft tissue or skin] noted to the forehead...Patient [Patient 21] has contractures [the tightening or shortening of muscles, tendons, skin, or ligaments that causes joints to become stiff and restricts normal movement] to the lower extremities [legs]...” A facility document titled, “ED notes,” dated December 3, 2025, authored by a Registered Nurse (RN) 1, was reviewed. The document indicated, “...[name of provider] made aware of code gold [a protocol which establishes early interventions for patients after sustaining a fall within the facility]; pt [Patient 21] fell while being transported to CT via wheel chair with radiology [a medical specialty which uses imaging technology to diagnose and treat diseases inside the body] transport [name of RTP]; Staff member reports he was taking pt [Patient 21] to CT in wheel chair without foot pegs [leg rests] when her legs got pulled back and she fell hitting her head; denies loc [level of consciousness, a person’s state of arousal, alertness, and awareness of themselves and their surroundings], no thinners [blood thinning medications] no change in mental status; pt [Patient 21] has abrasions [a minor, superficial injury where the top layer of skin is scraped or rubbed away] to forehead near hair line; pt [Patient 21] placed in wheel chair with appropriate foot pegs, will get CT of head as previously ordered...” An untitled facility document, dated December 3, 2025, at 8 p.m., was reviewed with RS 2. The document indicated, “...Fall Occurrence...Fall Date: 12/3/2025 [December 3, 2025]...Fall Time: 2000 [8 p.m.]...Type of Fall: Accidental fall...Anatomical Location Involved: Head...Injury: Yes, laceration to forehead...Interventions due to Fall: Applied ice; Cleaned wound...Patient Activity During Fall; Wheelchair...Location at time of fall: ER [Emergency Room] lobby...Staff that Observed Fall: [name of RTP]...” A facility document titled, “CODE GOLD CHECKLIST,” dated December 3, 2025, was reviewed with the RS. The document indicated, “...Date: 12/3/25...Time Code GOLD Called: 2000...Patient Name and MRN [medical record number, a unique, patient-specific code assigned by a hospital to identify you and manage your medical history]: [Patient 21 and MRN]...Unwitnessed fall or Patient Hit Head...Perform Post Vitals [measurements of the body’s most basic functions immediately after an event] and Neuro Status Assessments [a rapid, systematic evaluation of a person’s brain, spinal cord, and nerve function] Q [every] 15 min [minutes] x [times] 4 [four]; Q 30 mins x 2 [two]; Q 1 [one] hour x 4; Q4 hours x 48 hours...” An untitled facility document, dated December 3, 2025, was reviewed with RS 2. The document indicated, “...[Patient 21]...Injury: Y [yes]...EER [electronic event report, a digital, web-based, or software-driven tool used to capture, document, and analyze incidents, safety errors, or unexpected occurrences] summary...pt [Patient 21] fell while being transported to CT with radiology transport [name of RTP]; Staff member reports he was taking patient [Patient 21] to CT in wheelchair without foot pegs when her legs got pulled back and she fell hitting her head; denies LOC, no thinners, no change in mental status; pt [Patient 21] has abrasion to forehead near hairline; pt [Patient 21] placed in wheelchair with appropriate foot pegs, will get CT of head as previously ordered. Patient [Patient 21] was going for head CT coming from emergency room. Patient [Patient 21] appeared altered upon visual examination and was slanted sideways in wheelchair. Hospital wheelchair did not have footrests. While taking patient [Patient 21] outside on the sidewalk heading towards CT trailer, patients [Patient 21] feet began to drag to the ground suddenly. Patients [Patient 21’s] foot/sandal then got caught on an unknown source on the sidewalk and began to fall forward out of wheelchair. Patient’s [Patient 21’s] forehead then made contact with the sidewalk face first and I [RTP] responded by going to the patients [Patient 21’s] side and lifting her up under her arms. I [RTP] rested the patients [Patient 21’s] upper half on my lap and spotted 3 [three] guests walking out of the emergency. I [RTP] shouted out to the guest and told them to go inside and tell the ER front desk to call a code gold...COMMENTS to EER...[name of Radiology Manager]...I [Radiology Manager] emphasized to staff that patients are not to be placed in situations leading to potential injury, to include transportation without footrest. Patients should be transferred to a wheelchair with footrests or attach footrests (if available) to the wheelchair occupied by the patient...” On February 11, 2026, at 2:45 p.m., an interview was conducted with the Director of Quality and Patient Safety (DQPS). The DQPS stated, “[name of Patient 21] should never have been placed in a wheelchair with no leg rests, especially considering she had contractures to her lower extremities and recently sustained a fall prior to coming into the ED.” On February 12, 2026, at 10:21 a.m., an interview was conducted with the Radiology Manager (RM). The RM stated it is important to have the footrests attached to the wheelchair because we never want the patient to drop their feet to the ground while moving the wheelchair. The RM further stated, “I spoke with him [RTP] to remind him of the department expectation and that footrests must be attached to the wheelchair to avoid patient injury.” On February 12, 2026, at 10:50 a.m., an interview was conducted with RN 1. RN 1 stated she was the ED charge nurse on December 3, 2025, and was made aware of Patient 21 falling out of the wheelchair. RN 1 stated the wheelchair did not have legs rest, which was the causing factor. RN 1 stated transporting a patient in a wheelchair without leg rest is not acceptable. RN 1 further stated she reminded the transporter to always use appropriate equipment while transporting patients. A facility document titled, “JOB DESCRIPTION,” was reviewed with the Director of HR (Human Resource) Partners (DHRP). The document indicated, “...Tech Assistant/Transporter...Job Summary...The Technician Assistant/ Transporter position is of a service nature dedicated to the prompt, courteous and efficient transfer of patients and materials within the hospital...Maintains working knowledge of departmental standard operating procedures, which includes the use of specialized equipment, quality control requirements, and preventative maintenance...Essential Duties...Performs patient lifting and handling procedures so as to minimize patient discomfort and potential for injury...Understands operating and safety procedures of equipment...Demonstrates the knowledge and skills for age specific factors necessary to perform safe and effective transport on patients of all ages...Identify safety issues, intervenes notifies supervisor...” A review of the facility’s P&P titled, “IN HOUSE TRANSPORT OF PATIENTS,” dated February 2025, was conducted. The P&P indicated, “...Transportation shall be provided via appropriate method of transport...Specific equipment determined by patient acuity level and needs...” A review of the facility’s P&P titled, “MEDICAL EQUIPMENT MANAGEMENT AND SAFETY,” dated April 2025, was conducted. The P&P indicated, “...Assure that equipment is in compliance with applicable codes and standards...Ensure that equipment problems, failures, repairs, and operator errors shall be identified in action of resolution taken and documented...Ensure that staff is knowledgeable in the following there is...Basic equipment operating and safety procedures...Capabilities, limitations, and applications for equipment use...Staff shall be responsible to use equipment safely checking it prior to: Use and leaving it in good condition after use...””

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to provide quality medical care for one of 21 sampled patient’s (Patient 3), when a worsening chest x-ray was not addressed prior to discharge from the facility. This failure had the potential to result in delayed medical care, readmission, and could result in death. Findings: On February 10, 2026, at 10:45 a.m., a review of Patient 3’s medical record was conducted with Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated November 12, 2023, was reviewed. The document indicated Patient 3 was admitted to the facility on November 12, 2023, with a diagnosis of congestive heart failure (a chronic condition where the heart cannot pump blood efficiently, often causing fluid buildup in the lungs and body) exacerbation (a sudden worsening of heart failure symptoms). A facility document titled, “Radiology Result,” dated November 20, 2023, was reviewed. The document indicated, “X-ray...Chest...Comparison: November 16, 2023...Findings:...Lungs: Increased airspace disease throughout the right chest...Impression: Worsening airspace disease throughout the right chest...” A facility document titled, “Physician Discharge Summary,” dated November 20, 2023, was reviewed. There was no documented evidence Patient 3’s worsening chest x-ray was acknowledged or addressed. There was no documented evidence Patient 3 was informed of the worsening chest x-ray. A facility document titled, “Physician Discharge Summary,” dated November 21, 2023, was reviewed. The document indicated Patient 3 was discharged home on November 21, 2023. There was no documented evidence Patient 3’s worsening chest x-ray had been acknowledged or addressed prior to his discharge on November 21, 2023. During the review of Patient 3’s medical record with RS 1 there was no documented evidence Patient 3 was informed of his worsening chest x-ray. On February 12, 2026, at 10:09 a.m., an interview and record review was conducted with Medical Doctor (MD) 1. MD 1 stated Patient 3’s chest x-ray on November 20, 2023, looked worse compared to the prior chest x-ray. MD 1 stated he did not see where Patient 3’s worsening chest x-ray had been addressed by the attending physician. MD 1 stated “the change in the chest x-ray not being addressed in the physician notes is a problem.” MD 1 further stated he would not have discharged Patient 3 home. A facility document titled, “General Rules and Regulations,” dated December 6, 2025, was reviewed. The document indicated, “A discharge clinical summary shall...include...significant findings...and treatment rendered...All final diagnoses, any complications, and operative reports should be recorded in full at the time of discharge...” A facility policy and procedure (P&P) titled, “Patients’ Rights and Responsibilities,” dated December 2025, was reviewed. The document indicated, “...[Name of the facility] is committed to protecting and promoting each patient’s rights...patients shall have certain rights as stated below...Receive information about health status, diagnosis, prognosis, prospects for recovery and outcomes of care...The patient has the right to effective communication and to participate in the development and implementation of the plan of care...””

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to ensure medical bylaws were enforced for one of 21 sampled patients (Patient 11), when a consulted physician did not evaluate a patient within 24 hours. This failure had the potential to delay patient care and prolong hospitalization. Findings: On February 11, 2026, at 1:38 p.m., a review of Patient 11’s medical record was conducted with Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated January 7, 2026, was reviewed. The document indicated Patient 11 was admitted to the facility on January 7, 2026, with a diagnosis of nondisplaced fracture (a bone break where it remains in alignment) of posterior (back) column of right acetabulum (the socket of the hip bone). An untitled facility document dated January 2, 2026, at 9:14 p.m., indicated “Orthopedics [a branch of medicine dealing with conditions affecting bone and muscle] Consult [Consultation, an evaluation of health concerns requested by another physician]...Order date: January 2, 2026...Order Time: 9:14 p.m....Reason for consult? pelvic fractures, mechanical fall [a fall that occurs due to an external force such as tripping, slipping, or a misstep]...Is this consult for Admission? Yes...Transfer Service: Orthopedic Surgery...” A facility document titled, “Physical Therapy [a healthcare profession focused on the improvement, maintenance, or restoration of physical movement and health],” dated January 3, 2026, at 11 a.m., was reviewed. The document indicated, “...Attempted to see pt [patient] for PT [Physical Therapy] eval [evaluation]. However upon chart review, pt is awaiting ortho [Orthopedics] consult, as xray showed pelvic and acetabular subacute fractures [a bone injury in the early healing phase]. Will defer PT eval until ortho has cleared [medical clearance, an examination by a physician to determine if a patient is healthy enough to participate in activity or undergo surgery] pt to work with PT...” A facility document titled, “Physical Therapy,” dated January 4, 2026, at 10:30 a.m., was reviewed. The document indicated, “...Attempted to see pt for PT eval, however upon chart review, pt was still awaiting ortho consult. PT will defer eval at this time until cleared by ortho to be seen...” A facility document titled, “Orthopedic Surgery Consult,” dated January 4, 2026, at 10:28 p.m. (48 hours after consult was requested), was reviewed. The document indicated, “...Orthopedics was consulted for inferior rami fractures [a break in the lower bone of the pelvis], right acetabulum fractures...” On February 12, 2026, at 11:25 a.m., an interview was conducted with the Fourth Floor Manager (FFM). The FFM stated consulted physicians have 24 hours to evaluate a patient after the consultation is requested. On February 12, 2026, at 12:47 p.m., an interview was conducted with Physical Therapist (PT) 1 and the Director of Rehabilitation Therapy (DRT). PT 1 stated with any orthopedic patient, the medical record is reviewed to assess what the consult is for and if the patient has been cleared by orthopedics to be evaluated by physical therapy and has weight bearing status (the amount of weight or pressure a physician allows a patient to place on an injured limb). PT 1 stated if a patient has an ortho consult he waits until the patient is medically cleared to be seen for the safety of the patient. The DRT stated it is standard practice for the therapist to review the chart prior to the evaluation and to wait for medical clearance for sacral fractures. The DRT stated PT “could be doing a lot more damage” to the patient if they aren’t stable to move. The DRT stated PT cannot decide weight bearing tolerance or ability to move and they must receive the information from a physician. A facility document titled, “General Rules and Regulations,” dated December 6, 2025, was reviewed. The document indicated, “...Requested or Required Consultations...Consultations shall be performed within 24 hours...””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50433 Based on interview and record review, the facility failed to ensure a care plan was individualized with patient goals and nursing care in accordance with the patient’s diagnosis, for one of 21 sampled patient’s (Patient 10). This failure had the potential to increase the patient’s risk of safety incidents and clinical deterioration. Findings: On February 11, 2026, at 11:21 a.m., a review of Patient 10’s medical record was conducted with Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated January 1, 2026, was reviewed. The document indicated Patient 10 was admitted to the facility on January 1, 2026, with a diagnosis of slurred speech (a condition in which words are spoken in an unclear, slow, or jumbled manner) and cerebrovascular accident (CVA, the medical term for a stroke, a sudden even where blood flow to part of the brain is blocked leading to potential brain damage). A facility document titled, “Care Plan,” was reviewed. There was no documented evidence a stroke care plan or any neurological (disorders affecting the brain) care plan was initiated on Patient 10. On February 12, 2026, at 9:55 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated care plans are reviewed every shift by the assigned RN. RN 2 stated there is a stroke care plan which should be included for a patient diagnosed with a stroke. RN 2 stated it is important to complete a patients care plan because it reflects the problems of the patient and if the patient met their goals of care and are progressing towards discharge. An undated facility policy and procedure (P&P) titled, “Nursing Documentation,” was reviewed. The P&P indicated, “...Care plans should be implemented within 24 hours of admission ...Documentation on applicable goals and interventions...should be modified to add detail specific to each patient...” A facility P&P titled, “Patient Care Process and Documentation,” dated April 2025, was reviewed. The P&P indicated, “...A plan of care for each patient shall be initiated by a registered nurse based on the outcome of patient assessment and reassessment activities and in coordination with the medical plan of care...””

“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: 50454 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for three of 21 sampled patients (Patients 7, 10, and 21) when: 1. For Patient 7, medication for hypertension (high blood pressure) was not administered in accordance with the physician order; 2. For Patient 10, complete neurologic checks (an assessment by healthcare professionals to evaluate how well a person’s brain, spinal cord, and nerves are functioning) were not documented as ordered, a National Institute of Health (a nationally recognized federal agency for medical research) Stroke Scale (NIHSS, a standardized tool used by healthcare providers to objectively quantify the severity of a stroke [a sudden even where blood flow to part of the brain is blocked leading to potential brain damage] was not performed at discharge as ordered, and the care plan was not individualized with patient goals and nursing care in accordance with the patient’s diagnosis; and 3. For Patient 21, a code gold (a protocol which establishes early interventions for patients after sustaining a fall within the facility) was activated, and Patient 21 was not properly monitored after falling. These failures had the potential to compromise patient safety, delay treatment, and may result in prolonged hospitalization for Patient’s 7, 10, and 21. Findings: 1. On February 11, 2026, at 9:30 a.m., a review of Patient 7’s medical record was conducted with Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated February 6, 2026, was reviewed. The document indicated Patient 7 was admitted to the facility on February 6, 2026, with a diagnosis of hypoxemic respiratory failure (a medical condition where the lungs cannot transfer enough oxygen into the blood). The document further indicated Patient 7 had a medical history of hypertension (high blood pressure). A facility document titled, “Vital Signs [measurements of the body’s most basic functions including heart rate, blood pressure, respiratory rate, temperature, and pain level, used by medical professionals to assess physical health],” dated February 7, 2026, was reviewed. The document indicated Patient 7 had an elevated blood pressure of 169/87 (a normal, healthy blood pressure for most adults is 120/80) at 12:16 a.m. and 163/103 at 4:29 a.m. A facility document titled, “Medication,” dated February 6, 2026, was reviewed. The document indicated an order was placed on February 6, 2026, at 1:48 a.m. for clonidine (a medication to treat high blood pressure) tablet 0.1 mg (milligrams, a unit of measurement) 4 (four) times daily PRN (as needed) “...this medication is 1st choice for systolic blood pressure [top number] over 160 or diastolic blood pressure [bottom number] over 90...” A facility document titled, “Medication Administration Report,” dated February 7, 2026, was reviewed. There was no documented evidence Patient 7 received the ordered medication for his high blood pressure. On February 12, 2026, at 9:55 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated most patients have PRN blood pressure medications with parameters (numerical or other measurable factors used as a guideline) ordered. RN 2 stated she would administer PRN blood pressure medications if the parameter was met or would notify the physician of the patient’s blood pressure if there were no PRN medications ordered. A facility policy and procedure (P&P) titled, “Medication Administration and Errors,” dated February 2025, was reviewed. The P&P indicated, “...Medications that are ordered...shall...be administered according to specified parameters...” A facility P&P titled, “Diagnostic, Therapeutic and Standing Orders,” dated July 2025, was reviewed. The document indicated, “...An RN shall ‘acknowledge [verify, accept responsibility for, and initiate the action ordered by a provider]’ CPOE [Computerized Provider Order Entry, orders entered into the electronic health record] orders...” 2.a. On February 11, 2026, at 11:21 a.m., a review of Patient 10’s medical record was conducted with Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated January 1, 2026, was reviewed. The document indicated Patient 10 was admitted to the facility on January 1, 2026, with a diagnosis of slurred speech (a condition in which words are spoken in an unclear, slow, or jumbled manner) and cerebrovascular accident (CVA, the medical term for a stroke). A facility document titled, “Neurological Checks,” dated January 1, 2026, was reviewed. The document indicated Patient 10 had a physician order for Neurological Checks every four hours. A facility document titled, “Flowsheet, Neuro Assessment” dated January 2, 2026, through January 4, 2026, was reviewed. The document indicated on January 2, 2026, at 12 p.m. and 3:38 p.m., an assessment of motor function (an evaluation of muscle strength, tone, coordination, and movement included in a neuro assessment) was not performed. The document further indicated a neuro assessment was not performed on January 3, 2026, at 4 a.m., and on January 4, 2026, at 12 a.m. and 4 a.m. On February 12, 2026, at 9:55 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated a complete neuro check includes mentation (the evaluation of a person’s brain functioning, thinking ability and emotional state), pupillary response (an evaluation of nerves by checking if pupils are equal, round, and reactive to light), eye reactions (an assessment of the muscles controlling eye movement), motor functions, and mobility (an assessment of the patient’s ability to move). A facility document titled, “Ischemic [restricted blood flow to tissues of organs, causing a critical shortage of oxygen] Stroke or TIA [transient ischemic attack, mini-stroke, a temporary blockage of blood flow to the brain] Patient Shift Checklist,” dated December 8, 2025, was reviewed. The document indicated, “...Assess each of the following at minimum for each neuro check:...Headache...Pupil assessment...GCS Score [Glasgow Coma Scale, a neurologic scale ranging from 3 to 15, used to assess a person’s awareness level after a brain injury]...Extremities [arms and legs]: Upper & [and] lower extremity strength & sensation...” A facility document titled, “Diagnostic, Therapeutic and Standing Orders,” dated July 2025, was reviewed. The document indicated, “...An RN shall ‘acknowledge’ CPOE orders...” 2 b. A facility document titled, “NIH Stroke Scale,” dated January 1, 2026, was reviewed. The document indicated Patient 10 had a physician order for a NIHSS assessment to be completed on discharge from the facility. A facility document titled, “Physician Discharge Summary,” dated January 4, 2026, was reviewed. The document indicated Patient 10 was discharged home on January 4, 2026. A facility document titled, “Flowsheet, NIH Stroke Scale” dated January 4, 2026, was reviewed. There was no documented evidence a NIHSS was assessed for Patient 10 prior to discharge. On February 12, 2026, at 9:55 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated an NIHSS is performed on discharge to make sure the patient has improved. RN 2 stated if the assessment is not performed the patient could be discharged with worsening symptoms which could lead to readmission to the facility. A facility document titled, “Clinical Guideline, Code Stroke/Code Neuro,” dated September 24, 2025, was reviewed. The document indicated, “...Criteria for Discharge...NIHSS documented just prior to discharge...” A facility document titled, “Diagnostic, Therapeutic and Standing Orders,” dated July 2025, was reviewed. The document indicated, “...An RN shall ‘acknowledge’ CPOE orders...” 3 c. A facility document titled, “Care Plan,” was reviewed. There was no documented evidence a stroke care plan or any neurological care plan was initiated on Patient 10. On February 12, 2026, at 9:55 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated care plans are reviewed every shift by the assigned RN. RN 2 stated there is a stroke care plan which should be included for a patient diagnosed with a stroke. RN 2 stated it is important to complete a patients care plan because it reflects the problems of the patient and if the patient met their goals of care and are progressing towards discharge. An undated facility P&P titled, “Nursing Documentation,” was reviewed. The P&P indicated, “...Care plans should be implemented within 24 hours of admission...Documentation on applicable goals and interventions...should be modified to add detail specific to each patient...” A facility P&P titled, “Patient Care Process and Documentation,” dated April 2025, was reviewed. The P&P indicated, “...A plan of care for each patient shall be initiated by a registered nurse based on the outcome of patient assessment and reassessment activities and in coordination with the medical plan of care...” 3. On February 10, 2026, at 1:20 p.m., a review of Patient 21’s medical record was conducted with Regulatory Specialist (RS) 2. A facility document titled, “ED [Emergency Department, a specialized unit providing immediate, unscheduled care for acute, life-threatening, or severe injuries and illnesses] provider notes,” dated December 3, 2025, was reviewed. The document indicated Patient 21 presented to the ED for an unwitnessed fall in the bathroom at a senior living facility and now experiencing pain and redness to her right hand. The document further indicated, “...While being taken to CT [computed tomography, a type of imaging which uses X-ray techniques to create detailed images of the body], patient [Patient 21] got her foot stuck, causing her to fall face forward from her wheelchair, hitting her head...Moderate distress...There is a contusion [an injury to the soft tissue or skin] noted to the forehead...Patient [Patient 21] has contractures [the tightening or shortening of muscles, tendons, skin, or ligaments that causes joints to become stiff and restricts normal movement] to the lower extremities [legs]...” A facility document titled, “ED notes,” dated December 3, 2025, at 8 p.m., authored by a registered nurse (RN)1 was reviewed. The document indicated, “...[name of provider] made aware of code gold; pt [Patient 21] fell while being transported to CT via wheel chair with radiology [a medical specialty which uses imaging technology to diagnose and treat diseases inside the body] transport [name of transporter]; Staff member reports he was taking pt [Patient 21] to CT in wheel chair without foot pegs [equipment on a wheelchair designed to support the patient’s feet and lower legs] when her legs got pulled back and she fell hitting her head; denies loc [level of consciousness, a person’s state of arousal, alertness, and awareness of themselves and their surroundings], no thinners [blood thinning medications] no change in mental status; pt [Patient 21] has abrasions [a minor, superficial injury where the top layer of skin is scraped or rubbed away] to forehead near hair line; pt [Patient 21] placed in wheel chair with appropriate foot pegs, will get CT of head as previously ordered...” An untitled facility document, dated December 3, 2025, at 8 p.m., was reviewed with the Regulatory Specialist (RS) 2. The document indicated, “...Fall Occurrence...Fall Date: 12/3/2025 [December 3, 2025]...Fall Time: 2000 [8 p.m.]...Type of Fall: Accidental fall...Anatomical Location Involved: Head...Injury: Yes, laceration to forehead...Interventions due to Fall: Applied ice; Cleaned wound...Patient Activity During Fall; Wheelchair...Location at time of fall: ER [Emergency Room] lobby...Staff that Observed Fall: [name of transporter]...” A facility document titled, “CODE GOLD CHECKLIST,” dated December 3, 2025, was reviewed with RS 2. The document indicated, “...Date: 12/3/25...Time Code GOLD Called: 2000...Patient Name and MRN [medical record number, a unique, patient-specific code assigned by a hospital to identify you and manage your medical history]: [Patient 21 and MRN]...Unwitnessed fall or Patient Hit Head...Perform Post Vitals [measurements of the body’s most basic functions immediately after an event] and Neuro Status Assessments [a rapid, systematic evaluation of a person’s brain, spinal cord, and nerve function] Q [every] 15 min [minutes] x [times] 4 [four]; Q 30 mins x 2 [two]; Q 1 [one] hour x 4; Q4 hours x 48 hours...” (vital signs and neuro status checks started at 8:50 p.m. and ended at 11:35 p.m. Patient 21 was monitored approximately 2.5 hours after code gold was activated). A facility document titled, “ED notes,” dated December 3, 2025, at 11:28 p.m. was reviewed with RS 2. The documented indicated, “...Called [name of returning facility] and was able to speak with [name of returning facility staff member]. I was able to discuss pt’s [Patient 21’s] discharge instructions and she verbalized understanding. [Name of returning facility staff member] was also informed about the incident that happened earlier to the pt [Patient 21] when she fell off the wheelchair on the way to CT scan...” A facility document titled, “ED notes,” dated December 4, 2025, at 1:45 a.m. authored by RN 1 was reviewed. The document indicated, “ ...Pt [Patient 21] picked up by...BLS [basic life support] transport...to go back to [name of returning facility]...” On February 12, 2026, at 2:45 p.m., an interview was conducted with the Director of Quality and Patient Safety (DQPS). The DQPS stated when a patient falls and hits their head, they should be monitored for 48 hours. The DQPS stated Patient 21 should have been monitored for 48 hours post fall, as per the policy. The DQPS stated even if Patient 21 was returning to her facility, it should have been documented for the facility to continue monitoring Patient 21’s vital signs and neuro checks for the remaining hours. The DQPS further stated education regarding a patient falling and hitting their head was not included in the discharge instructions when it should have been. On February 12, 2026, at 10:50 a.m., an interview was conducted with RN 1. RN 1 stated she was not aware of the 48-hour monitoring requirement for Patient 21. RN 1 stated, “I don’t think the physicians are aware of this requirement”. RN 1 stated it was important to monitor Patient 21 for up to 48 hours to make sure she did not have any neurological changes, swelling or bruising to the brain. RN 1 further stated, “I don’t think 2.5 hours of monitoring was sufficient now that I know the policy.” A review of the facility’s P&P titled, “CODE GOLD,” dated October 2025, was conducted. The P&P indicated, “...SUMMARY/INTENT...The purpose of this policy it to define the process for post fall interventions for witnessed and unwitnessed falls or for patients who hit their head during a fall. The treatment bundle for a fall included in the “Code Gold” is a protocol to establish early interventions...This policy also identifies the “Code Gold” members and defines the responsibilities of the “Code Gold” team after a patient has fallen...Receiving the Gold Treatment (RGT): a set of interventions to be carried out together I a time sensitive fashion, as stated I the RGT guidelines for any patient who has fallen...RGT for patient who hits head or has an unwitnessed fall...Check vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation)...Q4 hours x 48 hours...Assess neurological status (Pupil size and reaction, verbal and motor response and limb response)...Q4 hours x 48 hours...””

“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: 50433 Based on interview and record review, the facility failed to ensure medication was administered in accordance with the physician order for one of 21 sampled patients (Patient 7). This failure had the potential to cause patient harm and prolong hospitalization. Findings: On February 11, 2026, at 9:30 a.m., a review of Patient 7’s medical record was conducted with Regulatory Specialist (RS) 1. A facility document titled, “History and Physical,” dated February 6, 2026, was reviewed. The document indicated Patient 7 was admitted to the facility on February 6, 2026, with a diagnosis of hypoxemic respiratory failure (a medical condition where the lungs cannot transfer enough oxygen into the blood). The document further indicated Patient 7 had a medical history of hypertension (high blood pressure). A facility document titled, “Vital Signs [measurements of the body’s most basic functions including heart rate, blood pressure, respiratory rate, temperature, and pain level, used by medical professionals to assess physical health],” dated February 7, 2026, was reviewed. The document indicated Patient 7 had an elevated blood pressure of 169/87 (a normal, healthy blood pressure for most adults is 120/80) at 12:16 a.m. and 163/103 at 4:29 a.m. A facility document titled, “Medication,” dated February 6, 2026, was reviewed. The document indicated an order was placed on February 6, 2026, at 1:48 a.m. for clonidine (a medication to treat high blood pressure) tablet 0.1 mg (milligrams, a unit of measurement) 4 (four) times daily PRN (as needed) “...this medication is 1st choice for systolic blood pressure [top number] over 160 or diastolic blood pressure [bottom number] over 90...” A facility document titled, “Medication Administration Report,” dated February 7, 2026, was reviewed. There was no documented evidence Patient 7 received the ordered medication for his high blood pressure. On February 12, 2026, at 9:55 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated most patients have PRN blood pressure medications with parameters (numerical or other measurable factors used as a guideline) ordered. RN 2 stated she would administer PRN blood pressure medications if the parameter was met or would notify the physician of the patient’s blood pressure if there were no PRN medications ordered. A facility document titled, “Diagnostic, Therapeutic and Standing Orders,” dated July 2025, was reviewed. The document indicated, “...An RN shall ‘acknowledge [verify, accept responsibility for, and initiate the action ordered by a provider]’ CPOE [Computerized Provider Order Entry, orders entered into the electronic health record] orders...” A facility policy and procedure (P&P) titled, “Medication Administration and Errors,” dated February 2025, was reviewed. The P&P indicated, “...Medications that are ordered...shall...be administered according to specified parameters...””

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50122 Based on interview, and record review, the facility failed to ensure patient rights for one patient (Patient 26), when an anaphylactic allergy to contrast was not discussed with the patient prior to issuing an order for a Computerized Tomography (CT) of the Abdomen/Pelvis with and without contrast (a detailed imaging test using X-rays to create cross-sectional pictures of your belly organs, blood vessels, and pelvis, taking scans before and after giving a special dye (contrast) orally or intravenously to highlight issues like tumors, inflammation, infections, or bleeding that aren’t visible on the non-contrast scans). This failure jeopardized the patient’s well-being, and had the potential to delay treatment, cause an increase in stay, and further complications to the patient. Findings: On December 2, 2025, at 2:04 p.m., Patient 26’s medical record was reviewed with the Regulatory Specialist (RS) 2. A review of the facility document titled, “H&P [history and physical] Note,” dated October 9, 2025, at 7:03 p.m., by MD 1 was conducted. The document indicated, Patient 26 was admitted to the facility on October 9, 2025, at 2:13 p.m., for Acute cholecystitis (sudden inflammation of the gallbladder) vs.[versus] choledocholithiasis (presence of gallstones in the common bile duct). A review of the facility document titled, “CT Abdomen And Pelvis W [with] Wo [without] Con [contrast] Order,” dated October 9, 2025, at 6:32 p.m., was conducted. The document indicated an order for a CT of the abdomen and pelvis with and without contrast by MD 1. A review of the facility document titled, “Murrieta Emergency General Surgery (MEGS) Note,” dated October 10, 2025, at 7:38 p.m., by MD 1 was conducted. The document indicated, “...Allergies...Contrast Dye [a special substance given during imaging tests to make specific organs, blood vessels, or tissues appear clearer and more detailed]...Reactions...Anaphylaxis [a severe, potentially life-threatening allergic reaction]...Recommendations...CT abd/pel [abdomen/pelvis] with contrast, iodine allergy protocol...Please obtain CT abdomen and pelvis with IV contrast for surgical planning...” There was no documented evidence of a conversation with Patient 26 regarding her anaphylactic allergy to contrast and no documentation of Patient 26 verbalizing understanding or approval of the order for the CT abdomen/pelvis with and without contrast. A review of the facility document titled, “Report Viewer,” dated October 11, 2025, at 2:21 p.m., by RN 1 was conducted. The document indicated, “...Order changed for CT without contrast...” On December 2, 2025, at 2:04 p.m., an interview was conducted with the RS 2. The RS 2 stated there was a secure chat message sent to Nurse Practitioner (NP) 1 from RN 1 stating Patient 26 was refusing the CT with contrast due to an allergy to contrast. NP 1 then discontinued the order for CT with contrast and notified MD 1. There was no reason given for discontinuation of the CT with and without contrast. The RS 2 stated, “I did not see any documentation of any communication from the physician or provider to the patient regarding the order for a CT with contrast and/or allergy to contrast. A review of the facility P&P titled, “PATIENTS’ RIGHTS AND RESPONSIBILITIES,” dated, March 2021, was reviewed. The P&P indicated, “...Receive information about health status, diagnosis, prognosis, course of treatment...in terms they can understand. The patient has the right to effective communication and to participate in the development and implementation of the plan of care...Request or refuse treatment...””

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 50122 Based on observation, interview, and record review, the facility failed to provide privacy for one patient, (Patient 28), while in the a hallway bed. This failure jeopardized the patient’s well-being, rights, and personal privacy. Findings: . On December 3, 2025, at 2:40 p.m., a tour of the Emergency Department was conducted with the Regulatory Specialist (RS) 2, the Emergency Department Director (EDD), and the Director of Surge and Patient Care Services (DSPCS). During the tour in the radiology hallway, Patient 28 was observed in a bed in the radiology hallway, and appeared upset and crying. Patient 28 was loud and yelling at the nurse about the lack of privacy and lack of care to wounds on body. Patient 28 stated she was very upset about the lack of privacy. Patient 28 stated she has been using her blanket to provide privacy and has not been offered anything else. Patient 28 stated she had voiced her concerns to nursing and they had not done anything to address concerns. Patient 28 stated she wanted to leave against medical advice because they are not treating her wounds which is why she is admitted there. On December 3, 2025, at 3:15 p.m., an interview was conducted with the charge nurse for surge (CNS). The CNS stated she had spoken to the nurse regarding Patient 28’s complaints and notified Patient Relations regarding her complaints. The CNS stated Patient 28’s concerns are because she is in the hallway and the lack of room, space, privacy, and care given by the nurse. The CNS stated they had privacy screens available. On December 3, 2025, at 3:20 p.m., an observation was conducted with the RS 2, the EDD and the DSPCS. The nurse for Patient 28 was applying dressings to Patient 28’s chest wall with tops of breast and chest wall exposed to hallway. There were no visible curtains or screens in place to provide the patient with privacy. Patient 28 had the gown lowered on the chest, exposing the skin, wound to the chest wall, and draining fluid on the wound on the chest. An interview was conducted with the DOQ. The DOQ stated, “...curtains would impede egress if placed in the hallway....they do not have enough curtains for all the patients. They could use a screen...can utilize changing rooms for privacy...” A review of the facility P&P titled, “PATIENT RIGHTS AND RESPONSIBILITIES,” dated March 2021, was conducted. The P&P indicated, “...[Name of facility] patient shall have the rights as stated below...Considerate and respectful care, and to be made comfortable. The patient has the right to respect for...personal values, beliefs, and preference...Have personal privacy respected...Case...examination and treatment are confidential and should be conducted discretely...Privacy curtains shall be used in semi-private rooms...Have his/her wishes considered...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48776 Based on interview, and record review, the facility failed to ensure a physician order for physical restraint (device that limits a patient’s movement to keep them safe and prevent them from harming themselves or another person) was obtained in accordance with policy and procedures for one of 28 sampled patients (Patient 1), and assessments and monitoring were not documented as performed. This failure had the potential to result in a potential violation of the patient’s rights. On December 2, 2025, at 2:10 p.m., a review of Patient 1’s medical record was conducted with the Regulatory Specialist (RS) 1. A facility document titled, “H&P [History and Physical],” dated November 8, 2025, at 6:07 p.m., was reviewed. The document indicated Patient 1 was admitted to the facility for cardiac arrest (the heart suddenly stops beating effectively, causing a person to collapse, lose consciousness, and stop breathing). A facility document titled, “Frequent Charting,” dated November 8, 2025, at 9:45 p.m., was reviewed. The document indicated, “...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Start...” A facility document titled, “Restraint Non-violent or Non-self Destructive (Order),” dated November 9, 2025, at 2:30 a.m., was reviewed. The document indicated, “...Created on 11/9/25 [November 9, 2025]...0230 [2:30 a.m.]...” A facility document titled, “Frequent Charting,” dated November 9, 2025, at 7 p.m., was reviewed. The document indicated, “...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued... A facility document titled, “Frequent Charting,” dated November 9, 2025, at 4 a.m., was reviewed. The document indicated, “...I attest the patient was monitored/assessed per Patient Care Practices...[blank]...” A facility document titled, “Frequent Charting,” dated November 11, 2025, at 6 a.m., was reviewed. The document indicated, “...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued... A facility document titled, “Frequent Charting,” dated November 11, 2025, at 7:30 p.m., was reviewed. The document indicated, “...I attest the patient was monitored/assessed per Patient Care Practices...[blank]...” On December 2, 2025, at 2:20 p.m., an interview was conducted with the RS 1. RS 1 stated, “the restraint order should have been obtained when the patient was placed in wrist restraints” on November 8, 2025. RS 1 stated there was no documented evidence that the physician was notified of Patient 1’s need for restraints until November 9, 2025, at 2:30 a.m. RS 1 further stated that there was no restraint monitoring and assessment completed every two hours for the night shift on November 9, 2025, and day shift November 11, 2025. RS 1 stated the facility’s policy was not followed. A review of Policy and Procedure (P&P) titled, “RESTRAINTS AND SAFETY DEVICES,” dated December 2025, was conducted. The P&P indicated, “...Initiation: Each episode of restraint or seclusion shall be initiated...Upon the order of a licensed independent practitioner who is responsible for the patient, or...a qualified registered nurse if he/she determines that restraining the patient prior to receiving an order is necessary to protect the patient or others. An order from a responsible licensed independent practitioner shall be obtained as soon as clinically appropriate...Patients requiring restraints for non-violent behaviors shall be subject to ongoing monitoring and assessment. Monitoring and assessment shall occur at least every 2 [two] hours...””

“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: 48776 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for 11 of 28 sampled patients (Patient 1, 2, 3, 9, 10, 13, 16, 17, 19, 20 and 26 ), when: 1. For Patient 1, restraint (device that limits a patient’s movement to keep them safe and prevent them from harming themselves or another person) order was not obtained and assessments and monitoring were not documented as performed; 2. For Patients 1, 10, 13, 16, and 17, critical lab values (test result that is so far outside the expected normal range that it indicates a potentially life-threatening situation) were not documented as having been reported to the provider; 3. For Patients 2, 3, and 9, pain was not reassessed after medication administration, the provider was not notified of unrelieved pain, and pain medication orders were not followed as prescribed; 4. For Patient 9, a leaving against medical advice (AMA) form (AMA form, document a patient is asked to sign when they choose to leave a hospital or refuse a specific recommended treatment, even though their doctor believes it is unsafe for them to do so), and an electronic event report (EER, incident report, a formal document that records any unplanned or unexpected occurrence that disrupts normal operations, causes harm, or could have caused harm) were not completed; 5. For Patients 19, and 20, patients were sitting outside of the emergency department unsupervised by hospital staff with peripheral intravenous (PIV, a tiny tube in a vein to give you medication or fluids) lines in place; and 6. For Patient 26, an order for pain medication was not clarified prior to dispensing. These failures had the potential to compromise patient safety, resulting in poor pain management, and delays in medical care and/or death. Findings: 1. On December 3, 2025, at 2:10 p.m., a review of Patient 1’s medical record was conducted with the Regulatory Specialist (RS) 1. A facility document titled, “H&P [History and Physical],” dated November 8, 2025, at 6:07 p.m., was reviewed. The document indicated Patient 1 was admitted to the facility for cardiac arrest (the heart suddenly stops beating effectively, causing a person to collapse, lose consciousness, and stop breathing). A facility document titled, “Frequent Charting,” dated November 8, 2025, at 9:45 p.m., was reviewed. The document indicated, “...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Start...” A facility document titled, “Restraint Non-violent or Non-self Destructive (Order),” dated November 9, 2025, at 2:30 a.m., was reviewed. The document indicated, “...Created on 11/9/25 [November 9, 2025]...0230 [2:30 a.m.]...” A facility document titled, “Frequent Charting,” dated November 9, 2025, at 7 p.m., was reviewed. The document indicated, “...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued...” A facility document titled, “Frequent Charting,” dated November 9, 2025, at 4 a.m., was reviewed. The document indicated, “...I attest the patient was monitored/assessed per Patient Care Practices...[blank]...” A facility document titled, “Frequent Charting,” dated November 11, 2025, at 6 a.m., was reviewed. The document indicated, “...Restraint Type...Soft Restraint R [right] Wrist...Soft Restraint [left]...Continued...” A facility document titled, “Frequent Charting,” dated November 11, 2025, at 7:30 p.m., was reviewed. The document indicated, “...I attest the patient was monitored/assessed per Patient Care Practices...[blank]...” On December 3, 2025, at 2:20 p.m., an interview was conducted with the RS 1. RS 1 stated, “the restraint order should have been obtained when the patient was placed in wrist restraints” on November 8, 2025. RS 1 stated there was no documented evidence the physician was notified of Patient 1’s need for restraints until November 9, 2025, at 2:30 a.m. RS 1 further stated there was no restraint monitoring and assessment completed every two hours for the night shift on November 9, 2025, and day shift November 11, 2025. RS 1 stated the facility’s policy was not followed. A review of the facility’s P&P titled, “RESTRAINTS AND SAFETY DEVICES,” dated December 2025, was conducted. The P&P indicated, “...Initiation: Each episode of restraint or seclusion shall be initiated...Upon the order of a licensed independent practitioner who is responsible for the patient, or...a qualified registered nurse if he/she determines that restraining the patient prior to receiving an order is necessary to protect the patient or others. An order from a responsible licensed independent practitioner shall be obtained as soon as clinically appropriate...Patients requiring restraints for non-violent behaviors shall be subject to ongoing monitoring and assessment. Monitoring and assessment shall occur at least every 2 [two] hours...” 2a. On December 3, 2025, at 2:10 p.m., a review of Patient 1’s medical record was conducted with the Regulatory Specialist (RS) 1. A facility document titled, “Partial Thromboplastin Time [PTT, a blood test measures how long it takes your blood to clot]: Patient Communication,” dated November 10, 2025, at 9:05 p.m., was reviewed. The document indicated, “...Reference range: 25.1 - [a range of values, from one number to another] 36.5 seconds...Value 140.9!! [two punctuation marks used to show strong feeling, excitement, or urgency]...Comment...Verified by replicate analysis; Critical APTT [the result is so high it reaches a dangerous level and requires immediate attention]...” During the review of Patient 1’s medical record with the RS, there was no documented evidence the physician was notified of Patient 1’s critical PTT level on November 10, 2025, at 9:05 p.m. A facility document titled, “Hgb [hemoglobin, lab test that measures the amount of an important, iron-rich protein in your red blood cells that is responsible for carrying oxygen from your lungs to the rest of your body]: Patient Communication,” dated November 13, 2025, at 10:48 a.m., was reviewed. The document indicated, “...Reference range 10.5 - 15.0 g/dL [grams / (per) deciliter, unit of measurement]...Value 6.6!!...Comment...Critical Hgb called...” During the review of Patient 1’s medical record with the RS, there was no documented evidence the physician was notified of Patient 1’s critical Hgb level on November 13, 2025, at 9:05 p.m. A facility document titled, “Na [Sodium, lab test that measures the concentration of sodium, an electrolyte in the blood to help evaluate a person’s general health and fluid balance]: Patient Communication,” dated November 14, 2025, at 4:57 p.m., was reviewed. The document indicated, “...Reference range 134 - 147 mMol/L [millimoles/ (per) liter, unit of measurement]...Value 161!!...Comment...Critical Na called...” During the review of Patient 1’s medical record with RS 1, there was no documented evidence the physician was notified of Patient 1’s critical Na level on November 14, 2025, at 4:57 p.m. On December 3, 2025, at 2:10 p.m., an interview was conducted with the RS 1. RS 1 stated, “the physician should have been notified of any critical lab values as soon as possible and this was not done.” RS 1 stated there was no documented evidence the physician was notified of Patient 1’s critical PTT, Hgb, and Na lab values. RS 1 stated the facility’s policy was not followed. 2b. On December 8, 2025, at 10:45 a.m., a review of Patient 10’s medical record was conducted with the Regulatory Specialist (RS) 1. A facility document titled, “H&P [History and Physical],” dated November 8, 2025, at 3:49 a.m., was reviewed. The document indicated Patient 10 was admitted to the facility for rectal bleeding and abdominal pain. A facility document titled, “Blood culture [a lab test that checks blood to find out if there are any germs, like bacteria or fungi, causing an infection in the bloodstream] Identification...Enterococcus faecalis [a serious medical condition that occurs when a type of bacteria normally living harmlessly in the gut enters the bloodstream] Detected,” dated November 14, 2025, at 9:44 p.m., was reviewed. The document indicated, “...Reference range: Not Detected...Comment...Critical Enterococcus faecalis called...” During the review of Patient 10’s medical record with RS 1, there was no documented evidence the physician was notified of Patient 10’s critical blood culture result on November 14, 2025, at 9:44 p.m. A facility document titled, “K [Potassium, a test that measures the amount of potassium, a mineral that helps your body’s cells, nerves, and muscles function properly]: Patient Communication,” dated November 16, 2025, at 10:45 a.m., was reviewed. The document indicated, “...Reference range 3.5 - 5.0 mMol/L ...Value 6.2!!...Comment...Critical K result called...” During the review of Patient 10’s medical record with RS 1, there was no documented evidence the physician was notified of Patient 10’s critical K level on November 16, 2025, at 10:45 a.m. On December 8, 2025, at 11:15 a.m., an interview was conducted with the RS 1. RS 1 stated, “the blood culture result and critical K should have been reported to the physician.” RS 1 stated there was no documented evidence the physician was notified of Patient 10’s positive blood culture and K critical lab values. RS 1 stated the facility’s policy was not followed. 2c. On December 2, 2025, at 10:15 a.m., a review of Patient 13’s medical record was conducted with the Regulatory Specialist (RS) 3. A facility document titled, “H&P,” dated November 28, 2025, at 2:05 p.m., was reviewed. The document indicated Patient 13 was admitted to the facility for acute hypoxemic respiratory failure (a sudden condition where the lungs can’t get enough oxygen into the blood) and atrial fibrillation with rapid ventricular response (an irregular heart rhythm where the heart beats very fast). A facility document titled, “Partial Thromboplastin Time [PTT, a blood test measures how long it takes your blood to clot]: Patient Communication,” dated November 29, 2025, at 11:04 p.m., was reviewed. The document indicated, “...Reference range: 25.1 - [a range of values, from one number to another] 36.5 seconds...Value 148.3!! [two punctuation marks used to show strong feeling, excitement, or urgency]...Comment...Verified by replicate analysis; Critical APTT [the result is so high it reaches a dangerous level and requires immediate attention]...” During the review of Patient 13’s medical record with the RS, there was no documented evidence the physician was notified of Patient 13’s critical PTT level on November 29, 2025, at 11:04 p.m. On December 2, 2025, at 10:25 a.m., an interview was conducted with the RS 3. RS 3 stated, “the critical PTT should have been reported to the doctor.” RS 3 stated there was no documented evidence the physician was notified of Patient 13’s critical lab value. RS 3 stated the facility’s policy was not followed. 2d. On December 3, 2025, at 11:16 a.m., a review of Patient 16’s medical record was conducted with RS 3. A facility document titled, “H&P,” dated November 25, 2025, at 11:17 p.m., was reviewed. The document indicated Patient 16 was admitted to the facility for acute hypoxic respiratory failure and suspected septic shock (a severe, life-threatening condition where an infection causes the blood pressure to drop dangerously low, and the organs do not get enough blood). A facility document titled, “Troponin T, High Sensitivity [hs-TnT, a blood test that can detect very small amounts of heart muscle injury] : Patient Communication,” dated November 26, 2025, at 3:46 a.m., was reviewed. The document indicated, “...Reference range ng/L [nomograms/ (per) liter, a very tiny amount in a liter of blood]...Value 66!!...Comment...Critical Troponin result called...” During the review of Patient 16’s medical record with the RS there was no documented evidence the physician was notified of Patient 16’s critical Troponin level on November 26, 2025, at 3:46 a.m. On December 3, 2025, at 11:39 a.m., an interview was conducted with the RS 3. RS 3 stated, “the critical troponin should have been reported to the doctor.” RS 3 stated there was no documented evidence the physician was notified of Patient 16’s critical lab value. RS 3 stated the facility’s policy was not followed. 2e. On December 5, 2025, at 9:40 a.m., a review of Patient 17’s medical record was conducted with RS 3. A facility document titled, “H&P,” dated November 26, 2025, at 3:36 a.m., was reviewed. The document indicated Patient 17 was admitted to the facility for diabetic ketoacidosis (a condition where the body does not have enough insulin, so it breaks down fat for energy and makes acids (ketones, chemicals that body make) that build up in the blood). A facility document titled, “Osmolality, Serum [a test that measures how concentrated the blood is]: Patient Communication,” dated December 3, 2025, at 7:23 a.m., was reviewed. The document indicated, “...Reference range 277- 297 mOsm/kg [milliosmoles per kilogram, a unit of measurement how concentrated a fluid is]...Value 364!!...Comment...Critical OSMO [Osmolality] result called...” During the review of Patient 17’s medical record with the RS there was no documented evidence the physician was notified of Patient 17’s critical Osmolality level on December 3, 2025, at 7:23 a.m. On December 5, 2025, at 10:04 a.m., an interview was conducted with RS 3. RS 3 stated, “the critical result should have been reported to the doctor.” RS 3 stated there was no documented evidence the physician was notified of Patient 17’s critical lab value. RS 3 stated the facility’s policy was not followed. A review of the facility’s P&P titled, “REPORTING OF CRITICAL TEST RESULTS,” dated July 2022, was conducted. The policy indicated, “...All critical test results shall be reported as immediately as is practicable. The length of time from discovery of the critical test result to the time the information is relayed to the physician or appropriate caregiver shall not exceed one hour...Clinical Laboratory: 10 [ten] minutes...” 3a. On December 5, 2025, at 9:45 a.m., a review of Patient 2’s medical record was conducted with RS 1. A facility document titled, “H&P,” dated November 23, 2025, at 1:32 a.m., was reviewed. The document indicated Patient 2 was admitted to the facility for right foot pain from a right foot stump ulcer (an open sore or a break in the skin that develops on the remaining part of a limb after an amputation) and concerns for infection and possible osteomyelitis (a bone infection, usually caused by bacteria, that leads to inflammation, pain, swelling, and can destroy bone tissue if not treated). A facility document titled, “Care Plan (a personalized roadmap detailing a patient’s health needs, goals, and the interventions required to achieve them),” was reviewed. The document indicated, “Problem...Pain/Discomfort...Goal...Patient’s pain/discomfort is manageable...Reassess pain after intervention...” A facility document titled, “Flowsheet,” dated November 25, 2025, was reviewed. The document indicated, Patient 2’s pain score on November 25, 20205, at 7:35 p.m., was five (Pain intensity reference, where a pain score of 1-3 is mild/minor pain, pain score of 4-6 is moderate pain, and pain score of 7-10 is severe pain), and received pain medication at 7:40 p.m. During the review of Patient 2’s medical record with RS 1, there was no documented evidence Patient 2’s pain level was reassessed following the medication administration on November 25, 2025, at 7:40 p.m. A facility document titled, “Flowsheet,” dated November 30, 2025, was reviewed. The document indicated, Patient 2’s pain score on November 30, 20205, at 10 a.m., was eight, and received pain medication at 10 a.m. During the review of Patient 2’s medical record with RS 1, there was no documented evidence Patient 2’s pain level was reassessed following the medication administration on November 30, 2025, at 10 a.m. On December 5, 2025, at 10 a.m., an interview was conducted with RS 1. RS 1 stated Patient 2’s pain level “should have been reassessed after one hour following pain medication administration.” RS 1 stated there was no documented evidence that Patient 2’s pain was reassessed, as required by Patient 2’s care plan. RS 1 further stated the clinical nursing skills (the essential, evidence-based procedures and knowledge registered nurses and other healthcare professionals use to provide direct patient care in a clinical setting) were not followed. 3b. On December 5, 2025, at 11:30 a.m., a review of Patient 3’s medical record was conducted with RS 1. A facility document titled, “H&P,” dated November 29, 2025, at 3:42 a.m., was reviewed. The document indicated Patient 3 was admitted for acute onset (began suddenly) of petechial rash (cluster of tiny, flat, pinpoint-sized red, purple, or brown spots on the skin caused by minor bleeding from broken, tiny blood vessels under the skin’s surface). The document further indicated that Patient 3 has a history of uterine (womb) sarcoma (a rare type of cancer that begins in the muscle wall or supporting tissues of the uterus). A facility document titled, “Care Plan,” was reviewed. The document indicated, “Problem...Pain/Discomfort...Goal...Patient’s pain/discomfort is manageable...Give pain meds [medications] as ordered and monitor for effectiveness...” A facility document titled, “Flowsheet,” dated December 2, 2025, was reviewed. The document indicated, Patient 3’s pain score on December 2, 20205, at 3:25 p.m., was eight, and received pain medication at 3:25 p.m. During the review of Patient 3’s medical record with RS 1, there was no documented evidence that Patient 3’s pain level was reassessed following the medication administration on December 2, 2025, at 3:25 p.m. A facility document titled, “Flowsheet,” dated December 3, 2025, was reviewed. The document indicated, Patient 3’s pain score on December 3, 2025, at 8:16 a.m., was ten, and received pain medication at 8:16 a.m. The document further indicated Patient 3’s pain score on December 3, 20205, at 9:16 a.m., was seven. During the review of Patient 3’s medical record with RS 1, there was no documented evidence the physician was notified when Patient 3’s pain was not relieved following medication administration on December 3, 2025, at 8:16 p.m. On December 5, 2025, at 11:50 a.m., an interview was conducted with RS 1. RS 1 stated Patient 3’s pain level “should have been reassessed after one hour following pain medication administration.” RS 1 stated there was no documented evidence that Patient 3’s pain was reassessed, following pain medication administration on December 2, 2025, at 3:25 p.m. RS 1 also stated Patient 3’s physician should have been notified on December 3, 2025, when Patient 3’s pain level was not relieved with the ordered pain medication. RS 1 further stated the clinical nursing skills were not followed. 3c. On December 2, 2025, at 2:25 p.m., a review of Patient 9’s medical record was conducted with RS 1. A facility document titled, “H&P,” dated August 16, 2025, at 5:32 a.m., was reviewed. The document indicated Patient 9 was admitted for “...worsening right leg pain with swelling, despite previous negative imaging for DVT [deep vein thrombosis, a blood clot that forms in a large vein that can break loose and travel to the lungs, causing a potentially fatal blockage] or major fracture...” A facility document titled, “Care Plan,” was reviewed. The document indicated, “Problem...Pain/Discomfort...Goal...Patient’s pain/discomfort is manageable...Assess pain every 4 [four] hours, medicate per order, provide non pharmacological pain methods [ways to ease pain without using medicine], reassess pain 30-60 [thirty to sixty] minutes after treatment...” A facility document titled, “Order Summary,” was reviewed. The document indicated, “...Start Date/Time...8/16/25 [August 16, 2025] 0429 [4:29 a.m.]...HYDROmorphone [a strong pain medication used to treat severe pain]...0.2 [two tenths] mg [milligram, unit of measurement]...Intravenous [administered in the vein]...Every 4 [four] hours PRN [as needed] for Severe Pain 7-10 [seven to 10 pain level on a pain scale from 0-10]...” A facility document titled, “Order Summary,” was reviewed. The document indicated, “...Start Date/Time...8/16/25 [August 16, 2025] 0429 [4:29 a.m.]...HYDROcodone-aceteminophen [a pain medication used to treat moderate to severe pain]...1 [one] tablet...Every 6 [six] hours PRN for Moderate Pain 4-6 [four to six pain level on a pain scale from 0-10]...” A facility document titled, “Flowsheet,” dated August 15, 2025, was reviewed. The document indicated, Patient 9’s pain score on August 15, 2025, at 8:38 p.m., was ten and the non pharmacological intervention of rest was implemented. During the review of Patient 9’s medical record with RS 1, there was no documented evidence Patient 9’s pain level was reassessed until August 16, 2025, at 3:26 a.m., and the pain score was seven. Additionally, the review found no documented evidence of any pain intervention provided at the time of the 3:26 a.m. assessment. A facility document titled, “Flowsheet,” dated August 16, 2025, was reviewed. The document indicated, Patient 9’s pain score on August 16, 2025, at 4:37 a.m., was six, and received pain medication at 4:47 a.m. During the review of Patient 9’s medical record with RS 1, there was no documented evidence that Patient 9’s pain level was reassessed following the medication administration on August 16, 2025, at 4:37 a.m. A facility document titled, “Flowsheet,” dated August 16, 2025, was reviewed. The document indicated, Patient 9’s pain score on August 16, 2025, at 11:53 a.m., was eight, and received pain medication at 11:53 a.m. The document further indicated that Patient 9’s pain score on August 16, 2025, at 12:53 p.m. was five. A facility document titled, “Flowsheet,” dated August 16, 2025, was reviewed. The document indicated, Patient 9’s pain score on August 16, 2025, at 7:44 p.m., was ten, and received pain medication at 7:44 p.m. The document further indicated that Patient 9’s pain score on August 16, 2025, at 8:44 p.m. was four. A facility document titled, “Medication Administration Report,” was reviewed. The document indicated, Patient 9 received Hydrocodone-acetaminophen on August 16, 2025, at 11:53 a.m., when the pain score was eight. The document also indicated, Patient 9 received Hydrocodone-acetaminophen on August 16, 2025, at 7:44 p.m., when the pain score was ten. On December 2, 2025, at 3 p.m., an interview was conducted with RS 1. RS 1 stated Patient 9’s pain level should have been reassessed after non-pharmacological methods or after the administration of pain medication. RS 1 stated there was no documented evidence that Patient 9’s pain was reassessed following the non-pharmacological intervention of rest on August 15, 2025, at 8:38 p.m., or after the administration of pain medication on August 16, 2025, at 4:47 a.m. RS 1 further stated that Patient 9 should have received Hydromorphone on August 16, 2025, at 11:53 a.m., when the pain score was eight, and again at 7:44 p.m., when the pain score was ten, in accordance with the physician’s order for severe pain, instead of the Hydrocodone-acetaminophen, or if Patient 9 requested the lower dose of medication, then this have been documented in the medical record. RS 1 also stated that the physician should have been notified when Patient 9’s pain level was not relieved with the ordered pain medication. RS 1 stated the clinical nursing skills were not followed. A review of the facility’s P&P titled, “MEDICATION ADMINISTRATION AND ERRORS,” dated February 2025, was conducted. The P&P indicated “...Medications that are ordered with a dosage range shall either be administered according to specified parameters (e.g. [example] level of pain, anxiety/agitation)...Per patient request, the nurse may administer the following while awaiting contact with provider for adjustments to PRN pain management medication orders...A lower DOSE of PRN pain medication (same medication) than ordered...A PRN pain MEDICATION which has been ordered for the patient but indicated for a PAIN SCALE lower than that reported by the patient...The nurse shall document the reason for the lower dose/medication, and the provider contact...” A review of the facility’s untitled document, dated July, 2021, was conducted. The document indicated, “...Assess the patient’s pain using an organization-approved pain scale...Assess the patient’s response to previous pharmacologic interventions...If nonpharmacologic intervention are unsuccessful and if analgesics are ineffective or none have been ordered, consult the practitioner regarding an order...Administer analgesics [pain medication] as ordered...Reassess the patient’s pain status...Assess, treat, and reassess pain...Clinical nursing skills & [and] techniques...” 4. On December 2, 2025, at 2:25 p.m., a review of Patient 9’s medical record was conducted with RS 1. A facility document titled, “Multidisciplinary Progress Note,” dated August 19, 2025, at 4:43 p.m. was reviewed. The document indicated, “...1422 [2:22 p.m.] NP [nurse practitioner] made aware patient’s family at the bedside requesting to go home today because the pain on right lower leg has not been control [sic] while in the hospital and her primary doctor already ordered medication that will help her with the pain...1515 [3:15 p.m.] Charge nurse made aware and will follow up with NP...1635 [4:35 p.m.] Per charge nurse, NP order MRI [Magnetic Resonance Imaging, a medical test that uses a strong magnet and radio waves to take detailed pictures of the body] of right leg and no agree with d/c [discharge] order. Family made aware and patient daughter still wants to leave...” A facility document titled, “Discharge Summary,” dated August 19, 2025, at 5:20 p.m. was reviewed. The document indicated, “...Discharge...Left Against Medical Advice...” During the review of Patient 9’s medical record with RS 1, there was no documented evidence that Patient 9 or Patient 9’s family was provided with information regarding why continued hospitalization was recommended, what the risks and potential consequences of leaving were, and that alternatives were available, so the patient could make an informed decision. On December 3, 2025, at 10:30 a.m., an interview was conducted with RS 1. RS 1 stated “the physician should have attempted to provide the patient with information regarding risk of leaving the hospital AMA.” RS 1 further stated an AMA form should have been signed by the patient, and a EER should have been completed, but neither was done. RS 1 stated the policy was not followed. On December 3, 2025, at 11 a.m., an interview was conducted with the Quality and Patient Safety Specialist (QPSS). The QPSS stated both the Registered Nurse (RN) and physician should have documented that Patient 9 wanted to leave AMA and recommendations on why to stay and this was not done. On December 5, 2025, at 10:50 a.m., an interview was conducted with RN 1. RN 1 stated she cared for Patient 9 on August 19, 2025 on the day she left AMA. RN 1 stated Patient 9 wanted to leave AMA because the leg pain was not being controlled. RN 1 further stated a AMA form should have been completed and this was not done. A review of the facility’s P&P titled, “PATIENTS LEAVING AGAINST MEDICAL ADVICE,” dated August 2024, was conducted. The P&P indicated “...If the patient or his or her legal representative makes the decision to be discharged prior to completion of treatment or contrary to medical advice, the physician should first attempt to provide the patient or the legal representative with information regarding why continued hospitalization is recommended, what the risk and potential consequences of leaving are, and what alternative are available, so the patient or legal representative can make an informed decision...Clinical Nurse/Charge Nurse...Requests that the patient or legal representative sign the ‘AMA’ form...Completes an Electronic Event Report (EER)...” 5a. On December 3, 2025, at 1:55 p.m., a tour of the Emergency Département (ED) was conducted with the Regulatory Specialist (RS) 2, RS 3, the Emergency Department Director (EDD), the Flow Charge (FC), and the Director of Surge (DS). During the tour, Patients 19 and 20 were observed sitting outside in front of the Emergency Department (ED) entrance with peripheral intravenous (IV) lines in place. The patients were unsupervised by hospital staff at the time of the observation. No staff members were present to monitor the safety and integrity of the IV sites. At the entrance of the ED there was a sign posted that stated, “Attention: Please notify staff if you choose to wait outside. Patients with an IV in place are not permitted to wait outside. Thank you.” On December 5, 2025, at 9:40 a.m., a review of Patient 19’s medical record was conducted with the Regulatory Specialist (RS) 3. A facility document titled, “Emergency Department Notes,” dated December 3, 2025, at 11:49 a.m., was reviewed. The document indicated Patient 19 was seen in the ED for chief complaint of cough and shortness of breath. A facility document titled, “Patient Care Timeline,” dated December 3, 2025, at 12:46 p.m., was reviewed. The document indicated, “...Peripheral IV [intravenous]...Placement Date/Time ...December 3, 2025, 12:46 [p.m.] Size (Guage) 20 G...Left Location: Antecubital [the bend of the arm]...” On December 3, 2025, at 2:07 p.m., an interview was conducted with Patient 19. Patient 19 stated, “I was not told I could not wait outside. They put in my IV and then put me out here.” Patient 19 stated she was not informed by any staff members that she was not permitted to wait outside with an IV in place. 5b. On December 5, 2025, at 10:20 a.m., a review of Patient 20’s medical record was conducted with the RS 3. A facility document titled, “Emergency Department Notes,” dated December 3, 2025, at 11:51 a.m., was reviewed. The document indicated Patient 20 was seen in the ED for chief complaint of abdominal pain and headache. A facility document titled, “Patient Care Timeline,” dated December 3, 2025, at 12:48 p.m., was reviewed. The document indicated, “...Peripheral IV...Placement Date/Time...December 3, 2025, 12:48 [p.m.] Size [Guage] 20 G Length: 1 inch [unit of length]...Left Location: Antecubital...” On December 3, 2025, at 2:07 p.m., an interview was conducted with Patient 20’s father. Patient 20’s father stated, “We were not told he [Patient 20] could not wait outside. They put in his [Patient 20’s] IV and sent us [Patient 20 and his father] to the waiting room and we [Patient 20 and his father] decided to wait outside due to crowd and no available seats.” On December 3, 2025, at 2:48 p.m., an interview was conducted with the Quick View Nurse (QVN) 1. QVN 1 stated, typically we [nurses] have everyone stay inside. We [nurses] cannot force them [patients] to stay inside. On December 3, 2025, at 2:51 p.m., an interview was conducted with the QVN 2. QVN 2 stated, we [staff] were not aware patients [Patient 19 and 20] were outside with IVs. On December 5, 2025, at 11:17 a.m., an interview and record review was conducted with RS 3. RS 3 stated, “I do not see any documentation in the Electronic Medical Record [EMR] indicating Patient 19 and 20 were instructed to remain to the waiting room.” On December 9, 2025, at 3:30 p.m., an interview was conducted with QVN 3. QVN 3 stated the primary role is to monitor patients in the waiting room. QVN 3 further stated it is not standard practice for patients to go outside with IVs because we cannot monitor them for safety. A facility undated document titled, “JOB DESCRIPTION...Job Title: Clinical Nurse B-ED,” was reviewed. The document indicated, “...Identifies and reports processes or systems and risks that could potentially lead to errors or adverse events. Participate s in the design of safe systems and processes as requested...Minimizes the existence of unsafe conditions in the work environment and clinical practice as follows: embraces and incorporates a culture of safety; demonstrates knowledge of and implements emergency management procedures as appropriate...” A review of the facility’s P&P titled, “Plan For Providing Care,” dated November 2, 2019, was conducted. The policy indicated, “...The Emergency Department is committed to compliance, performance improvement, risk management, safe environment care, commitment to health information management, and service excellence...” 6.On December 2, 2025, at 2:04 p.m., Patient 26’s medical record was reviewed with the Regulatory Specialist (RS) 2. A review of the facility document titled, “H&P [history and physical] Note,” dated October 9, 2025, at 7:03 p.m., by MD 1 was reviewed. The document indicated, Patient 26 was admitted to the facility on October 9, 2025, at 2:13 p.m., for Acute cholecystitis (sudden inflammation of the gallbladder) vs.[versus] choledocholithiasis (presence of gallstones in the common bile duct). A review of the facility document titled, “Medication,” dated October 9, 2025, at 6:37 p.m., was reviewed. The document indicated an order for “...oxyCODONE [is a semi-synthetic narcotic analgesic used to relieve severe pain]...5 mg [milligrams-unit of measurement]...Route...Oral [by mouth]...Frequency [how often]...Every 4 hours PRN [as needed] for Moderate Pain 4-6 [Moderate pain is pain that interferes with daily activities - scale utilized from 0-10 pain], Severe Pain 7-10 [Severe pain is categorized as 7 to 10 are considered severe because they greatly affect your ability to function and complete daily tasks]...” A review of the facility document titled, “View Doc Flowsheet...Pain Assessment...,” dated October 12, 2025, at 7:03 p.m., was reviewed. The document indicated Patient 26 complained of “...Pain Assessment...0-10...Pain Score...7...Pain Type...Acute pain...Pain Location...Abdominal...Pain Onset...On-going...” A review of the facility document titled, “Medication Administration Report (MAR),” dated October 12, 2025, at 7:03 p.m., was reviewed. The document indicated, “...oxyCODONE (ROXICODONE) immediate release tablet 5 mg...” was administered at 7:03 p.m. On December 5, 2025, at 2:30 p.m., an interview was conducted with the Director of 4th Floor (DFF). The DFF stated, “...the order should have been clarified...she would call the provider to get clarification of the order...” A review of the facility’s P&P titled, “DIAGNOSTIC, THERAPEUTIC AND STANDING ORDERS,” dated July 2025, was reviewed. The P&P indicated, “...It is acceptable to administer medication with vital sign parameters utilizing documented vital signs...Unclear orders shall be clarified before being implemented...””

“SAFETY POLICY AND PROCEDURES CFR(s): 482.26(b) [§482.26 Condition of Participation: Radiologic Services §. If therapeutic services are also provided, they, as well as the diagnostic services, must meet professionally approved standards for safety and personnel qualifications.] §482.26(b) Standard: Safety for Patients and Personnel The radiologic services, particularly ionizing radiology procedures, must be free from hazards for patients and personnel. This Standard is not met as evidenced by: 48776 Based on interview, and record review, the facility failed to complete a vascular duplex ultrasound (a non-invasive, test that uses high-frequency sound waves to see how blood is moving through the arteries and veins) timely for one of 28 sampled patients (Patient 9), when a radiology order was discontinued without a provider order. This failure had the potential to compromise care and result in delays in medical care. Findings: On December 2, 2025, at 2:25 p.m., a review of Patient 9’s medical record was conducted with the Regulatory Specialist (RS) 1. A facility document titled, “H&P,” dated August 16, 2025, at 5:32 a.m., was reviewed. The document indicated Patient 9 was admitted for “...worsening right leg pain with swelling, despite previous negative imaging for DVT [deep vein thrombosis, a blood clot that forms in a large vein that can break loose and travel to the lungs, causing a potentially fatal blockage] or major fracture [break]...” A facility document titled, “Vas [vascular] Duplex Lower Ext [extremity] Vein Bilat [bilateral] Order,” was reviewed. The document indicated the order was placed on August 16, 2025, at 8:08 a.m. The document further indicated, “...This Order Has Been Canceled...Order Status Canceled...Reason Other: Recent negative venous ultrasound, documented in notes. Duplicate order...Discontinued mode Radiology Protocol...Entered by [Name of Vascular Sonographer (VS)]...On August 16, 2025 1318 [1:18 p.m.]...” During the review of Patient 9’s medical record with RS 1, there was no vascular duplex ultrasound of the lower extremities result located in the record. On December 3, 2025, at 1 p.m., an interview was conducted with the VS. VS stated she canceled the vascular duplex lower extremity bilateral because the H&P (History and Physical) indicated Patient 9 had the test performed at another facility and it was negative for DVT. VS further stated this would be considered a duplicate test and did not speak to the physician who ordered the test prior to discontinuing the test. VS stated she used secure chat (a way of communicating digitally where messages are protected so only the person sending and receiving the message can read them), but did not receive a response back from the provider. On December 3, 2025, at 1:40 p.m., an interview was conducted with RS 1. RS 1 stated Patient 9 did not have a vascular duplex ultrasound of the lower extremities completed at the facility at the time of the order on August 16, 2025, at 8:08 a.m., and therefore would not be considered a duplicate order. RS 1 further stated that a physician telephone order was required to discontinue an existing order and that radiology protocol should not be used for this purpose. On December 3, 2025, at 3:45 p.m., an interview was conducted with the Director of Quality (DOQ). The DOQ stated VS should “speak to the provider and enter a telephone order to cancel or change the order,” and Patient 9 did not have a vascular duplex ultrasound of the lower extremities completed at the facility; therefore, the order would not be considered a duplicate. The DOQ further stated orders are not accepted via secure chat and the policy was not followed. A review of the facility’s P&P titled, “DIAGNOSTIC, THERAPEUTIC AND STANDING ORDERS,” dated July, 2025, was conducted. The P&P indicated, “...Orders shall not be transmitted/accepted via electric device (e.g. [example] texting, email)...The provider shall be notified if the order cannot be carried out...Verbal or Telephone Orders: Use of verbal/telephone orders (VO/TO) shall be minimized...Shall be read back to the authorized practitioner after they are written/entered to confirm the orders before implementation...””

“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: 48776 Based on interview and record review, the facility failed to ensure patient care was provided to warrant the safety and well-being of the patients when: 1. For Patient 4, nursing staff used the Aspira pleural drainage system (a medical device specifically designed to manage pleural effusions, which are accumulations of fluid in the pleural space surrounding the lungs. This system facilitates the removal of fluid through a soft, flexible tube that is inserted through the skin and into the pleural space, and allows for regular drainage of the fluid buildup, thereby alleviating symptoms such as shortness of breath and discomfort) without training or competency (having the right knowledge, and skills); 2. Patient 11 had three episodes of chest pain following a cardiac procedure and it was not reported to the physician. In addition, a stat EKG (electrocardiogram, a test that records your hearts electrical activity) was not performed and the rapid response (a specially trained team that provides immediate care for hospitalized patients whose condition is rapidly deteriorating) team was not notified to assist in Patient 11’s change in condition; and 3. For Patient 12, the rapid response form was not documented with details of Patient 12’s change in health status and there was no documentation of family notification of the rapid response. The cumulative effects of these facility failures had the potential to place patients’ at risk for harm, compromise their safety, delay critical interventions, negatively impact health outcomes, and contribute to the subsequent death of Patient 11.”

“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: 48776 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures were implemented, for three of 20 sample patients (Patients 4, 11, and 12), when: 1. For Patient 4, nursing staff used the Aspira pleural drainage system (a medical device specifically designed to manage pleural effusions, which are accumulations of fluid in the pleural space surrounding the lungs. This system facilitates the removal of fluid through a soft, flexible tube that is inserted through the skin and into the pleural space, and allows for regular drainage of the fluid buildup, thereby alleviating symptoms such as shortness of breath and discomfort) without training or competency (having the right knowledge, and skills); 2. Patient 11 had three episodes of chest pain following a cardiac procedure and it was not reported to the physician. In Addition, a stat EKG (electrocardiogram, a test that records your hearts electrical activity) was not performed and the rapid response (a specially trained team that provides immediate care for hospitalized patients whose condition is rapidly deteriorating) team was not notified to assist in Patient 11’s change in condition. 3. For Patient 12, the rapid response form was not documented with details of Patient 12’s change in health status and there was no documentation of family notification of the rapid response. The cumulative effects of these facility failures had the potential to place patients’ at risk for harm, compromise their safety, delay critical interventions, negatively impact health outcomes, and contribute to the subsequent death of Patient 11. Findings: 1. On August 19, 2025, at 1:30 p.m., Patient 4’s record was reviewed with the Quality and Patient Safety Specialist (QPSS). A facility document, titled, “History and Physical [H&P],” dated April 2, 2025, was reviewed and indicated Patient 4 was admitted to Unit 1 for generalized weakness, urinary tract infection, increased congestion, and right sided pleural effusion (extra fluid that builds up in the pleural space between the lungs and the chest wall making it harder for a person to breath). A facility document, titled, “IR [Interventional Radiology] Pleural Drain Perc [Percutaneous] Cath [Catheter] [small chest tube placed through the skin into the pleural space to drain extra fluid],” dated April 7, 2025, was reviewed and indicated, Patient 4 underwent placement of a right sided tunneled (placed under the skin) Aspira pleural catheter for recurrent right pleural effusions. A facility document, titled, “IR Thoracentesis [procedure where a physician uses a small tube to remove extra fluid from around the pleural space],” dated April 14, 2025, was reviewed and indicated Patient 4 underwent aspiration of fluid due to a left pleural effusion. A facility document, titled, “IR Insert [Insertion of] Pleural Cath [Catheter],” dated April 23, 2025, was reviewed and indicated, Patient 4 underwent placement of a left sided tunneled Aspira pleural catheter for recurrent left pleural effusions. An untitled facility document, “View Flowsheet,” dated April 11, 2025, through April 26, 2025, was reviewed and indicated: -On April 11, 2025, at 12:40 p.m., RN (Registered Nurse) 1 drained “Chest Tube Right...Output (mL, milliliter, unit of measure)...950 mL; -On April 14, 2025, at 4 p.m., RN 2 drained “Chest Tube Right...Output...900 mL; -On April 16, 2025, at 4:43 p.m., RN 3 drained “Chest Tube Right...Output...1000 mL; -On April 19, 2025, at 3:20 a.m., RN 4 drained “Chest Tube Right...Output...675 mL; -On April 21, 2025, at 9:44 a.m., RN 5 drained “Chest Tube Right...Output...1100 mL; -On April 24, 2025, at 11:45 a.m., RN 6 drained “Chest Tube Left...Output...350 mL; -On April 24, 2025, at 6:45 p.m., RN 6 drained “Chest Tube Right...Output...1000 mL; -On April 25, 2025, at 6:21 p.m., RN 7 drained “Chest Tube Right...Output...150 mL; -On April 25, 2025, at 6:21 p.m., RN 7 drained “Chest Tube Left...Output...400 mL; -On April 26, 2025, at 5 p.m., RN 8 drained “Chest Tube Right...Output...450 mL; and -On April 26, 2025, at 6 p.m., RN 8 drained “Chest Tube Left...Output...250 mL; A facility document, titled, “Multidisciplinary Progress Note,” dated, April 18, 2025, at 5:55 p.m., and authored by RN 7 was reviewed and indicated, “With the help of [Name of RN 4]...attempted to drain...Order states to drain 3 times a week...When I called IR earlier in the shift I was told IR is not able to come up and assist...IR provided Aspira drainage bottle which is not compatible with the patient’s drain, there is a missing adaptor piece...” A facility document, titled, “Multidisciplinary Progress Note,” dated, April 18, 2025, at 6:15 p.m., authored by RN 4 was reviewed and indicated, “...Was requested to assist with the drainage of a Aspira pleural drain. Supplies at bedside were incompatible...” On August 19, 2025, at 1:45 p.m., an interview was conducted with the Director of Quality (DOQ). The DOQ stated while Patient 4 was admitted, the nursing staff on Unit 1 did not have the necessary training to use the Aspira pleural drain. Only the Interventional Radiology (IR) nurses were trained and competent in its use. After Patient 4 was discharged, the Aspira representative was contacted and provided Unit 1 staff training. The DOQ further stated Unit 1 staff should not have attempted to drain Patient 4’s pleural drain without proper training and competencies. On August 19, 2025, at 3 p.m., an interview was conducted with the IR Charge Nurse (RN 9). RN 9 stated, the facility utilizes two brands of pleural drains, Aspira and Pleurx. RN 9 stated each brand has different connectors and they are not interchangeable. RN 9 further stated nurses should not have attempted to use the Aspira drain unless they had the necessary training. On August 19, 2025, at 3:15 p.m., an interview was conducted with the Manager of Unit 1 (Manager 1). Manager 1 stated that the facility did not have documentation of competency or training for Unit 1 nurses who performed the drainage of Patient 4’s Aspira pleural drain. Manager 1 further stated RNs 1, 2, 3, 4, 5, 6, 7, and 8 had not received training until after Patient 4 was discharged. On August 20, 2025, at 11:15 a.m., an interview was conducted with RN 6. RN 6 stated Patient 4 had a pleural drain and was not aware that the facility had two brands of pleural drains. RN 6 stated in-service training on Aspira pleural drainage system was provided after Patient 4 was discharged. On August 20, 2025, at 11:45 a.m., an interview was conducted with the Director of Patient Care Services (DPS). The DPS stated that the nursing staff should not have attempted to drain Patient 4’s Aspira drain using incompatible equipment. The DPS further stated nursing staff should have had the proper training before using the equipment. The facility has a process for introducing new equipment, which involves notifying the professional practice/clinical practice committee to ensure proper training and supplies are available. However, the DPS stated this process was not followed. The DPS concluded that Unit 1 nursing staff received training on the Aspira pleural system after Patient 4 was discharged. On August 20, 2025, at 12 p.m., an interview was conducted with RN 3. RN 3 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged. On August 20, 2025, at 1:20 p.m., an interview was conducted with RN 2. RN 2 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged. On August 20, 2025, at 1:30 p.m., an interview was conducted with IR technician (IRT). IRT stated the Aspira pleural drainage system is different from the Pleurx pleural drainage system and the supplies for each are not compatible. IRT stated the connector was damaged from use of incompatible equipment and needed to be replaced. On August 21, 2025, at 8:45 a.m., an interview was conducted with the rapid response nurse (RN 4). RN 4 stated the rapid response nurse is a resource for nurses and was contacted on April 18, 2025, due to the incompatibility of supplies and trouble with lung drainage of Patient 4’s pleural drain system. RN 4 stated Patient 4 was experiencing respiratory distress and was lethargic (sleepy) and needed to have lung drained urgently. RN 4 stated supplies for the Aspira system were difficult to find and IR did not provide them when asked. RN 4 further stated training for the Aspira pleural drainage system was never provided and there was no policy or procedure in place for its use. RN 4 stated Patient 4’s home discharge supplies were utilized to drain the Aspira pleural drain system. On August 21, 2025, at 9:20 a.m., an interview was conducted with RN 8. RN 8 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged. On August 21, 2025, at 9:45 a.m., an interview was conducted with RN 7. RN 7 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged. RN 7 further stated IR and the rapid response nurse was contacted on two shifts due to “broken” connections and incompatibility issues with the Aspira drainage system. On August 21, 2025, at 11:45 a.m., an interview was conducted with RN 1. RN 1 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged. A review of the facility document titled, “Job Description,” was conducted and indicated, “...Job title: Clinical Nurse B-Inpatient...Job Summary...Meets qualifications, licensure, certifications and competencies as defined in the unit/department-specific Plan for Providing Care...Demonstrated basic competencies in clinical nursing...” A review of the facility document titled, “Plan For Providing Care [Name of Facility] Medical and Surgical Services,” dated September 2022, was reviewed and indicated, “...Qualifications/Licenses/Certifications Required of Staff...All employees are required to complete a department specific orientation upon hire and maintain hospital-wide required competencies as indicated by hospital policy...Registered Nurses...Initial and annual competencies are performed as determined by the need of the department, high risk low volume, standardized procedure, regulatory, process improvement, or new product...” A review of untitled document, dated May, 2025, flowchart process for new equipment was reviewed and indicated, “...New Device or Equipment: Supply Chain update, Pilot, Institution Implementation, SOS [standardization of supplies] Committee...Frontline Staff Identified Need - Proposed Change / Update to Practice from Professional Governance Committees...Update to Policy...Education Need Identified...Education Needed...Forward to Nursing Oversight Council...” 2. On August 19, 2025, at 9 a.m., a review of Patient 11’s medical record was conducted with the Regulatory Specialist (RS). A review of the facility document titled, “ED [Emergency Department] Provider Notes,” dated July 19, 2025, authored by MD 1, indicated Patient 11 was brought into the facility by ambulance with chest pain radiating to the left chest and arm. Further review of the document indicated, MD 2 agreed to a STEMI (ST-segment elevation myocardial infarction, a type of heart attack where there is a blockage in one of the major arteries that supplies blood to the heart muscle) activation and Patient 11 was admitted for acute MI (myocardial infarction). A review of the facility document titled, “Cardiology [study of heart diseases] Consult Note,” dated July 20, 2025, at 12:19 a.m., authored by MD 2, was reviewed. The document indicated, “...On arrival patient [Patient 11] continues to have chest pain. Patient [Patient 11] will be taken to Unit B immediately for PPCI [Post Percutaneous Coronary Intervention, involves using a catheter to open blocked arteries, often with the placement of a stent [tube], to restore blood flow to the heart muscle]...” A review of an untitled facility document dated July 21, 2025, at 11:07 a.m., indicated, “Transfer Patient...Level of Care: Unit 1...” A review of a facility document titled “Multidisciplinary Progress Note,” dated July 21, 2025, at 12:06 a.m., indicated, “...Patient [Patient 11] called stating she [Patient 11] is feeling cold and sweaty...Vital signs normal. HR [heartrate] tends to go to 120s when patient [Patient 11] is anxious...Patient [Patient 11] has been complaining of being hot and then cold at other times...Patient [Patient 11] stated she at home has anxiety as well and can’t sleep well at home as well [sic]. But now she is getting scared that when she sleeps she might not wake up...” There was no documented evidence the physician was notified of Patient 11’s symptoms. A review of the facility document titled, “View Doc flowsheet,” dated July 21, 2025, at 12 p.m., indicated, “...pain assessment [a process of collecting detailed information to identify pain with 0 being the least pain experienced and 10 the highest pain] 0-10 pain score 8...pain type acute pain pain location chest...pain descriptors pressure pain onset ongoing...” There was no documented evidence the physician was notified Patient 11 had chest pain. A review of an untitled facility document, dated July 21, 2025, at 1:54 a.m., indicated, “DC [discontinue] Telemetry monitoring [a system that continuously measures and transmits heart data from a remote location to a central station ...” A review of the facility document titled, “View Doc Flowsheet,” dated July 21, 2025, at 8:01 p.m., indicated, “...pain assessment 0-10...pain score 2...pain type Acute pain, pain location chest...pain descriptors dull; Pressure pain onset On-going...” A review of the facility document titled, “View Doc Flowsheet,” dated July 22, 2025, at 8:20 a.m., indicated, “...pain assessment 0-10 pain score 7...pain type acute pain pain location chest...pain descriptors aching ...” There was no documented evidence the physician was notified Patient 11 had chest pain. A review of the facility document titled, “Rapid Response Note,” dated July 22, 2025, indicated, “...Primary RN [Registered Nurse] called me to inform me that the pt [Patient 11] was about to be discharged and then started c/o [complaint of] chest pain. EKG [electrocardiogram, a test that records your hearts electrical activity] was performed showing changes compared to previous EKG and STEMI...I arrived and saw pt [Patient 11]...Pt [Patient 11] was c/o 9/10 chest pain..I called a rapid overhead just to initiate the process...I waited with Pt [Patient 11] until Unit 2 arrived which was within minutes. Pt [Patient 11] was awake and conversing, vitals stable, still having chest pain ...Unit 2 took pt [Patient 11] down...Once I arrived in Unit 2 with chart a code blue [a hospital emergency code indicating an adult patient with a life-threatening medical emergency] was called 1724 [5:24 pm]...” A review of the facility document titled, “Discharge Summary,” dated July 22, 2025, authored by MD 3, indicated, “...pt [Patient 11] became unresponsive...ACLS [Advanced Cardiac Life Support, advanced medical training to include airway management, medication administration, reading EKGs and using the defibrillator [a machine that shocks the heart into a normal heartbeat] protocol patient intubated, patient remained in pulseless electrical activity (PEA) [a condition where the heart shows electrical activity on an EKG, but there is no pulse or blood pressure], CPR [cardiopulmonary resuscitation, an emergency treatment that’s done when someone’s breathing or heartbeat has stopped] continued...Ultimately code was called off after 30 minutes and patient expired...” On August 20, 2025, at 10:04 a.m., a review of the medical record and concurrent interview was conducted with Registered Nurse (RN) 10 and the director of Patient Care Services (DPS). RN 10 stated, the protocol if a patient has chest pain is to get a stat EKG, a set of vital signs and call the physician. RN 10 stated, on July 21, 2025, at 8:20 a.m., Patient 11 complained of chest pain and the physician was called but it wasn’t documented. RN 10 stated a stat EKG and a rapid response was not called for Patient 11. On August 21, 2025, at 2 p.m., an interview was conducted with MD 3. MD 3 stated any chest pain episode should be reported to the physician or the Residents who are caring for the patient. MD 3 stated the policy should have been followed to the letter and the Acute Coronary Syndrome Guideline is an accurate account of the practice that should have been followed. 3. On August 20, 2025, at 8:20 a.m., a review of Patient 12’s record was conducted with the RS. A facility document titled, “ED Provider Notes,” dated July 19, 2025, at 12:33 p.m., was reviewed. The document indicated, Patient 12 was admitted to the ED with leg swelling and worsening discoloration to both legs for one week. Further review of the document indicated Patient 12 had a history of hypertension (high blood pressure) and CHF (congestive heart failure, a chronic condition in which the heart doesn’t pump blood as well as it should). A facility document titled, “Progress Notes,” dated July 23, 2025, at 7:46 a.m., authored by Provider 1 was reviewed. The document indicated, “ ...Pulmonary embolism [a condition where a blood clot travels to and blocks one or more arteries in the lungs]: Active-Noted on CT [Computed Tomography, known as a CAT scan is an imaging technique that uses X-rays to create detailed images of the body’s internal structures] chest 7/22 [July 22]-Pulmonary [refers to the lungs] artery thrombectomy [a medical procedure that involves removing a blood clot from a blood vessel] performed 7/22 [July 22]- IVC filter [Inferior Vena Cava filter is a small, umbrella shaped metal device implanted in the large vein that carries blood from your lower body to your heart and lungs] placed 7/22 [July 22]...” A review of the facility document titled, “Multidisciplinary Progress Note,” dated July 25, 2025, at 8:02 p.m., was reviewed. The document indicated, “At 1821, [6:21 pm] Rapid response was activated, Patient [Patient 12] SOB [shortness of breath] at rest worsening, show breathing, currently on oxygen NC [nasal cannula, a thin flexible tube used to deliver oxygen directly into the nostrils] at 2L [liters, unit of measurement] at 98%, VSS [vital signs stable, physiological measurements such as temperature, blood pressure, heart rate and respiratory rate are normal]. Patient mildly anxious...” On August 20, 2025, at 1p.m., a record review and concurrent interview was conducted with the Quality and Patient Safety Specialist 1 (QPSS) 1. The QPSS 1 stated, a rapid response code was called for Patient 12 due to breathing difficulty but there is no documentation on the rapid response template with the details what occurred. The QPSS 1 further stated there was no documented evidence family was notified of the rapid response and per the policy the family must be notified for any change in condition. On August 21, 2025, at 4 p.m., an interview was conducted with the Rapid Response Nurse (RRN). The RRN stated the rapid response template must be filled out by the rapid response team or primary/charge nurse with an account of vital signs, medications given and patients response. The RRN stated the family must be notified of what happened during the rapid response and it must be documented. A review of the facility’s P&P titled, “Rapid Response Team Management for Adults,” dated September 2023, indicated “...The Rapid Response Team is to facilitate necessary immediate care to patients in which a healthcare provider continues to have concerns about patient condition...Rapid Response Team Member Responsibilities: ...Speak with physician/family/employee about the situation...documentation using Code/Rapid Response Narrator in EMR [electronic medical record]...””

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to implement their “Discharge Planning,” policy, for one of 30 sampled patients (Patient 17), when a discharge planning assessment was not done within 48 hours of admission. This failure had the potential for Patient 17 to not receive the necessary care after discharge from the facility. Findings: On April 22, 2025, at 11 a.m., a review of Patient 17’s medical record was conducted with the Quality and Patient Safety Specialist (QPSS). A review of the facility document titled, “History & Physical (H&P),” dated February 14, 2025, indicated Patient 17 was admitted to the Emergency Department (ED) on February 13, 2025, from a skilled nursing facility. The diagnoses included recent femur (thigh bone) fracture, Chronic Obstructive Pulmonary Disease (COPD, (COPD-a chronic lung disease causing difficulty in breathing), and lung cancer which spread to the brain. Patient 17 was admitted to the facility for a Gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement. A facility document titled, “Physician Discharge Summary,” dated March 12, 2025, indicated, Patient 17 was stable for discharge to the skilled nursing facility with outpatient close follow-up with the primary care provider, general surgery and oncology (a physician who treats cancer). During the review of Patient 17’s medical record, there was no documented evidence that a discharge planning assessment was completed within 48 hours of Patient 17’s admission. On April 22, 2025, at 2:40 p.m., an interview was conducted with the Registered Nurse Case Manager (RNCM). The RNCM stated each patient is seen for a discharge planning assessment within 48 hours of admission to determine what the needs are. The RNCM stated, if the initial discharge planning assessment was not completed, the RNCM should continue to reach out to the patient or approved person involved in the patient’s care, to complete the assessment. On April 22, at 2:50 p.m., an interview was conducted with the Director of Case Management (DCM). The DCM stated, Patient 17 had a high lace score (a tool used in healthcare to predict the likelihood of hospital readmission within 30 days after discharge) triggered on admission. The DCM stated the goal is to re-evaluate the discharge plan if the lace score is high and the Case Manager should have followed up with a discharge planning assessment per facility policy. A review of the facility policy and procedure titled, “Discharge Planning,” dated August 3, 2021, indicated, “...The Hospital will identify, as soon as or as close to time of admission as possible, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. Discharge planning shall be initiated upon admission through the initial Nursing Admission Assessment...””

“DISCHARGE PLANNING-FREEDOM OF CHOICE CFR(s): The hospital , as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services and must, when possible, respect the patient’s or the patient’s representative goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patients. This Standard is not met as evidenced by: 33972 Based on interview and record review the facility failed to ensure the patients representative was informed and approved of the patients discharge plan, prior to being discharged, for one (Patient 1) of 30 sample patients. This failure resulted in Patient 1 being discharged to a facility without patient representative agreement or notification. Findings: On March 20, 2025, an unannounced visit was conducted at the facility for a complaint validation survey. On March 20, 2025, at 1:30 p.m., Patient 1’s medical record was reviewed with the Quality Patient Specialist (QPS). The facility document titled, “ED Provider Notes” dated February 24, 2025, at 2:04 p.m., indicated Patient 1 came in on February 24, 2025, for constipation. The document further stated, “...Hospice and patient daughters attempting placement...The patient’s daughter states she will arrange a place for her mother [Patient 1]...” The facility document titled, “Multidisciplinary Progress Note,” dated February 24, 2025, at 12:59, and authored by Social Worker (SW) 1 was reviewed and indicated, “...1525[3:25 p.m.]: Called second time and left another message for pt’s [Patient 1] daughter to call back regarding DCP [Discharge Planning]. SW will continue efforts to find placement for patient. At this time, patient [Patient 1] is not fully (A&O) [alert and oriented] and next of Kin, Tasha (daughter) will need to provide directive on DCP...” The facility document titled, “Consults” dated February 25, 2025, at 10:59 a.m., and authored by SW1 was reviewed and indicated, “...Summary: Placement...Spoke with pt’s daughter this morning and she requested to communicate only with the Director. She was transferred to the CM[Case Management]/SW Director...ED [Emergency department] Physician and RN [Registered Nurse] notified and will prepare pt for discharge...” The facility document titled, “Multidisciplinary Progress Notes” dated February 25, 2025, at 1:07 p.m., was reviewed and indicated, “Received call from Stephanie R&B [Room and Board]...that patient is going to Joy’s Room and Board...SW 3 way called with Joy and Stephanie. Joy is aware and will be expecting the patient soon...” The facility document titled, “ED Notes,” dated February 25, 2025, at 12:41 p.m., was reviewed and indicated, “[Name of local transport] contacted to transport the patient... ETA [Estimated Time Arrival] 1320[1:20 p.m.] - 1340 [1:40 p.m.]...” The facility document titled, “ED Notes” dated February 25, 2025, at 1:24 p.m. was reviewed and indicted, “...Pt’s [Patient 1] daughter called upset after patient was placed in a new board and care by [Name of SW 1]. She was upset she did not approve this prior to the transfer...” An interview was conducted on March 21, 2025, at 8:30 a.m., with SW 1. SW 1 stated he called the pt’s [Patient 1] daughter and left a voicemail. He stated she refused to talk to him and only wanted to talk with the supervisor. He stated he received a call from Stephanie from the R&B stating the patient [Patient 1] was going to go to her sister’s R&B. He further stated he had a three way call with Stephanie and Joy to make arrangements for Patient 1’s transport. He further stated he never spoke with, informed, or received approval from Patient 1’s daughter for the transfer. SW 1 further stated he should have spoken to Patient 1’s daughter prior to her being transferred. An interview was conducted on March 21, 2025, at 8:45 a.m., with the Director of Case Management (DCM). The DCM stated she recalled Patient 1’s daughter not wanting to speak with SW 1 an requested to speak with his supervisor. She stated she was able to reach Patient 1’s daughter on the telephone. The DCM further stated, she did not inform or receive approval from Patient 1’s daughter for Patient 1 to be transferred to any facility. The DCM further stated SW 1 should have informed Patient 1’s daughter of the placement and gotten approval prior to Patient 1 being discharged. A review of the facility policy titled, “Clinical Management” revised August 2021, was conducted and indicated, “...The patient, family, and/or significant others shall be included in the planning process, and shall be informed, orally or in writing...” A review of the facility policy titled, “Patient’s Rights”, revised March 2021, was conducted and indicated, “...Be informed by the physician, or delegate of the physician, of continuing health care requirements and options following discharge from the hospital. The patient has the right to be involved in the development and implementation of the discharge plan. Upon the patient’s request, a friend or family member may be provided this information also...” A review of the facility policy titled, Case Management” revised August 2021, was conducted and indicated, “...Discharge planning services are provided to patients with the involvement of an interdisciplinary team including the patient, the patient’s family/significant other, licensed medical provider and staff involved in the patient’s care, treatment and services to appropriately deal with the impact of illness...””

“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: 44871 Based on interview and record review, the facility failed to ensure the facility’s infection control program was maintained or methods to prevent the transmission of infections were implemented within the facility when: 1. Patients were not placed on Enteric Precaution (special steps taken in the hospital to prevent the spread of germs this means wearing gloves and gown when entering the patient’s room and washing hands with soap and water) when orders for testing were placed for Clostridium difficile (C. diff., a bacteria found in the colon and large intestines), for 11 of 30 sampled patients (Patient 5, 8, 9, 14, 19, 20, 21, 22, 23, 25, and 26); and 2. Patients were not provided indwelling urinary catheter care (a thin tube that drains urine from the bladder into a bag) /peri care (washing the genital and anal areas), in accordance with the facility’s policy and procedures (P&P), for three of 30 sampled patients (Patients 2, 7, and 17 ); These failures had the potential to result in the transmission and spread of pathogens (bacteria, virus, or other microorganism) to the patients receiving care in the facility. Findings: 1 a. A review of Patient 5’s medical record was conducted on September 6, 2024, at 9:20 a.m., with the Regulatory Specialist (RS) 2. A review of the facility document titled, “History and Physical,” indicated Patient 5 was admitted to the facility on July 14, 2024, for diarrhea of presumed infection origin (infection starting in a certain part of the body), acute abdominal pain (pain in the abdomen), and colitis (inflamed colon). A review of the facility’s untitled, document indicated, C. diff. Glutamate Dehydrogenase (GHD)/Toxin test ( a chemical found in the bacteria Clostrium difficile, that can be used to detect the presence of C. diff in stool) for Patient 5 was ordered on July 14, 2024, at 10:02 a.m. It further indicated the specimen was collected on July 14, 2024, at 11:40 a.m. The C. diff. resulted on July 14, 2024, at 11:40 p.m., as negative. On September 6, 2024, at 9 a.m., an interview was conducted with RS 2. RS 2 stated Patient 5 was not placed in isolation during the rule out of C. diff, and should have been. b. A review of Patient 8’s medical record was conducted on September 6, 2024, at 10:30 a.m., with RS 2. A review of the facility document titled, “History and Physical,” dated June 26, 2024, indicated Patient 8 was admitted to the facility on June 26, 2024, for diarrhea of infectious origin, acute febrile illness (sickness that comes on suddenly and causes a fever), and septic shock (serious condition when an infection spreads throughout the body). A review of the facility’s untitled document, indicated, C. diff. GHD /Toxin test for Patient 8 was ordered on June 27, 2024, at 1:44 p.m. It further indicated the specimen was collected on June 27, 2024, at 7:50 a.m., The C. diff. resulted on June 27, 2024, as negative. On September 6, 2024 at 10: 40 a.m., an interview was conducted with RS 2. RS 2 stated Patient 8 was not placed in isolation during the C. diff. rule out period and should have been per hospital policy. c. A review of Patient 9’s medical record was conducted on September 6, 2024, at 3:30 p.m., with RS 2. A review of the facility document titled, “History and Physical,” dated June 21, 2024, indicated Patient 9 was admitted to the facility on June 21, 2024, for acute coronary syndrome (when blood flow to the heart is suddenly blocked), symptomatic anemia (low red blood cells), and high risk pulmonary embolism (serious blood clot in the lungs). A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 9 was ordered on June 23, 2024, at 9:02 a.m. It further indicated the specimen was collected on June 23, 2024, at 9:48 a.m. C. diff. test resulted on June 24, 2024, as positive and an enteric isolation order was placed on June 25, 2024 after the positive result. On September 6, 2024, at 3:45 p.m., an interview was conducted with RS 2. RS 2 stated Patient 9 was not placed in isolation during the C. diff rule out time and should have been per hospital policy. RS 2 stated Patient 9 was placed on isolation precaution two days after initial testing and one day after positive test result. d. A review of Patient 14’s medical record was conducted on September 9, 2024, at 9:40 a.m., with the RS 2. A review of the facility document titled, “History and Physical,” dated June 24, 2024, indicated Patient 14 was admitted to the facility on January 24, 2024, for essential paroxysmal tachycardia (fast heart beat), hyperkalemia (high potassium in the blood), altered mental status (confusion, acting differently than normal), and sepsis. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 14 was ordered on February 1, 2024, at 10:25 a.m. It further indicated the specimen was collected on February 1, 2024, at 1:05 p.m. C. diff. test results on February 2, 2024, at 2:15 p.m., as positive for C. diff. On September 9, 2024, at 10 a.m., an interview was conducted with RS 2. RS 2 stated Patient 14 was not placed in isolation during the C. diff rule out time and should have been per hospital policy. RS 2 verified Patient 14 was placed on isolation precaution two days after initial testing. e. A review of Patient 19’s medical record was conducted on September 6, 2024, at 9:23 a.m., with RS 3. A review of the facility document titled, “History and Physical,” dated June 2, 2024, indicated Patient 19 was admitted to the facility on June 2, 2024, for colitis, suspect infectious, rectal bleed, and diarrhea. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 19 was ordered on June 2, 2024, not timed. If further indicated the specimen was collected on June 2, 2024, at 12:55 p.m. C. diff. test resulted on June 2, 2024, not timed, as negative. On September 6, 2024, at 9:40 a.m., an interview was conducted with RS 3. RS 3 stated Patient 19 was not placed in isolation during the C. diff rule out time and there was no documented evidence Patient 19 was placed in isolation. RS 3 further stated there was no order for isolation and the facility’s P&P was not followed. On September 6, 2024, at 1:49 p.m., an interview was conducted with the Executive Director of Epidemiology and Infection Control (EDEIC). The EDEIC stated any time there is a rule out C. diff. the patient should be placed on Enteric Precautions. She further stated when there is an order to rule out C. diff. the nurse should call and get the isolation order right away, place signage on the door, and PPE (personal protective equipment) readily available. f. A review of Patient 20’s medical record was conducted on September 6, 2024, at 2 p.m., with the RS 3. A review of the facility document titled, “History and Physical,” dated August 5, 2024, indicated, Patient 20 was admitted to the facility on August 5, 2024, for rectal bleeding, colitis, and rectal carcinoma (cancer that forms in the tissues of the rectum). A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 20 was ordered on August 2, 2024, at 5:04 a.m. It further indicated the specimen was collected on August 2, 2024, at 5:35 a.m. C. diff. test resulted on August 3, 2024, at 3:19 p.m., as negative. On September 6, 2024, at 2:28 p.m. an interview was conducted with RS 3. RS 3 stated patient 20 was not placed on Enteric Precautions during the C. diff. rule out time and the policy was not followed. g. A review of Patient 21’s medical record was conducted on September 9, 2024, at 9:20 a.m., with the RS 3. A review of the facility document titled, “History and Physical,” dated June 3, 2024, indicated, Patient 21 was admitted to the facility on June 3, 2024, for pancolitis (inflammation of the entire colon) and watery diarrhea. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 21 was ordered on June 3, 2024, not timed. It further stated the specimen was collected on June 3, 2024, at 3:57 a.m. C. diff. test resulted on June 3, 2024, at 1:36 p.m., as negative. On September 9, 2024, at 9:35 a.m. an interview was conducted with RS 3. RS 3 stated there was no order for Patient 21 to be placed on Enteric Precautions during C. diff. during rule out period. RS 3 stated the expectation would be to place the patient in Enteric precautions as soon as the patient is tested for C. diff. RS 3 further stated the policy was not met. h. A review of Patient 22’s medical record was conducted on September 9, 2024, at 10 a.m., with the RS 3. A review of the facility document titled, “History and Physical,” dated June 14, 2024, indicated, Patient 22 was admitted to the facility on June 14, 2024, for chest pain, diarrhea, with a history of C. diff. 2 months ago. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 22 was ordered on June 10, 2024, at 3:34 p.m. It further indicated the specimen was collected on June 10, 2024, at 6:21 p.m. C. diff. test resulted on June 11, 2024, at 5:39 p.m., as positive and Patient 22 was placed on Enteric Precautions on June 14, 2024, three days after a positive result. On September 9, 2024, at 10:06 a.m., an interview was conducted with RS 3. RS 3 stated the patient should have been placed on Enteric Precautions when the C. diff. test was ordered. RS 3 further stated the Patient 22 was placed on Enteric Precautions June 14, 2024, despite a positive C. diff. result on June 11, 2024. RS 3 stated the policy was not followed. i. A review of Patient 23’s medical record was conducted on September 9, 2024, at 10:20 a.m., with the RS 3. A review of the facility document titled, “History and Physical,” dated May 16, 2024, indicated Patient 23 was admitted to the facility on May 16, 2024, for a postoperative infection (infection that occurred after surgery), elevated troponin (protein found in muscles of the heart), and sepsis. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 23 was ordered on May 25, 2024, at 6:41 p.m. It further stated the specimen was collected on May 25, 2024, at 6:43 p.m. C. diff. test resulted on May 26, 2024, at 3:20 p.m., as positive. On September 9, 2024, at 10:39 a.m., an interview was conducted with RS 3. RS 3 stated the patient was placed on Enteric Precautions after a positive result of C. diff. not during the rule out period. She further stated the patient should have been placed on Enteric Precaution on May 25, 2024, when the specimen was collected, the policy was not followed. j. A review of Patient 24’s medical record was conducted on September 9, 2024, at 2 p.m., with the RS 3. A review of the facility document titled, “History and Physical,” dated July 24, 2024, indicated Patient 25 was admitted to the facility on July 24, 2024, for C. diff., colitis. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 24 was ordered on July 23, 2024, at 4:28 p.m. It further indicated the specimen was collected on July 23, 2024, at 5:27 p.m. C. diff. test resulted on July 24, 2024, at 1:19 p.m., as positive. On September 9, 2024, at 2:04 p.m., an interview was conducted with RS 3. RS 3 stated Patient 24 was placed on Enteric Precautions after a positive result of C. diff. not during the rule out period. She further stated the patient should have been placed on Enteric Precaution on July 23, 2024, when the specimen was collected, the policy was not. k. A review of Patient 26’s medical record was conducted on September 9, 2024, at 2 p.m., with the RS 3. A review of the facility document titled, “History and Physical,” dated July 30, 2024, indicated Patient 26 was admitted to the facility on July 30, 2024, for nausea, vomiting, and diarrhea. A review of the facility’s untitled, document indicated, C. diff. GHD /Toxin test for Patient 26 was ordered on July 30, 2024, at 12:12 p.m. It further indicated the specimen was collected on July 30, 2024, at 12:58 p.m. C. diff. resulted on July 31, 2024, at 2:46 p.m., as positive. On September 9, 2024, at 2:32 p.m., an interview was conducted with RS 3. RS 3 stated Patient 26 should have been placed on Enteric Precautions during the C. diff. rule out period. RS 3 further stated the the policy was not followed. A review of the facility’s Policy and Procedure (P&P) titled, “STANDARD AND TRANSMISSION-BASED PRECAUTION,” dated January 2021, was conducted. It indicated, “...Enteric Precautions shall be used when caring for patients for whom fecal personal hygiene is unable to be maintained OR who are known/suspected to be infected/colonized with epidemiologically important microorganisms transmitted by fecal material...” 2a. A review of Patient 2’s medical record was conducted on September 6, 2024, at 9:23 a.m., with the Regulatory Specialist 2 (RS 2). A review of the facility document titled, “History and Physical,” dated September 4, 2024, indicated Patient 26 was admitted to the facility on September 4, 2024, for acute exacerbation of chronic obstructive pulmonary disease (COPD, lung disease), symptomatic bradycardia (slow heart rate), dementia (condition that affects the brain), and COVID-19 (coronavirus, symptoms like fever cough and trouble breathing.) A review of the facility’s untitled document, indicated Patient 2’s foley catheter (a flexible tube placed into the bladder to drain urine) was placed on September 3, 2024. A review of the facility’s document titled, “Hygiene Flow Sheet,” dated September 4, 2024, through September 5, 2024, day shift (7 a.m.- 7 p.m.) and night shift (7 p.m. - 7 a.m.), indicated perineal care (cleaning the genitals and buttocks area) was not provided to Patient 2 on September 5, 2024, day and night shift. On September 6, 2024, at 10 a.m., an interview was conducted with RS 2. RS 2 stated Patient 2 did not receive perineal care on September 5, 2024, for day or night shift and should have been per hospital policy. b. A review of Patient 7’s medical record was conducted on September 9, 2024, at 9:50 a.m., with the RS 2. A review of the facility document titled, “History and Physical,” dated June 10, 2024, indicated Patient 7 was admitted to the facility on on June 10, 2024, for postoperative wound infection (infection that developed after surgery), acute osteomyelitis (infection in a bone), and acute cystitis (infection of the bladder) without hematuria (blood in urine). A review of the facility’s untitled document, indicated Patient 7’s foley catheter was placed on on June 10, 2024. A review of the facility’s document titled, “Hygiene Flow Sheet,” dated June 11, 2024, indicated perineal care was not provided to Patient 11 on June 11, 2024. On September 9, 2024, at 10 a.m., an interview was conducted with RS 2. RS 2 stated Patient 7 did not receive perineal care on June 11, 2024, per hospital policy. c. A review of Patient 17’s medical record was conducted on September 6, 2024, at 11 a.m., with the RS 2. A review of the facility document titled, “History and Physical,” dated September 2, 2024, indicated, Patient 17 was admitted to the facility on September 2, 2024, for COVID-19, pneumonia (infection to the lungs) and weakness. The History and Physical document indicated, “...patient has a foley catheter in place due to bladder infection...” A review of the facility document titled, “Hygiene Flow Sheet,” dated September 2, 2024, p.m. shift (7 p.m. to 7 a.m.) indicated, perineal care was not provided for Patient 17. On September 6, 2024, at 11:06 a.m., an interview and record review were conducted with RS 3. RS 3 stated I did not see that pericare was provided for Patient 17 on September 2, p.m. shift. She further stated the policy was not followed. On September 6, 2024, at 2:07 p.m., an interview was conducted with the Director of Quality and Patient Safety (DQPS). The DQPS stated there is no policy for foley catheter care, however, the facility follows the nursing skills guidelines, and the nurses are held to it. A review of the facility undated skill titled, “URINARY CATHETER MALE [NAME OF CITY],” indicated, “...Perineal Care...Perineal care should be performed once per shift and PRN (as needed) when a patient has a dwelling catheter...” .”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to ensure stabilizing treatment and the maintenance of safety and security relevant to the psychiatric emergency medical condition (EMC) was provided for 1 out of 21 sampled patients (Patient 11) when he was admitted on a psychiatric hold (5150; when a person is deemed a danger to self, others, or gravely disabled, could be involuntary detained for 72 hours) and eloped (patient leaving the hospital before discharged) from the Emergency Department (ED) twice. This failure resulted in Patient 11 running out of the the facility to a highway and walking in front of a moving vehicle and subsequently died. This failure has the potential to place other patients at a high risk for harm. Findings: On December 21, 2023, an unannounced visit was conducted at the facility for an EMTALA survey. The facility’s document titled, “ED Provider Notes,” dated December 18, 2023, at 4:56 p.m. was reviewed. The document indicated, “...Chief Complaint...Suicidal...history of anxiety with presumed recent auditory hallucinations [hearing noises without an external stimulus] returns after eloping the ER [emergency room]. He was brought back by family. The patient stated to both staff and family that he is actively suicidal but will not state a plan. He is placed on 5150...” A review of the facility’s document titled, “Application For Assessment, Evaluation, and Crisis Intervention or Placement For Evaluation and Treatment,” dated December 18, 2023, at 4:45 p.m. indicated, “...[Patient 11’s name] ...Brought in by family for acute SI [Suicidal Ideation; thinking about or planning suicide]...Patient [Patient 11] with history of depression [medical illness that negatively affects how someone feels] presents for acute SI. Patient seen earlier at [Facility Name] ED for anxiety/paranoia [delusional beliefs about persecution, threat or conspiracy] then eloped. Patient brought back by family and now states actively suicidal...signature: [Name of physician]...” A review of facility’s document titled, “Suicide Screening,” dated December 18, 2023, at 5:04 p.m., indicated Patient 11 was suicidal. A review of the facility’s document titled, “ED Pt. care timeline,” dated December 18, 2023, at 5:05 p.m., indicated, Patient 11 was admitted in ED as Emergency Severity Index 2 (ESI, a five-level triage tool utilized by ED with two meaning emergent). A review of the facility’s document titled, “ED Notes,” dated December 18, 2023, at 9:15 p.m. signed by RN 3 was conducted. The document indicated, “...At around 9:10 p.m., received phone call from Operator that security is outside with this patient that eloped from the ED ...RN reports patient’s sitter, [name of assigned sitter], CNA [certified nurse assistant] was with the patient waiting for the restroom in the ED lobby when he suddenly ran out...” A review of the facility’s document titled, “ED Notes,” dated December 18, 2023, at 9: 20 p.m. signed by RN 3 was conducted. The documented indicated, “...After phone call from operator to the ER [emergency room] main line, desk tech, [name of desk tech] called [ local police department] and made them aware of the 5150 patient that eloped from our facility...” A review of the facility’s document titled, “...Incident from night 12/18/2023 [December 18, 2023],” signed by sitter/CNA [certified nurse assistant assigned to patient] indicated, “...I was assigned to a patient in the ER...I section of the hospital which was a bed in a hallway...the patient requested to go to the bathroom, so I stood up and took him to the nearest restroom, someone was in the bathroom so I advised him to wait until the person in the bathroom comes out. After a couple of minutes, the patient hurried and escaped through the nearest exit door and started running away...I grabbed him by the gown but he ripped it off and kept running, I started shouting out for security so they can help capture the patient. Security finally caught up to us and try to talk to the patient and convince him to return back to the hospital. but the patient didn’t want to listen, he continued walking away until he crossed the road and jumped a barbed wire fence an entered the freeway where he was standing on the shoulder lane, immediately when he saw a speeding vehicle coming down the highway he then used that opportunity to run and jump in front of the vehicle therefore killing himself...” An interview with the Director of Quality and Patient Safety (DQPS) on December 22, 2023, at 11:00 a.m., was conducted. The DQPS stated there were two videos of Patient 11’s elopement. The videos were reviewed with the DQPS. Patient 11 was observed walking to the nearest restroom accompanied by the assigned sitter/CNA. Patient 11 then began walking toward the double doors out to the ED main lobby. The sitter began to yell for assistance and a staff nurse knocked on the security’s office window. Another video footage showed security in pursuit, outside toward the parking lot. The DQPS further stated, “If we would have known what his plan was, and we knew that his plan was to run to the freeway, then we would or could have taken more measures such as placing two sitters with him any time he was getting up. He stated he was suicidal but never verbalized his plan.” An interview with the Security Manager (SM) on December 22, 2023, at 11:32 a.m., was conducted. The SM stated, “This is not the first time a 5150 tried to run to the freeway. We have been able to stop them. Once we know their plan then we make sure we do what ever it takes to not let them get to the street.” A review of the policy and procedure (P&P) titled, “Patients Suspected or Determined to be a Danger to Self or Others, or Gravely Disabled,” dated March 29, 2022, was conducted. The P&P indicated, “...Provide constant visual observation of patient to ensure safety and prevent access to items that can be used for harm...””