Temecula Valley Hospital

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to ensure the appropriate medication was ordered for one of 12 sampled patients (Patient 4), when Patient 4 was discharged home with prescribed medication that was resistant (medication is not effective to treat organism) to Patient 4’s urine organism. This failure resulted in Patient 4 having to return to the hospital for admission and a potential for a delay in patient care. Findings: On January 13, 2026, at 10:15 a.m., a review of Patient 4’s medical record was conducted with the Quality Coordinator (QC). A facility document titled, “Results Review...Microbiology [the study of micro-organisms, a group of organisms that are too small to be seen with the naked eye],” dated October 21, 2025, at 12 p.m., was reviewed. The document indicated, “...Specimen information...order: C urine...last update...October 21, 2025, at 12 p.m....Escherichia coli ESBL [bacteria that produces an enzyme called Extended-Spectrum Beta-Lactamase (ESBL), which makes it resistant to many common antibiotics]...drug...Cefdinir [name of antibiotic medication]: R [Resistant, medication is not effective to treat organism]...Final on October 21, 2025, at 12 p.m...” A facility document titled, “Discharge Summary,” dated October 22, 2025, was reviewed. The document indicated, “...Urine culture positive for E. Coli...Reviewed all labs...Electronically signed by [name of MD] on October 22, 2025, at 11:15 a.m.” A facility document titled, “History and Physical [H&P],” dated October 22, 2025, was reviewed. The document indicated, “...Chief Complaint...BIBA [brought in by ambulance] from home, was DC [discharged] x 1 hr [one hour] ago, got a phone call to come back d/t [due to] antibiotic script issue...he was discharged home today, however urine cultures were positive for ESBL E. Coli resistant to the Cefdinir prescribed...” An interview and record review were conducted on January 14, 2026, at 10:58 a.m., with the Lab Director (LD). The LD stated Patient 4’s report indicated the results were finalized on October 21, 2025. The LD stated urine cultures and sensitivities are not considered critical and so are not called in to the medical doctor by the lab. The LD stated the results go into the system for the medical doctor to review. An interview was conducted on January 14, 2026, at 11:11 a.m., with the Director of Med Surg (Medical surgical, unit in the hospital that cares for a variety of patients) (DMS). The DMS stated antibiotic sensitivities and urine cultures are not critical results and it is the responsibility of the provider to check results prior to discharging the patient, not the nurse. An interview was conducted on January 14, 2026, at 1:02 p.m., with Medical Doctor (MD) 1. MD 1 stated the MD assigned to the patient should review culture and sensitivity results prior to discharge. MD 1 stated if a result is missed, the provider would notify the patient as soon as possible and call them to come back to the hospital. A facility document titled, “[Name of Hospital] Medical Staff General Rules & Regulations,” dated June 10, 2019, was reviewed. The document indicated, “...members of the medical staff shall be responsible for management of his/her patient’s medical condition and coordination of daily medical care...treatment of the patient...appropriate treatment of each patient...and accuracy of the medical record...Determining the appropriateness of care for each patient is based in part on a review of patient’s...diagnostic data...””

“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: 44871 Based on interview and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented for five of 17 sampled patients (Patients 4, 8, 15, and 16) when: 1. For Patient 4, an initial assessment was not completed while in the emergency department (ED); 2. For Patients 4, and 15, pain was not reassessed after medication administration; and 3. For Patients 4, 8, and 16, pain was not addressed. These failures had the potential to compromise patient safety, delay in initiation of appropriate pain management interventions, inadequate monitoring of patient comfort and response to treatment, and meet standards of nursing assessment and patient-centered care. Findings: 1. On January 13, 2026, at 1:45 p.m., a review of Patient 4’s medical record was conducted with the Quality Coordinator (QC). A facility document titled, “ED Physician Report,” dated October 19, 2025, was reviewed. The document indicated, Patient 4 presented to the emergency department for left foot pain after a ground-level fall the prior night. A facility document titled, “Body Systems Assessment,” dated October 19, 2025, was reviewed. The document indicated, “...Musculoskeletal [the body’s system of muscles, bones, joints, ligaments, and tendons that provide structure, support, movement, and posture]...Integumentary [the skin]...” During the review of Patient 4’s medical record with the QC there was no documented evidence that a Musculoskeletal or Integumentary assessment was completed. A concurrent interview and record review were conducted on January 13, 2026, at 2 p.m., with the QC. The QC stated there was no documented evidence an integumentary and musculoskeletal assessment was completed for Patient 4. The QC further stated the patient should have been assessed by the RN (Registered Nurse). The facility P&P titled, “Assessment and Reassessment in the Emergency Department,” dated April 24, 2023, was reviewed. The document indicated, “...Initial RN MSE [Medical Screening Exam] involves a brief rapid assessment to identify actual or potential life threatening illness...” 2a. On January 13, 2026, at 1:45 p.m., a review of Patient 4’s medical record was conducted with the QC. A facility document titled, “H&P,” dated October 20, 2025, was reviewed. The document indicated Patient 4 was admitted to the facility on October 20, 2025, for a left hip fracture and urinary tract infection (UTI, baterial infection in the urinary system). A facility document titled, “Pain Assessment Detail,” dated October 20, 2025, at 5:48 p.m., was reviewed. The document indicated, “...Pain Assessment Tool Utilized...Numeric [a pain scale 0-10 a way for a patient to rate their pain, 0 = [equals] no pain ...10 = the worst pain imaginable]...Numeric Pain Scale...7...Location...foot...” A facility document titled, “MAR [Medication Administration Record],” dated October 20, 2025, at 5:49 p.m., was reviewed. The document indicated, “...Ibuprofen [medication used to treat moderate pain] 400 mg [a unit of measurement] ...oral...PRN [As Needed] pain (4-6, moderate)...” was given. A concurrent interview and record review were conducted on January 13, 2026, at 2:20 p.m., with the QC. The QC stated the patients’ (Patient 4) pain level should have been reassessed after medication administration and there was no evidence in the patient’s chart that this occurred. The QC stated the nurse did not follow the policy for reassessing pain. 2b. On January 14, 2026, at 1:25 p.m., a review of Patient 15’s medical record was conducted with the Cardiac Program Manager (CPM). A facility document titled, “H&P,” dated January 12, 2026, was reviewed. The document indicated Patient 15 was admitted to the facility on January 11, 2026, for diabetic ketoacidosis (a serious condition where the body does not have enough insulin and creates dangerous acids that build up in the blood). A facility document titled, “Pain Assessment Detail,” dated January 11, 2026, at 9:10 p.m., was reviewed. The document indicated, “...Pain Assessment Tool Utilized ...Numeric...Numeric Pain Scale 5 = Mode [Moderate]...Location ...Throat...” A facility document titled, “MAR,” dated January 11, 2026, at 9:12 p.m., was reviewed. The document indicated, “...Morphine [medication used to treat moderate to severe pain] 4 mg...iv [intravenous, given through the veins] push...” A concurrent interview and record review were conducted on January 14, 2026, at 2:20 p.m., with the CPM. The CPM stated the patients’ pain level should have been reassessed after medication administration, there was no evidence in the patient’s chart that this occurred. The CPM stated the nurse did not follow the policy for reassessing pain. The facility P&P titled, “Assessment and Reassessment in the Emergency Department,” dated April 24, 2023, was reviewed. The document indicated, “ ..after medication administered for pain (per policy)...pain should be reassessed 15 to 30 minutes after a 1 [sic] medication or a non-pharmacologic intervention...” 3a. On January 13, 2026, at 10:15 a.m., a review of Patient 4’s medical record was conducted with the QC. A facility document titled, “H&P,” dated October 20, 2025, was reviewed. The document indicated Patient 4 was admitted to the facility on October 20, 2025, for a left hip fracture and UTI. A facility document titled, “Pain Assessment Detail,” dated October 21, 2025, through October 23, 2025, was reviewed. The document indicated, “...Pain Assessment Tool Utilized ...Numeric...Numeric Pain Scale...Location...”, on the following dates and times: -On October 21, 2025, at 4 a.m., “pain...2...location [left blank]...”; -On October 21, 2025, at 1:30 p.m., “pain...4...location...Hip...”; and -On October 22, 2025, at 12:40 a.m., “pain...2 ..location...hip...”. A facility document titled, “MAR,” dated October 20, 2025, through October 23, 2025, was reviewed. There was no documented evidence Patient 4 received any pain mediations on the following dates and times: -On October 21, 2025, at 4 a.m.; -On October 21, 2025, at 1:30 p.m.; and -On October 22, 2025, at 12:40 a.m. A concurrent interview and record review were conducted on January 13, 2026, at 2:20 p.m., with the QC. The QC stated there was no documented evidence that Patient 4’s pain was addressed on the above listed dates and times. The QC stated the patient’s pain should have been addressed and the nurse did not follow the policy for pain. 3b. On January 14, 2026, at 2 p.m., a review of Patient 8’s medical record was conducted with the QC. A facility document titled, “H&P,” dated October 14, 2025, was reviewed. The document indicated Patient 8 was admitted to the facility on October 14, 2025, for shortness of breath and diarrhea. A facility document titled, “Pain Assessment Detail,” dated October 28, 2025, at 5 p.m., was reviewed. The document indicated, “...Pain Assessment Tool Utilized ...Numeric...Numeric Pain Scale...7...”. A facility document titled, “MAR,” dated October 28, 2025, was reviewed. There was no documented evidence that Patient 8 received pain medication until 5:30 p.m. A concurrent interview and record review were conducted on January 14, 2026, at 2:20 p.m., with the QC. The QC stated there was no documented evidence that Patient 8’s pain was addressed on October 28, 2025, at 5 p.m. The QC stated the patient’s pain should have been addressed and the nurse did not follow the policy for pain. On January 14, 2026, at 11:11 a.m., an interview was conducted with the DMS. The DMS stated when a patient complains of pain it should be addressed as soon as possible. The DMS stated if there is an order for pain medication, medication should be given based on the order and pain schedule. The DMS further stated if there is no order for pain medication then the nurse should call the MD for an order. On January 14, 2026, at 11:11 a.m., an interview was conducted with the RN. The RN stated patients should be assessed for pain every four hours. The RN stated if the patient has pain they should be given pain medications and then reassessed within one hour if given oral medication. 3c. On January 14, 2026, at 2:20 p.m., a review of Patient 16’s medical record was conducted with the CPM. A facility document titled, “H&P,” dated January 10, 2026, was reviewed. The document indicated Patient 16 was admitted to the facility on January 10, 2026, for cervical radiculopathy (a condition in which nerves in the neck are compressed or irritated causing pain, numbness, tingling, or weakness). A facility document titled, “Pain Assessment Detail,” dated January 14, 2026, at 11:40 a.m., was reviewed. The document indicated, “ ...Pain Assessment Tool Utilized ...Numeric...Numeric Pain Scale 4...Location...Neck...” A facility document titled, “MAR,” dated January 14, 2026, at 7 a.m., through 6:59 p.m., was reviewed. The document indicated,”...Norco [medication used to treat moderate pain] 5 mg 325 mg oral tablet...1 Tabs [one tablet]...q4H [every four hours] PRN Pain 4-6 (Moderate)...” A concurrent interview and record review were conducted on January 14, 2026, at 2:40 p.m., with the CPM. The CPM stated there was no documented evidence found in the patient’s chart that the PRN medication (Norco) was given on January 14, at 11:40 a.m., when patient complained of pain. The CPM stated the pain policy was not followed. The facility P&P titled, “Pain Management Standards,” dated March 11, 2024, was reviewed. The document indicated, “...Management of pain is a patient right and staff will convey to the patient/family that adequate pain management is a priority. Achieving optimum pain management is a joint effort between the patient and family, the physician, and the interdisciplinary team. Consistent care and good communication between the health care team will be utilized to achieve adequate pain management...””

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure quality of medical care and services provided to the patients met standards of care when: 1. Physician 1 conducted Ion Bronchoscopy (robotic-assisted bronchoscopy...invasive procedure used to examine and biopsy lesions in the lungs), for 20 patients (Patients 17 through 38), with an expired fluoroscopy certification and approved privileges on December 6, 2024, through August 14, 2025. (Tag A-0340); 2. Physician 2 conducted cerebral angiography (a medical imaging procedure that uses catheter, x-ray imaging guidance and an injection of contrast material to examine blood vessels in the brain for abnormalities.), for eight patients (Patients 40, 41, 42, 43, 44, 46, 47, and 49), without fluoroscopy certification and approved privileges on August 17, 2025, through September 2, 2025. (Tag A-0340); and 3. Patient 20 had an Ion bronchoscopy complication with a physician who had an expired temporary certificate for fluoroscopy. (Tag A-0945) The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients, compromise patient safety, and may cause complication and death during provision of patient care.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to conduct an initial Important Message from Medicare (IMM) document upon admission for one (Patient 11) of 54 sample patients. This failure had the potential for the patient to not be informed of their rights upon admission to the facility and could have jeopardized the health, well-being, and safety of the patient. Findings: On October 14, 2025, an unannounced visit was conducted at the facility for a complaint validation survey. On October 15, 2025, at 9:35 a.m., a review of Patient 11’s medical record was conducted with the Quality Clinical Effectiveness Coordinator (QCEC) 1 and Quality Clinical Effectiveness Coordinator (QCEC) 2. A review of the facility document titled, “History and Physical,” dated, September 29, 2025, at 10:22 p.m., was reviewed. The document indicated Patient 11 had a medical history of urinary tract infection (infection of the kidneys, ureters, bladder, and urethra), anemia (low red blood cell count in the blood), and hypertension (elevated blood pressure). It further indicated Patient 11 was admitted to the facility on September 29, 2025, for chest tightness. A review of Patient 11’s medical record did not indicate documented evidence of an initial Important Message from Medicare (IMM) document upon admission for Patient 11. On October 15, 2025, at 1:30 p.m., an interview with the Director of Patient Access Services (DPAS) was conducted. The DPAS stated, “...registration is required to complete the initial IMM within two days so that the patient can understand discharge rights...it was not done...” A review of the facility policy and procedure (P&P) titled, “Important Message from Medicare (IMM),” revised October 14, 2024, was conducted. The P&P indicated, “...It is the responsibility of our facilities to inform Medicare beneficiaries receiving part “A” Benefits of their rights when receiving inpatient Medicare covered services. Under federal legislation, Medicare beneficiaries are required to be given timely notification of their rights to appeal a hospital discharge. All Medicare inpatients will receive the initial IMM at the time of admission by the registration staff...as required by the Center of Medicare & Medicaid Services...””

“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: 50122 Based on interview and record review, the facility failed to follow a physician’s order for one (Patient 10) of 54 sample patients. This failure had the potential to jeopardize patient safety, and increase Patient 10’s pain. Findings: On October 14, 2025, an unannounced visit was conducted at the facility for a complaint validation survey. On October 15, 2025, at 9:35 a.m., a review of Patient 10’s medical record was conducted with the Quality Clinical Effectiveness Coordinator (QCEC) 1, and Quality Clinical Effectiveness Coordinator (QCEC) 2. A review of the facility document titled, “History and Physical,” dated August 2, 2025, at 4:17 p.m., was conducted. The document indicated Patient 10 had a medical history of Diabetes (a chronic condition characterized by high glucose levels), End Stage Renal disease on hemodialysis (permanent loss of kidney function that requires a machine to filter waste and excess fluid from the blood), was bed bound (not able to walk and confined to a bed), and hypertension (elevated blood pressure). It further indicated Patient 10 was admitted to the facility on August 2, 2025, for urinary retention (a condition where a person is unable to completely or partially empty their bladder). A review of the facility document titled, “Orders,” dated August 3, 2025, at 6:05 a.m., was conducted. The document indicated an order for “...Therapeutic Bed Low Air Loss...08/03/25 [August 3, 2025]...6:05 [6:05 a.m.]...Routine...” A review of the facility document titled, “Integumentary Preventative Measures,” dated August 9, 2025, at 8:30 p.m., was conducted. The document indicated, “...Pressure Relieving Support Surface...Therapeutic Mattress...” During the record review there was no documented evidence a therapeutic mattress was ordered for Patient 10. On October 15, 2025, at 1:35 p.m., an interview was conducted with the Inpatient Wound Care Program Manager (WCM). The WCM stated, “...Nurses are responsible for obtaining mattresses...they are in house...there was no indication of a therapeutic mattress in place prior to August 9, 2025...” On October 16, 2025, at 8:45 a.m. an interview was conducted with the Director of Quality and Education (DQE). The DQE stated, “...order for the mattress should have been completed by nursing and/or wound care team...if the order is not completed, it can cause an increase in discomfort for a bed bound patient...” A review of the facility policy and procedure (P&P) titled, “[name of facility] Physician’s Order,” dated May 9, 2024, was conducted. The P&P indicated, “...Provider orders will be accurately processed and promptly followed...” A review of the facility P&P titled, “Patient’s Rights and Responsibilities,” revised on February 14, 2022, was conducted. The P&P indicated, “...The care of the patient shall optimize the comfort and dignity of the patient through treating primary and secondary symptoms that respond to treatment as desired by the patient or the patient’s designated representative...effectively managing pain...appropriate assessment and management of pain...pain relief measures...””

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to conduct periodic reviews of physician’s privileges to appraise their qualifications to continue to practice their privileges when: 1. Physician 1 performed Ion Bronchoscopy (robotic-assisted bronchoscopy...invasive procedure used to examine and biopsy lesions in the lungs), for 20 patients (Patients 17 through 38), with an expired fluoroscopy certification, on December 6, 2024, through August 14, 2025; and 2. Physician 2 conducted cerebral angiography (a medical imaging procedure that uses catheter, x-ray imaging guidance and an injection of contrast material to examine blood vessels in the brain for abnormalities.), for eight patients (Patients 40, 41, 42, 43, 44, 46, 47, and 49), without fluoroscopy certification and approved privileges, on August 17, 2025, through September 2, 2025. This failure had the potential to impact the health and safety of the patients and may cause complication and death during provision of patient care. Findings: On October 14, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for a complaint validation survey. 1. Review of the medical records for Patients 17, 18, 19, and 20 were conducted on October 15, 2025, with the Quality Clinical Effectiveness Coordinator (QCEC 3) as follows: a. On October 15, 2025, at 10:50 a.m., a review of Patient 17’s medical record was conducted with the QCEC 3. The record indicated Patient 17 had an Ion Bronchoscopy performed on December 6, 2024, by Physician 1. b. On October 15, 2025, at 11:16 a.m., a review of Patient 18’s medical record was conducted with the QCEC 3. The record indicated Patient 18 had an Ion Bronchoscopy performed on December 12, 2024, by Physician 1. c. On October 15, 2025, at 11:37 a.m., a review of Patient 19’s medical record was conducted with the QCEC 3. The record indicated Patient 19 had an Ion Bronchoscopy performed on December 13, 2024, by Physician 1. d. On October 15, 2025, at 2:35 p.m., a review of Patient 20’s medical record was conducted with the QCEC 3. The record indicated Patient 20 had an Ion Bronchoscopy performed on December 13, 2024, by Physician 1. 2. Review of the medical records for Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37 and 38 were conducted with the Quality and Stroke Program Coordinator (QSCP) as follows: a. On October 16, 2025, at 11:39 a.m., a review of Patient 21’s medical record was conducted with the Quality and Stroke Program Coordinator (QSPC). The record indicated Patient 21 had an Ion Bronchoscopy performed on December 30, 2024, by Physician 1. b. On October 16, 2025, at 11:45 a.m., a review of Patient 22’s medical record was conducted with the QSPC. The record indicated Patient 22 had an Ion Bronchoscopy performed on February 14, 2025, by Physician 1. c. On October 16, 2025, at 11:48 a.m., a review of Patient 23’s medical record was conducted with the QSPC. The record indicated Patient 23 had an Ion Bronchoscopy performed on February 14, 2025, by Physician 1. d. On October 16, 2025, at 11:51 a.m., a review of Patient 24’s medical record was conducted with the QSPC. The record indicated Patient 24 had an Ion Bronchoscopy performed on February 14, 2025, by Physician 1. e. On October 16, 2025, at 11:55 a.m., a review of Patient 25’s medical record was conducted with the QSPC. The record indicated Patient 25 had an Ion Bronchoscopy performed on March 7, 2025, by Physician 1. f. On October 16, 2025, at 11:59 a.m., a concurrent interview and record review was conducted with the QSPC regarding Physician 1. The record indicated Patient 26 came in at the facility and had an Ion Bronchoscopy done on March 7, 2025, with Physician 1. g. On October 16, 2025, at 12:02 p.m., a review of Patient 27’s medical record was conducted with the QSPC. The record indicated Patient 27 had an Ion Bronchoscopy performed on March 7, 2025, by Physician 1. h. On October 16, 2025, at 12:27 p.m., a review of Patient 28’s medical record was conducted with the QSPC. The record indicated Patient 28 had an Ion Bronchoscopy performed on March 26, 2025, by Physician 1. i. On October 16, 2025, at 12:29 p.m., a review of Patient 29’s medical record was conducted with the QSPC. The record indicated Patient 29 had an Ion Bronchoscopy performed on March 27, 2025, by Physician 1. j. On October 16, 2025, at 12:31 p.m., a review of Patient 30’s medical record was conducted with the QSPC. The record indicated Patient 30 came had an Ion Bronchoscopy performed on April 4, 2025, by Physician 1. k. On October 16, 2025, at 12:34 p.m., a review of Patient 31’s medical record was conducted with the QSPC. The record indicated Patient 31 had an Ion Bronchoscopy performed on April 4, 2025, by Physician 1. l. On October 16, 2025, at 12:43 p.m., a review of Patient 32’s medical record was conducted with the QSPC. The record indicated Patient 32 had an Ion Bronchoscopy performed on April 11, 2025, by Physician 1. m. On October 16, 2025, at 12:49 p.m., a review of Patient 33’s medical record was conducted with the QSPC. The record indicated Patient 33 had an Ion Bronchoscopy performed on April 11, 2025, by Physician 1. n. On October 16, 2025, at 12:52 p.m., a review of Patient 34’s medical record was conducted with the QSPC. The record indicated Patient 34 had an Ion Bronchoscopy performed on May 9, 2025, by Physician 1. o. On October 16, 2025, at 12:54 p.m., a review of Patient 35’s medical record was conducted with the QSPC. The record indicated Patient 35 had an Ion Bronchoscopy performed on June 4, 2025, by Physician 1. p. On October 16, 2025, at 12:58 p.m., a review of Patient 36’s medical record was conducted with the QSPC. The record indicated Patient 36 had an Ion Bronchoscopy performed on July 22, 2025, by Physician 1. q. On October 16, 2025, at 1:06 p.m., a review of Patient 37’s medical record was conducted with the QSPC. The record indicated Patient 37 had an Ion Bronchoscopy performed on August 1, 2025, by Physician 1. r. On October 16, 2025, at 1:10 p.m., a review of Patient 38’s medical record was conducted with the QSPC. The record indicated Patient 38 had an Ion Bronchoscopy performed on August 14, 2025, by Physician 1. An interview was conducted on October 16, 2025, at 1:15 p.m., with the QCEC. The QCEC stated Patient’s 17-38 had an Ion Bronchoscopy procedure conducted under fluoroscopy by Physician 2 while Physician 2’s fluoroscopy certification and privileges were suspended. 3. On October 16, 2025, review of the medical records of Patients 40, 41, 42, 43, 44, 46, 47, and 49 were conducted with the Quality and Stroke Program Coordinator (QSCP) as follows: a. On October 16, 2025, at 10:02 a.m., a review of Patient 40’s medical record was conducted with the Quality and Stroke Program Coordinator (QSPC) . The record indicated Patient 40 had a cerebral angiography performed on August 27, 2025, and on August 29, 2025, by Physician 2. b. On October 16, 2025, at 1:25 p.m., a review of Patient 41’s medical record was conducted with the QSPC. The record indicated Patient 41 had a cerebral angiography performed on August 28, 2025, by Physician 2. c. On October 16, 2025, at 1:30 p.m., a review of Patient 42’s medical record was conducted with the QSPC. The record indicated Patient 42 had a cerebral angiography performed on August 27, 2025, by Physician 2. d. On October 16, 2025, at 1:50 p.m., a review of Patient 43’s medical record was conducted with the QSPC. The record indicated Patient 43 had a cerebral angiography performed on August 25, 2025, and on August 27, 2025, by Physician 2. e. On October 16, 2025, at 1:57 p.m., a review of Patient 44’s medical record was conducted with the QSPC. The record indicated Patient 44 had a cerebral angiography performed on August 22, 2025, by Physician 2. f. On October 16, 2025, at 2:14 p.m., a review of Patient 46’s medical record was conducted with the QSPC. The record indicated Patient 46 had a cerebral angiography performed on August 19, 2025, by Physician 2. g. On October 16, 2025, at 2:30 p.m., a review of Patient 47’s medical record was conducted with the QSPC. The record indicated Patient 47 had a cerebral angiography performed on August 19, 2025, by Physician 2. h. On October 16, 2025, at 2:39 p.m., a review of Patient 49’s medical record was conducted with the QSPC. The record indicated Patient 49 had a cerebral angiography performed on August 17, 2025, by Physician 2. An interview was conducted on October 16, 2025, at 2:45 p.m., with the QSPC. The QSPC stated Patients 40, 41, 42, 43, 44, 46, 47, and 49 had angiography procedure conducted under fluoroscopy by Physician 2 while Physicians 2’s fluoroscopy certification and privileges were suspended. An interview was conducted on October 14, 2025, at 9:48 a.m., with the Director of Risk Management (DRM). The DRM stated the facility conducted a record review and determined there was no patient harm from the procedures performed by Physician 1 and 2 while their fluoroscopy certification and privileges were suspended. An interview was conducted on October 15, 2025, at 10:05 a.m., with the Director of Medical Staff Services (DMSS). The DMSS stated, “Yes, the physicians need a fluoroscopy certificate to conduct procedures requiring imaging because there is a potential complication from exposure to fluoroscopy.” The DMSS stated she is responsible for maintaining the physician’s certifications and licenses. The DMSS stated, “I missed it.” An interview was conducted on October 16, 2025, at 9:50 a.m., with the Director of Imaging (DI). The DI stated during an Ion Bronchoscopy and cerebral angiography, a possibility and potential complication can occur. DI stated both procedures require fluoroscopy for imaging. The DI stated both Physicians 1 and 2 had no current certification when they conducted the procedures. The DI explained that to use fluoroscopy, physicians need to have a CDPH (California Department of Public Health) Fluoroscopy certification through the Radiological Health Branch. Physicians had to apply and pass an examination to get a certificate. When physicians are certified, they are allowed to perform fluoroscopy as approved by the state. The DI stated, “The certification signifies they are competent with radiation safety.” An interview was conducted on October 16, 2025, at 3:33 p.m., with the DMSS. The DMSS stated, “Delineation of privileges was specified, appointment and reappointment were outlined in the medical staff bylaws under Article 4. The DMSS stated Physician 1 had suspended fluoroscopy privileges. The DMSS stated Physician 1 had a temporary license and their credentialing software had not picked up the temporary license had expired. DMSS stated they run the expiration report monthly, but it failed to identify temporary licenses that expired. DMSS stated Physicians are required to take a test when applying for permanent renewable fluoroscopy license. A review of the facility’s undated document titled, “MEDICAL STAFF BYLAWS,” indicated, “ARTICLE 1 PURPOSE ...Purpose...These Bylaws are adopted in recognition of the mutual accountability, interdependence and responsibility of the Medical Staff and the Board of Directors in protecting the quality of medical care provided in the Hospital and assuring the competency of the Hospital’s Medical Staff...2.3 Particular Qualifications...2.3-1 Physicians...Except as otherwise provided in these Bylaws...(b) If a Member maintains board certification in a subspecialty, The Member need not renew board certification in the primary specialty; however, if the Medical Staff requires board certification in order to exercise Privileges in a particular subspecialty, the Member must be board certified in that subspecialty...ARTICLE IV PROCEDURES FOR APPOINTMENT AND REAPPOINTMENT...4.1 General...No person shall exercise Clinical Privileges in the Hospital unless and until that person applies for and receives appointment...or is otherwise granted Privileges as set forth in these Bylaws...””

“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: 50122 Based on interview and record review, the facility failed to complete transfer forms in accordance with the facility’s “Transfer - To Higher or Lateral Level of Care, Rehabilitation, or Skilled Nursing Facility,” policy and procedure (P&P), for two (Patients 10, and 11) of 54 sample patients when: 1 a. For Patient 10, was transferred to a board and care facility (board and care-a type of residential care home that provides housing and personal assistance to a small number of people who need help with daily activities but do not require skilled nursing care); and 1b. For Patient 11, was transferred to a skilled nursing facility (SNF - a healthcare setting that provides 24-hour medical care and rehabilitation services to individuals who require assistance with daily activities and medical treatments). This failure had the potential to jeopardize the well-being and safety of the patients after discharge. Findings: On October 14, 2025, an unannounced visit was conducted at the facility for a complaint validation survey. On October 15, 2025, at 9:35 a.m., a review of Patient 10’s medical record was conducted with the Quality Clinical Effectiveness Coordinator (QCEC) 1, and Quality Clinical Effectiveness Coordinator (QCEC) 2. 1a. A review of the facility document titled, “History and Physical,” dated August 2, 2025, at 4:17 p.m., was conducted. The document indicated Patient 10 had a medical history of Diabetes (a chronic condition characterized by high glucose levels), End Stage Renal disease on hemodialysis (permanent loss of kidney function that requires a machine to filter waste and excess fluid from the blood), was bed bound (not able to walk and confined to a bed), and hypertension (elevated blood pressure). It further indicated Patient 10 was admitted to the facility on August 2, 2025, for urinary retention (a condition where a person is unable to completely or partially empty their bladder). A review of the facility document titled, “Discharge Request,” dated August 21, 2025, at 10:09 a.m., was conducted. The document indicated an order for Patient 10 to be discharged “...Home with Home Health [medical care provided in a patient’s home to treat an illness, injury, or chronic condition]...” A review of the facility document titled, “Discharge Summary,” dated August 26, 2025, at 11:30 a.m., indicated, “...discharged to custodial SNF [skilled nursing facility]...Plan for DC [discharge] to B&C [board and care facility] today...” There was no documented evidence of a transfer form or documentation related to the transfer of the patient to the board and care facility. 1b. On October 15, 2025, at 9:35 a.m., a review of Patient 11’s medical record was conducted with the Quality Clinical Effectiveness Coordinator (QCEC) 1, and Quality Clinical Effectiveness Coordinator (QCEC) 2. A review of the facility document titled, “History and Physical,” dated, September 29, 2025, at 10:22 p.m., was conducted. The document indicated Patient 11 had a medical history of urinary tract infection (infection of the kidneys, ureters, bladder, and urethra), anemia (low red blood cell count in the blood), and hypertension (elevated blood pressure). It further indicated Patient 10 was admitted to the facility on September 29, 2025, for chest tightness. A review of the facility document titled, “Orders for Signature,” dated October 7, 2025, at 2:07 p.m. was conducted. The document indicated a discharge request to a SNF. A review of the facility document titled, “Discharge Summary,” dated October 7, 2025, at 2:09 p.m., was conducted. The document indicated Patient 11 was discharged to [name of facility] SNF. A review of the facility document titled “Progress Note-Nurse,” dated October 7, 2025, at 3:10 p.m., was conducted. The document indicated, “...[Name of Registered Nurse (RN) 2]...Called report to [name of accepting facility nurse] at [name of facility] at 1510 [3:10 p.m.]...” There was no documented evidence of a transfer form in Patient 11’s medical record. On October 16, 2025, an interview was conducted with the Director of Quality and Education (DQE). The DQE stated, “...they do not have a transfer form when a patient transfers to a facility or skilled nursing...the policy needs to be changed...” A review of the P&P titled, “Transfer - To Higher or Lateral Level of Care, Rehabilitation, or Skilled Nursing Facility,” revised March 10, 2025, was conducted. The P&P indicated, “...Physician signature will be obtained on transfer summary and a copy given to patient and/or patient’s legal representative...Registered Nurses on discharging units will complete the appropriate transfer form and have the physician sign. The Registered Nurse will send original copies of the transfer form to SNF...place a copy on patient’s chart and give patient and/or legal representative a copy...””

“GENERAL BLOOD SAFETY ISSUES CFR(s): 482.27(c) General blood safety issues. For lookback activities only related to new blood safety issues that are identified after August 24, 2007, hospitals must comply with FDA regulations as they pertain to blood safety issues in the following areas: (1) Appropriate testing and quarantining of infectious blood and blood components. (2) Notification and counseling of recipients that may have received infectious blood and blood components. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to administer blood or blood products safely to one patient (Patient 11) when an incompatible unit was dispensed and transfused prior to accurate completion of antibody testing. This failure had the potential to jeopardize the health, well-being, and safety of the patient. Findings: On October 14, 2025, an unannounced visit was conducted at the facility for a complaint validation survey. On October 15, 2025, at 9:35 a.m., a review of Patient 11’s medical record was conducted with the Quality Clinical Effectiveness Coordinator (QCEC) 1, and Quality Clinical Effectiveness Coordinator (QCEC) 2. A review of the facility document titled, “History and Physical,” dated, September 29, 2025, at 10:22 p.m., was conducted. The document indicated Patient 11 had a medical history of urinary tract infection (infection of the kidneys, ureters, bladder, and urethra), anemia (low red blood cell count in the blood), and hypertension (elevated blood pressure). It further indicated Patient 10 was admitted to the facility on September 29, 2025, for chest tightness. A review of the facility document titled, “Orders,” dated September 29, 2025, at 7 p.m., was conducted. The document indicated an order for ABO Rh (a medical request to determine a patient’s blood type before a transfusion) for a unit of blood products for Patient 11. A review of the facility document titled, “PATIENT CONSENT TO BLOOD OR BLOOD PRODUCT TRANSFUSION,” dated September 29, 2025, at 11:26 p.m. was conducted. The document indicated consent for blood transfusion was given by [name of family of Patient 11]. A review of the facility document titled, “Transfusion Summary,” dated September 29, 2025, at 7:06 p.m., was conducted. The document indicated, two units of red blood cells were ordered, and one unit was ready for transfusion. A review of the facility document titled, “...Navigator...Transfusion Reaction Workup,” dated September 29, 2025, at 9:20 p.m., was conducted. The document indicated, “...ABO-Rh 1...A POS [The patient has A positive blood. The red blood cells have A antigens and the Rh (D) antigen on their surface]...ABSC Gel...Positive [The antibody screen is positive, indicating that the patient has one or more antibodies against red blood cell antigens. The gel method is a common way to perform this test]...Antibody ID...Anti-E, Anti c, Anti-E [The specific antibodies detected are anti-E and anti-c. These are both IgG antibodies (a type of antibody, a protein produced by the immune system to fight infections) belonging to the Rh blood group system (a classification of blood based on the presence or absence of specific proteins (antigens) on the surface of red blood cells)]...Pt Antigen Type 1...E-, c-, K-, JkA+ [The patient’s own red blood cells lack the E, c, and K antigens. However, they do have the JkA (Kidd) antigen-A patient with these results requires careful blood matching for any future transfusions to ensure that the donated blood does not contain the E or c antigens. This specialized matching helps prevent a serious transfusion reaction where the patient’s antibodies would attack the new red blood cells]...” A review of the facility document titled, “PathNet BB Transfusion: Patient Product Inquiry...,” dated September 30, 2025, at 1:41 a.m., indicated, “...Blood Bank ID...JCG6074...”, a unit of red blood cells, was crossmatched by a laboratory technician. The document indicated on September 30, 2024, at 3:04 a.m., “...Blood Bank ID...JCG6074...” was dispensed for transfusion. A review of the facility document titled, “Transfusion Summary,” dated September 30, 2025, at 3:13 a.m., was conducted. The document indicated, “...Unit Number...W180625474417...RBC AS-1 500 mL [milliliter - unit of measurement] LR [a unit of red blood cells collected from a 500ml whole blood donation and stored in an AS-1 (Adsol) additive solution, which has also undergone a leukoreduction (LR-the process of removing white blood cells (leukocytes) from blood products before a transfusion to reduce the risk of adverse reactions and transmission of infections) process]...Event...Start...Date...9/30/2025 [September 30, 2025]...3:12 PDT [Pacific Daylight Time]...By...[name of RN 3]...End...9/30/2025 [September 30, 2025]...06:23 PDT...By...[name of RN 3]...” The document indicated the transfusion was completed at 6:23 a.m. A review of the facility document titled, “Progress Note,” dated September 30, 2025, at 3 p.m., was conducted. The document indicated, “...Received 1 unit of PRBC’s [packed red blood cells], blood bank discovered antibody not previously found on original crossmatch...Patient upgraded to PCU [progressive care unit-a hospital unit that provides a level of care between a standard medical-surgical floor and an Intensive Care Unit (ICU)] for close monitoring for delayed transfusion reaction...” A review of the facility documents titled, “Progress Note - Nurse,” dated September 30, 2025, at 5:01 p.m., was conducted. The document indicated, “...Nurse practitioner at bedside explaining to the patient and the patient’s husband about the concerns of the blood transfusion administered earlier today...” On October 15, 2025, at 2 p.m., an interview was conducted with the Director of Laboratory Services (DLS). The DLS stated, “...When a physician orders a Type and Screen, they look for a history of an ABO Rh to prevent a mismatch...if no history of a type and cross, they obtain a second sample from the patient...if screen is positive, they will identify the antibody...based on these results, they report a crossmatch to a unit of blood...the second antibody was not identified in the affected patient...the crossmatching tech would let them know the unit is incompatible...the potential miss was with crossmatch...risk for human error exists. Tried to go back to determine what was missed...could not find out why they determined compatible initially...They wouldn’t have known it was incompatible until the second tech saw the changes in the specimen...I was notified about 9 a.m., that they gave an incompatible unit of blood...” The DLS stated, they notified the medical director of laboratory services, and he notified the physician and the patient. On October 16, 2025, at 3 p.m., an interview was conducted with the laboratory technician (LT). The LT stated, “...her process is to review all work ups completed previously...view positive screens and identify the antibodies...what I found identified the need for additional workup...once I looked further, it extended the workup process...I confirmed the reactions and ran additional cells and conducted antigen typing...” The LT determined there were antibodies found on her screening that were not initially found on the initial crossmatch. She then escalated the situation. A review of the facility policy and procedure (P&P) titled, “Patient’s Rights and Responsibilities,” revised on February 14, 2022, was conducted. The P&P indicated, “...Considerate, respectful care in a safe setting...The patient has the right to expect reasonable safety insofar as Hospital practices...are concerned...” A review of the facility P&P titled, “Dispense and Return (Unused) Blood Products,” dated January 11, 2021, was conducted. The P&P indicated, “In order for a blood product to be issued to a patient for transfusion, systems are in place to document...conditions of the product at all times, thus safeguarding all qualities of the product...Guaranteeing that the correct blood component is being issued to the correct patient is paramount in averting a transfusion catastrophe...These systems...verify the transfusion recipient’s blood type, component blood type...crossmatch standing, and other serologic information...” A review of the facility document titled, “Crossmatch Testing,” reviewed February 13, 2023, was conducted. The document indicated, “...Selection of Donor Blood for Patients with Unexpected Antibodies...Notify patients’ nurse or physician of anticipated delays...Complete antibody identification before issuing blood...Patients whose plasma, serum, or history contains...reactive clinically significant antibody (including anti-D, -C, -c, -E, -e, -K...-Jka...) must receive units that have been typed and found negative for the corresponding antigen...Samples with clinically significant antibodies...should be referred to the American Red Cross reference laboratory for antibody identification / confirmation and to obtain antigen negative or compatible blood...””

“SURGICAL PRIVILEGES CFR(s): 482.51(a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service must maintain a roster of practitioners specifying the surgical privileges of each practitioner. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to ensure services provided to patients met standards of care for one (Patient 20) of 54 sample patients, when Physician 1 performed an Ion bronchoscopy (robotic-assisted bronchoscopy...invasive procedure used to examine and biopsy lesions in the lungs...), on Patient 20, while Physician 1’s temporary fluoroscopy certificate and approved privileges were expired. This failure compromised Patient 20’s safety and caused complication during the procedure. Findings: On October 14, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility for a complaint validation survey. On October 15, 2025, at 2:35 p.m., Patient 20’s medical record was reviewed with the Director Risk Management (DRM), and Clinical Effectiveness Coordinator (CEC) 3. The record indicated Patient 20 arrived to the facility on December 13, 2024, for an Ion Bronchoscopy for a right upper lobe nodule concerning for malignancy. It further indicated Patient 20 had the procedure performed by Physician 1, developed a pneumothorax [Collapsed Lung], and had a cardiac arrest. A review of the facility document received from the Director of Imaging (DI) on October 16, 2025, at 3:07 p.m., indicated, “An Ion bronchoscopy...Potential Complications...2. Pneumothorax [Collapsed Lung]. Air leaks into the space between the lungs and chest wall...May require observation or a chest tube.” An interview was conducted on October 14, 2025, at 9:48 a.m., with the Director Medical Staff Services (DMSS). The DMSS stated they (the facility) conducted record reviews and determined there were no noted patient harm from the procedures Physician 1 performed while temporary fluoroscopy certificate and approved privileges were expired. An interview was conducted on October 15, 2025, at 10:05 a.m., the DMSS. The DMSS stated Physician 1 had a total of 20 procedures requiring fluoroscopy completed on December 6, 2024, through August 14, 2025. The DMSS stated, “Yes, the physician needs a fluoroscopy license to conduct procedures requiring imaging and there are potential complications.” An interview was conducted on October 16, 2025, at 9:25 a.m., with the Director of Quality and Education (DQE). The DQE stated a peer review was conducted regarding Patient 20’s death. The DQE further stated she was not aware if the incident had been reported as an unusual occurrence. An interview was conducted on October 16, 2025, at 9:50 a.m., with the DI. The DI stated during an Ion Bronchoscopy, a possibility and potential complication can occur. DI stated that during a biopsy, a pneumothorax (a known complication of bronchoscopy with transbronchial biopsy, occurring when the lung is accidentally punctured, causing air to leak into the space between the lung and chest wall) can occur because there is a needle that is removing lung tissue. An interview was conducted on October 16, 2025, at 3:33 p.m., with the DMSS. The DMSS stated, “Delineation of privileges was specified, appointment and reappointment was outlined in the medical staff bylaws under Article 4. The DMSS stated Physician 1 had suspended fluoroscopy privileges. DMSS stated Physician 1 had a temporary license and their (the facility) credentialing software had not picked up the temporary license that expired. DMSS stated they run the expiration report monthly, but it failed to identify temporary licenses that had expired. DMSS stated Physician 1 is required to take a test when applying for permanent renewable fluoroscopy license.”

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to follow their policy and procedure of reporting an adverse event to the state agency in a timely manner for six patients (Patients 1, 2, 3, 4, 5, and 6), when a sterilization breach occurred. This failure had the potential to cause further complications to the patient, multiple procedures, and/or death. Findings: On July 17, 2025, at 3:23 p.m., the facility reported to the state agency, a sterilization breach that occurred at the facility on April 25, 2025. On July 28, 2025, at 2:49 p.m., a concurrent interview and record review were conducted with the Chief Nurse Officer (CNO), Clinical Effectiveness Coordinator (CEC) 1, and Scribe (S) 1 (S 1). The CNO stated, “We narrowed it down after conducting an investigation, there were six patients that may have been affected by the breach. The enzymatic cleaning solution, in a multi-step cleaning process, was switched out unintentionally with lubricant, the second enzymatic cleaning cycle was omitted, the instruments used did go through the sterilization process.” The CNO further stated Test Object Surgical Instrument (TOSI) passed, all six charts were reviewed, staff and physicians’ were interviewed, a root cause analysis (RCA), and improved process improvement measures were in place. The CNO stated disclosure was completed for all six patients, and testing was offered. On July 31, 2025, at 9:12 a.m., an interview was conducted with the CNO. The CNO stated this was not reported to the state agency because they (the facility) referenced the adverse event list and it did not fall under the category. A review of the facility Policy and Procedure (P&P) titled, “Event Reporting,” dated June 9, 2025, was reviewed. The P&P indicated, “...Occurrence...That which is not consistent with routine care of patient and/or the desired operations of the facility. The results of this event require or could have required (closed call/near miss) unexpected medical intervention, unexpected intensity of care, or causes or had the potential to cause an unexpected physical or mental impairment...Unsafe Condition, could lead to patient safety event; potential for error...Reporting to the State Department of Health Services (if required by state law)...Events will be reported to the State Department of Health as required by state law and regulation...” A review of the “...California Code of Regulations...Title 22, §70972...Adverse Event Reporting Requirements...Pursuant to Health and Safety Code sections 1279.1 and 1279.3...adverse events shall be reported by the hospital through a secure internet website maintained by the Department pursuant to the following timelines...Adverse events that are ongoing urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported within 24 hours after the adverse event is detected...All other adverse events shall be reported to the Department no later than five (5) calendar days after the adverse event is detected...””

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 45431 Based on interview and record review, the facility failed to perform a surgical procedure in a timely manner for one of 21 sample patient (Patient 19). This failure caused a delay in care, extended hospital stay, emotional stress, and potentially worsening medical condition. Findings: A review of Patient 19’s medical record was conducted on July 29, 2025, at 1:16 p.m., with Scribe (S) 1 and S 2. A facility document titled, “History and Physical,” dated July 19, 2025, at 6:28 p.m., was reviewed. The document indicated, “...History of present illness...past medical history of recently diagnosed cholelithiasis [the presence of one or more calculi (gallstones) in the gallbladder ] a month ago, eclampsia [a pregnancy disorder characterized by high blood pressure and protein in the urine], C-section [cesarean section, surgical procedure where a baby is delivered through incisions in the mother’s abdomen and uterus] 10 weeks ago, presenting with right upper quadrant pain...General surgery was consulted, plan possible cholecystectomy [surgical removal of the gallbladder] today or tomorrow...The patient will be admitted for further evaluation and management of possible cholecystitis [inflammation of the gallbladder] and choledocholithiasis [a condition where one or more gallstones are present in the common bile duct]...” A facility document titled, “Orders,” dated July 21, 2025, was reviewed. The document indicated,”...Diet Type...Regular...Diet Parameter...Fat Restriction...Advance as tolerated...Yes...Special Instructions...Low Fat diet...” A facility document titled, “Intake and Output Print Request,” dated July 20, 2025, through July 22, 2025, was reviewed. The document indicated Patient 19’s last meal was on July 20, 2025, between 2 p.m. to 2:59 p.m. A facility document titled, “Progress Note-Physician,” dated July 20, 2025, at 11:28 a.m., was reviewed. The document indicated, “...Clinical presentation is consistent with cholelithiasis and acute cholecystitis. Nonemergent laparoscopic cholecystectomy is indicated, however due to ultrasound findings, MRCP [Magnetic Resonance Cholangiopancreatography - medical imaging that takes detailed pictures of the bile and pancreatic ducts] is recommended to rule out further hepatobiliary disease prior to the procedure...She is eager to go home as she has twin sons that she is breast feeding. Surgery following...” A facility document titled, “Progress Notes-Physician,” dated July 21, 2025, at 5:14 a.m., was reviewed. The document indicated, “...MRCP positive. ERCP [endoscopic retrograde cholangiopancreatography, a procedure that examines and treats problems in the bile and pancreatic ducts] pending today...” A facility document titled, “Progress Notes- Physician,” dated July 22, 2025, at 10:48 a.m., was reviewed. The document indicated, “...She underwent EUS [Endoscopic ultrasound - a minimally invasive procedure that combines endoscopy and ultrasound to examine the digestive tract and surrounding organs] yesterday. EUS showed in CBD [common bile duct] and ERCP followed. ERCP demonstrated dominant major papilla with no stone in the CBD and sphincterotomy [a procedure, typically performed during endoscopic retrograde cholangiopancreatography (ERCP), where a small incision is made in the sphincter of Oddi, a muscle at the junction of the bile and pancreatic ducts with the small intestine] was done...scheduled to undergo laparoscopic cholecystectomy on 07/23 [July 23] evening. However, she has 11 week old twins and is lactating mother with the wait for scheduling being a source of frustration...Plan for laparoscopic cholecystectomy pending OR [Operating Room] availability if patient wants to stay...Attending Attestation...Pt upset that there is a delay in scheduling surgery. I had explained that there is short staffing pushing surgeries to very late into the evening, which is generally reserved for emergency procedures. I do not feel it is safe to perform a non-emergent cholecystectomy in the middle of the night with skeleton staffing who have already been working 12+ hours. I am unable to schedule her elective surgery as an outpatient due to her insurance. Alternatively, she is to FU [follow up] at [Name of another facility], should she not want to wait for surgery. They will discuss. Surgery team will continue to follow and offer surgery once OR is available...” A facility document titled, “[Facility Name] Main OR-Operating Room Schedule,” dated July 23, 2025, was reviewed. The document indicated, “...2000[8 p.m.]...Inpatient...[Patient 19] add-on...Yes...Procedure detail...Cholecystectomy Laparoscopic...[Name of MD 2]...” An interview was conducted on July 29, 2025, at 1:55 p.m., with the Perioperative Director (PD) and Perioperative Manager (PM). The PD stated they use five OR rooms daily for scheduled and add-on (a procedure that is scheduled after the initial operating room schedule has been finalized) surgery cases. The PD further stated the provider (doctor) can call the surgery scheduler to schedule an add-on case 24/7 (24 hour/7 days a week). The PM stated the OR has scheduled on call staff consisting of a Registered Nurse circulator, a surgery technician and an anesthesia (use of medications (called anesthetics) to keep you from feeling pain during procedures or surgery) provider daily beginning at 5 p.m. or 7 p.m. for a 12-hour shift. A facility document titled, “[Facility Name] Main OR-Operating Room Schedule,” dated July 1, 2025, through July 23, 2025, was reviewed. The document indicated add-on surgery cases were added on to the schedule and performed between 7:30 p.m. and 1:05 a.m. A concurrent interview and record review were conducted on July 29, 2025, at 2:29 p.m., with the PD. The facility document titled, “[Facility Name] Main OR-Operating Room Schedule,” dated July 21, 2025, through July 22, 2025, indicated the OR was using two OR rooms on July 21, 2025, and five OR rooms on July 22, 2025, for surgery cases. The PD stated Patient 19 could have been added on to these two rooms after scheduled cases were finished. The PD further stated he verified with the surgery scheduler, the Medical Doctor (MD 1) did not call them to add the patient [Patient 19] to the surgery schedule between July 21, 2025, through July 22, 2025. A review of the facility untitled document, dated July 19, 2025, through July 22, 2025, was conducted on July 29, 2025, at 2:47 p.m., with the PM. It indicated, “...C= Gen [general] Call...Gen and Heart call starts at 1700 [5 p.m.] - 0630 [6:30 a.m.] (M-F) [Monday - Friday]...” An interview was conducted on July 29, 2025, at 2:29 p.m., with the PM. The PM stated the document was the OR on-call schedule and they had on-call staff scheduled daily. An interview was conducted on July 29, 2025, at 2:58 p.m., with MD 1. MD 1 stated there was an anesthesia shortage, the surgery was non emergent and when MD 1 escalated the situation to the Chief of Operation, (COO), Chief of Surgery and the PD, the consensus was it was unnecessary to “bump” a surgery case because “...gallbladder surgery is not a life-threatening emergency. It’s urgent but not emergent...” An interview was conducted on July 29, 2025, at 3:24 p.m., with the COO and the Chief Nurse Officer (CNO). The COO stated he was made aware of Patient 19’s situation by MD 1 on July 22, 2025. The COO stated, per MD 1 Patient 19’s surgery was not an emergency and will not necessitate to “bump” a scheduled surgery case. The COO further stated, “...we could have potentially done the case earlier because we have the staff (OR staff) and Anesthesia on call...” The CNO stated, “... MD 1 was part of a larger group and could have reached out to her peer group/department or to the chair and find another surgeon to do the surgery...” An interview and record review were conducted on July 29, 2025, at 3:42 p.m., with the PD. The untitled document dated July 22, 2025, indicated the CRNA (Certified Registered Nurse Anesthetist - registered nurse who has completed advanced education and training to administer anesthesia) work schedule. The PD stated there were Anesthesia provider on-call staff scheduled and available. An interview and record review were conducted on July 29, 2025, at 3:43 p.m., with the Kaiser Permanente Case Manager (KPCM). The facility document, “Case Management Notes,” was reviewed. The record did not indicate documented evidence that KPCM were aware of the delayed surgery. The KPCM stated Patient 19’s case should have been discussed with the KP interdisciplinary team and inform them that this patient [Patient 19] was only waiting for surgery and possibly request for a transfer to an appropriate medical center. An interview was conducted on July 29, 2025, at 3:50 p.m., with the Kaiser Permanente Manager (KPM). The KPM stated the normal length of stay of a patient without serious complications undergoing a Laparoscopic Cholecystectomy was 1 to 2 days. KPM further stated the expectation was to ensure the KPCM team had close contact with the provider for updates on the plan, in this case KPCM should have helped coordinate to find another team or doctor to do the surgery instead of the patient waiting. A review of the facility’s Medical Staff Bylaws, dated April 11, 2022, indicated, “...Responsibilities of Membership...Each member of the Medical Staff must continuously comply with the provisions of these By laws, and Medical Staff Rules and Regulations, and Medical Staff Policies...Members must also: Provide continuous and timely care to all patients for whom the Practitioner maintains responsibility...””

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to implement their “Informed Consent,” policy for one of 21 sample patients (Patient 4), when a consent for surgery and anesthesia were not completed prior to the procedure. This failure resulted in being Patient 4 having a surgical procedure and anesthesia performed, without written consent. Findings: On July 30, 2025, at 9:36 a.m., a review of Patient 4’s medical record was conducted with the Clinical Effectiveness Coordinator (CEC) 1 and 2. A review of the facility document titled, “History and Physical,” dated April 24, 2025, at 3:20 p.m., was reviewed. The document indicated, “...history of kidney stones, biliary sludge [particles that precipitate out of bile and can be found in the gallbladder]...who presents...with complaints of acute onset abdominal pain...” A review of the facility document titled, “Operative Reports,” dated April 26, 2025, at 12:24 p.m., was reviewed. The document indicated, “...Indication for surgery....acute cholecystitis [inflammation of the gallbladder] necessitating a cholecystectomy [removal of the gallbladder]...Preoperative Diagnosis...acute cholecystitis...Postoperative Diagnosis...Same...” A review of the facility undated document titled, “Preprocedure Checklist,” was reviewed. The document indicated, “...Procedural Forms...Procedural Consent Signed...Anesthesia Consent Signed...Blood Consent Signed...” all left blank. There was no documented evidence of a consent for surgery, and anesthesia were completed, signed and placed in Patient 4’s medical record. On July 30, 2025, at 11:01 a.m., an interview was conducted with the Clinical Effectiveness Coordinator (CEC) 1 and 2. CEC 1 and 2 stated the consent for the surgical procedure and anesthesia were not found in Patient 4’s medical record. A review of the facility Policy and Procedure (P&P) titled, “Consents,” dated January 13, 2025, was reviewed. The P&P indicated, “...Informed consent is a process of communicating between a treating practitioner and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention...It is the responsibility of the treating provider to apprise the patient of nature, risks and alternate of a medical procedure or treatment before the treatment provider or healthcare professional begins any course...A licensed healthcare professional from the Hospital may witness the patient/legal representative sign the consent...All signed consents forms shall be placed in the medical chart...””

“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 the facility’s policies and procedures (P&P) were implemented, for five of 30 sample patients (Patients 6, 19, 22, 24, and 29), when: 1. For Patient 6, Oxygen therapy (treatment that provides extra oxygen to help breathe better when the body isn’t getting enough on its own) was administered without a physician order (Refer to A-0398); 2. For Patient 22, a central venous catheter (a thin, flexible tube that’s inserted into a vein in the neck, chest, arm, or groin and threaded into a large vein above the heart) was inserted without a physician order (Refer to A-0398); 3. For Patient 29, a lumbar puncture (procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid) was performed without a physician order (Refer to A-0398); 4. For Patients 6, and 24, Translation Services were not utilized for the non-English speaking patient (Refer to A-0398); 5. For Patient 6, and 29, Universal Protocol (UP, process used to identify the correct patient, the correct procedure, the correct proceduralist and the correct site) was not completed prior to an invasive procedure (a medical treatment where tools such as needles, tubes, or surgical instruments are used to diagnose or treat a condition) (Refer to A-0398); 6. For Patient 19, the discharge paperwork placed in the medical record was missing a signature from a witness. (Refer to ....) The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may cause delays in the provision of patient care.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48776 Based on interview, and record review, the facility failed to ensure informed consents (a process where the patient gives permission for a treatment or procedure after risks, benefits and alternatives are explained) and facility transfer forms were fully completed prior to transfer to another facility, and an invasive procedure (a medical treatment where tools such as needles, tubes, or surgical instruments are used to diagnose or treat a condition), for seven of 30 sampled patients (Patients 6, 8, 20, 22, 26, 27, and 29), when: 1. For Patients 6, 8, 20, 22, 26, 27, and 29, informed consent forms were not completed prior to invasive procedures; 2. For Patient 20, consent for transfer to another facility was not obtained prior to transfer. These failures had the potential to result in patients, or their responsible parties, not having the information needed to make informed decisions regarding their procedures and medical treatment. Findings: 1a. On January 8, 2025, at 10:30 a.m., a concurrent interview and review of Patient 6’s record was conducted with the Manager of the Orthopedic Program (MO). A facility document titled, “History and Physical (H&P),” dated September 28, 2024, indicated Patient 6 was admitted to the facility for worsening shortness of breath, and transaminitis (higher than normal levels of liver enzymes in the blood due liver irritation and/or inflammation). A facility document titled, “Progress Note-Physician,” dated October 2, 2024, was reviewed, and indicated. “...I [Name of Physician (MD 1)], discussed the purpose and indications with the patient regarding placement of a peripherally inserted central catheter (PICC, a long, thin flexible tube inserted into a vein in the arm used to deliver medications or fluids into the bloodstream or to draw blood). The purpose of placement is for IV [intravenous] Antibiotics...I explained the risks of the procedure which included...I explained the procedure in detail and drew out a diagram demonstrating the steps of the procedure and how it will be completed...The patient is of sound mind and judgement and is able to provide consent for the procedure...All questions have been answered and the patient understands all risk and benefits...The patient [Name of Patient 6] has provided oral consent to the procedure...” A facility document titled, “Nursing Admission Assessment” dated September 28, 2024, was reviewed, and indicated, Patient 6’s primary language was “Punjabi (language spoken by people from the Punjab region of India and Pakistan).” The MO stated an interpreter, utilizing the facility approved services, should have been utilized to obtain the PICC line consent and the physician should not be utilized as an interpreter. On January 8, 2025, at 1 p.m., an interview was conducted with the Quality Supervisor (QS). The QS stated GLOBO (interpreters language services)/translator line should have been utilized for obtaining the PICC line consent for Patient 6. The QS stated MD 1 should not have been utilized for translation. On January 8, 2025, at 2:20 p.m., an interview was conducted with MD 2. MD 2 stated Patient 6 spoke Punjabi. MD 2 stated all procedures were explained in detail to the patient by MD 1 who spoke the same language as the patient. A review of Policy & Procedure (P&P), titled, “[Name of Facility] Interpreter - Language Access for Limited English Proficient (LEP) and Hearing- Impaired Patients,” dated October 2022, was conducted. The P&P indicated, “...The hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients, and their surrogate decision makers for those with LEP and/or sensory impairments to ensure they have services provided to them in their primary language or have interpreter services provided to them during the delivery of healthcare services...If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations, conveying/ receiving simple messages, or for basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent [permission for a medical procedure after understanding risks, benefits, and alternatives] requires the use of a qualified medical interpreter available through the contracted language services provider...LEP Needs...GLOBO interpreters services can be used...” A facility document titled, “Procedure Note,” dated September 30, 2024, was reviewed, and indicated, Patient 6 underwent a thoracentesis (a procedure where a needle is used to remove fluid from around the lungs). No written form for consent or documentation of consent was found in the medical record. The MO stated there was no documented evidence a consent was obtained prior to Patient 6’s thoracentesis. On January 8, 2025, at 2:35 p.m., an interview was conducted with the QS. The QS stated a consent for the thoracentesis should have been obtained prior to Patient 6’s thoracentesis and this was not done. A review of P&P, titled, “[Name of Facility] Consents,” dated May 2024, was conducted. The P&P indicated, “...Informed consent is a process of communication between a treating practitioner and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention...The hospital may not permit any treatment unless the patient, or legally authorized representative has consented to the treatment...Established processes are in place to ensure that prior to conducting the informed consent discussion, the patient/legal guardian’s preferred language is identified, and a medical interpreter is provided, and the consent form or electronic medical record indicated whether an interpreter was used...It is the treating physician’s duty to obtain informed consent...The physician will explain to the patient (or appropriate surrogate decision maker)...The nature of the treatment or procedure...The risks, complications and expected benefits or effects of the procedure...Any alternatives to the treatment/procedures and their risks and benefits...If this required documentation is absent, the procedure will not be allowed...The physician must document in the medical record that he/she explained the nature of the treatment, its risk and benefits, and the alternatives and their risk and benefits, and that the patient (or surrogate decision maker) consented to have the procedure...This documentation is evidence for the patient ,the hospital and the physician that informed consent has been obtained prior to the procedure...By signing the “consent” form, the patient acknowledges that the physician adequately explained the operation or procedure to the patient and gave the patient all the information he or she desired...The informed consent form may be evidence for the patient, hospital and the physician that informed consent was obtained prior to the procedure...” A facility document titled, “Procedure Note,” dated October 2, 2024, was reviewed, and indicated, Patient 6 underwent a central line placement (a procedure where a thin, flexible tube is inserted into a large vein, usually in the neck or chest and is used to give medications or fluids directly into the bloodstream or to draw blood). No written form for consent or documentation of consent was found in the medical record. The MO stated consent should have been obtained prior to Patient 6’s central line placement. On January 8, 2025, at 2 p.m., an interview was conducted with MD 3. MD 3 stated they were informed a consent form for the central line had already been completed. MD 3 stated there should always be a consent present in the chart prior to a central line placement. On January 8, 2025, at 2:35 p.m., an interview was conducted with the QS. The QS stated consent for central line placement should have been obtained prior to Patient 6’s central line placement and this was not done. 1b. On January 8, 2025, at 3:30 p.m., a concurrent interview and review of Patient 8’s record was conducted with the MO. A facility document titled, H&P, dated November 28, 2024, was reviewed, and indicated Patient 8 was admitted to the facility for gastrointestinal bleeding. A facility document titled, “Procedure Note,” dated November 28, 2024, was reviewed, and indicated, Patient 8 underwent an Arterial line placement (a thin tube placed into an artery used to monitor blood pressure continuously). A facility document titled, “AUTHORIZATION FOR AND CONSENT TO SURGERY OR SPECIAL DIAGNOSTIC OR THERAPEUTIC PROCEDURES,” dated November 28, 2024, was reviewed, and indicated, a “phone [telephone] consent” was obtained for the Arterial line. There was no documentation of who provided the telephone consent. Additionally, there was no signature on the “Witness” line. The MO stated the consent should have been witnessed by a hospital employee and the name of the person whom the physician spoke to, in order to obtain telephone consent should have been documented in the medical record however, this was not done. A facility document titled, “Procedure Note,” dated November 28, 2024, was reviewed, and indicated, Patient 8 underwent a Central Venous Catheter placement (a procedure where a thin, flexible tube is inserted into a large vein, usually in the neck or chest and is used to give medications or fluids directly into the bloodstream or to draw blood). A facility document titled, “AUTHORIZATION FOR AND CONSENT TO SURGERY OR SPECIAL DIAGNOSTIC OR THERAPEUTIC PROCEDURES,” dated November 28, 2024, was reviewed, and indicated, a “phone [telephone] consent” was obtained for the Central Venous Catheter. There was no documentation of who provided the telephone consent. Additionally, there was no signature on the “Witness” line. The MO stated the consent should have been witnessed by a hospital employee and the name of the person whom the physician spoke to in order to obtain consent should be documented in the medical record however, this was not done. On January 8, 2025, at 3:45 p.m., an interview was conducted with the QS. The QS stated the Arterial line and Central line consents for Patient 8 should have the name of the person whom the physician obtained the verbal/telephone consent and should have been witnessed by a staff member and this was not done per the facility’s policy. 1c. On January 7, 2025, at 3:25 p.m., a concurrent interview and record review of Patient 20’s record was conducted with the QS and the Cardiac Services Manager (CSM). A review of the facility document titled, “History and Physical,” dated October 30, 2024, at 6:39 p.m., indicated Patient 22 had a history of squamous cell carcinoma (A type of cancer that can affect the skin, respiratory tract or digestive tract) of the tongue, and thyroid disease, and was admitted to the facility for a fall and weakness. On January 7, 2025, at 3:28 p.m., a review of the facility document titled, “Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures,” dated November 1, 2024, at 1:22 p.m., indicated a consent for Central Line Placement. The document further indicated there was no witness signature, no signature or verification of documentation with the Licensed Healthcare Provider, and no signature from Patient 22, a family member or a witness. The document further indicated, “emergent” written under Physician Certification with MD 3 signature and signature of RN. On January 7, 2025, at 3:30 p.m., a review of the facility document titled, “Procedure Note,” dated November 1, 2024, at 7:19 a.m., authored by MD 3, indicated a right femoral vein central venous catheter insertion was completed by MD 3. Documentation further indicated, “...Consent was obtained from the patient, indications risks and benefits were explained at length...” There was no documentation to indicate the procedure was done emergently or that any delay in treatment would jeopardize the health of the patient. On January 8, 2025, at 10:30 a.m., an interview was conducted with the QS. The QS stated, “...the consent should have been filled out completely or a note documented by the physician indicating the delay of the procedure would jeopardize the patient’s health...” The QS further indicated there was no note in the patient’s chart indicating the procedure was initiated emergently or would jeopardize health of patient. 1d. On January 7, 2025, at 4 p.m., a concurrent interview and review of Patient 22’s record was conducted with the QS and the CSM. A review of the facility document titled, “History and Physical,” dated October 21, 2024, at 4:19 p.m., indicated Patient 22 was admitted to the facility for abdominal pain with history of ventral hernia. On January 7, 2025, at 4:05 p.m., a review of the facility document titled, “[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures,” dated October 23, 2024, at 8:40 a.m., indicated Central Line Placement with no name of patient documented on the first page of consent document. The document further indicated no signature for the Licensed Healthcare Provider and no witness signature under patient signature. On January 7, 2025, at 4:10 p.m., a review of the facility document titled, “[Name of Facility] Procedure Note,” dated October 24, 2024, at 9:46 p.m., indicated, “...Central Venous Catheter Procedure Details...Right Internal Jugular Vein Central Venous Catheter Placement...informed consent...taken and place in the chart...” was performed by MD 2. On January 8, 2025, at 8:30 a.m., an interview with the QS was conducted. The QS indicated, “...A signature from the witness, a signature from the healthcare provider acknowledging documentation of required elements in the chart, and consent document should have been filled out completely per policy...” 1e. On January 8, 2025, at 8:30 a.m., a concurrent interview and review of Patient 26’s record was conducted with the QS and the CSM. A review of the facility document titled, “History and Physical”, dated November 23, 2024, at 11:21 a.m., indicated, Patient 26 was admitted from a dialysis center due to not being able to receive hemodialysis (a treatment to filter wastes and water from your blood) due to bilateral leg weakness and shaking. Patient 26 had a history of Myocardial Infarction (a medical emergency that occurs when blood flow to the heart is suddenly cut off or reduced), Hemodialysis, and Diabetes (a chronic disease that occurs when the body doesn’t produce enough insulin or can’t use it properly). On January 8, 2025, at 9:30 a.m., a review of the facility document titled, “[Name of Facility] Consult Nephrology [the study of the kidneys],” dated November 23, 2024, at 5:06 p.m., indicated, “...Patient agreeable for HD [hemodialysis] for today, r/b [risks and benefits] discussed...” On January 8, 2025, at 9:35 a.m., a review of the facility flowsheet document titled, “Order for Hemodialysis”, dated November 23, 2024, at 4:53 p.m., indicated an order was placed for hemodialysis. On January 8, 2025, at 9:40 a.m., a review of the facility flowsheet document titled, “Hemodialysis”, dated November 23, 2024, at 10:10 p.m., indicated hemodialysis was conducted. On January 8, 2025, at 9:45 a.m., a review of the facility document titled, “[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures,” dated November 23, 2024, at 2 p.m., indicated, there was no signature from a witness for hemodialysis procedure. On January 8, 2025, at 9:50 a.m., an interview with the QS was conducted. The QS stated, “...there should have been a signature from the witness on the consent per facility policy.” 1f. On January 8, 2025, at 8:30 a.m., a concurrent interview and review of Patient 27’s record was conducted with the QS and the CSM. A review of the facility document titled, “History and Physical,” dated December 10, 2024, at 8:40 a.m., indicated Patient 27 was admitted to the facility with complaints of chest pressure. The document further stated Patient 27 had a history of Hemodialysis. On January 8, 2025, at 8:40 a.m., a review of the facility document titled, “Orders,” dated December 11, 2024, was at 6:50 a.m., indicated an order was placed for Hemodialysis for Patient 27. On January 8, 2025, at 8:42 a.m., a review of the facility document titled, “Consult-Nephrology,” dated December 11, 2024, at 10:16 a.m., indicated, “...plan for HD [Hemodialysis] today...” On January 8, 2025, at 8:45 a.m., a review of the facility document titled, “Nursing flowsheet-Hemodialysis,” dated December 13, 2024, at 4:20 p.m., indicated Hemodialysis was completed. On January 8, 2025, at 8:49 a.m., a review of the facility document titled, “[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures,” indicated no name of the patient, date, time, physician name, or signature of Licensed Healthcare Provider on the consent form. On January 8, 2025, at 9:01 a.m., an interview was conducted with the QS. The QS stated, “...the consent document should have been filled out completely and the name of the patient, date, time, and Licensed Healthcare Provider should have been filled out on the consent...” 1g. On January 8, 2025, at 10:40 a.m., a concurrent interview and review of Patient 29’s record was conducted with the QS and the CSM. A review of the facility document titled, “[Name of Facility]History and Physical,” dated January 1, 2025, at 4:02 p.m., indicated Patient 29 was admitted to the facility for a fall and with right sided weakness. On January 8, 2025, at 10:45 a.m., a review of the facility document titled, “ED Physician Record,” dated, January 1, 2025, at 1:49 p.m., by MD 1, indicated a lumbar puncture (a needle is inserted into the space between two back bones to retrieve cerebral spinal fluid) was performed and CSF (cerebral spinal fluid) was obtained. On January 8, 2025, at 10:50 a.m., a review of the facility document titled, “[Name of Facility] Authorization For And Consent To Surgery Or Special Diagnostic Or Therapeutic Procedures,” dated January 1, 2025, at 3 p.m., indicated no signature from Licensed Healthcare Provider or witness. On January 8, 2025, at 10:55 a.m., an interview was conducted with the QS. The QS stated, “...There should have been a witness signature and signature from a Licensed Healthcare Provider on the consent form...The policy was not followed...” On January 9, 2025, at 10:30 a.m., a review of the facility P&P titled, “[Name of Facility] Patient’s Rights and Responsibilities”, dated February 14, 2022, indicated, “...The patient or the patient’s designated representative has the right to receive as much information about any proposed treatment or procedure needed in order to make treatment decisions that reflect the patient’s wishes and give informed consent or to refuse the course of treatment. The patient has the right to know who is responsible for authorizing and performing the procedures or treatment...” On January 9, 2025, at 10:45 a.m., a review of the facility P&P titled, “[Name of Facility] Consents,” dated May 13, 2024, indicated, “...It is the responsibility of the treating provider to apprise the patient of nature, risks, and alternatives of a medical procedure or treatment before the treating provider...begins any course...the witness serves only as a witness to the signature on the consent form by the patient or decision maker...” The document further indicated, “...in the case of a medical emergency, treatment may proceed without the patient’s consent if the patient or his legal representative is unable to give consent...the attending physician shall...Determine if there is an appropriate surrogate decision-maker to make decisions on behalf of the patient...Document in the medical record that a delay in treatment would jeopardize the health of the patient...consent is obtained at a later time if at all possible...” A review of P&P, titled, “[Name of Facility] Consents,” dated May 2024, was conducted. The P&P indicated, “...Informed consent is a process of communication between a treating practitioner and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention...The hospital may not permit any treatment unless the patient, or legally authorized representative has consented to the treatment...Established processes are in place to ensure that prior to conducting the informed consent discussion, the patient/legal guardian’s preferred language is identified, and a medical interpreter is provided, and the consent form or electronic medical record indicated whether an interpreter was used...It is the treating physician’s duty to obtain informed consent...The physician will explain to the patient (or appropriate surrogate decision maker)...The nature of the treatment or procedure...The risks, complications and expected benefits or effects of the procedure...Any alternatives to the treatment/procedures and their risks and benefits...If this required documentation is absent, the procedure will not be allowed...The physician must document in the medical record that he/she explained the nature of the treatment, its risk and benefits, and the alternatives and their risk and benefits, and that the patient (or surrogate decision maker) consented to have the procedure...This documentation is evidence for the patient, the hospital and the physician that informed consent has been obtained prior to the procedure...By signing the “consent” form, the patient acknowledges that the physician adequately explained the operation or procedure to the patient and gave the patient all the information he or she desired...The informed consent form may be evidence for the patient, hospital and the physician that informed consent was obtained prior to the procedure...” A review of P&P titled, “[Name of Facility] Consents,” dated May, 2024, was conducted. The P&P indicated, “Consent By Other Means...The responsible physician or designee shall discuss the patient’s condition and the recommended treatment with patient’s legal representative for healthcare treatment...Telephone Consent...Telephone discussion between physician or designee and patient’s legal representative for health care treatment must be witnessed by a hospital employee...Documentation in the form of a signature from both the witness and the physician, of the telephone consent shall be on all forms for admission to the hospital and informed consent forms...” 2. On January 7, 2025, at 12:27 p.m., a concurrent interview and review of Patient 20’s record was conducted with the QS and the CSM. A review of the document titled, “Progress Note - Physician,” dated November 18, 2024, at 11:49 a.m., by MD 4, indicated “...Discharge Planning: Discharge to, Anticipated: Acute Care Facility...” No indication of transfer to accepting facility or accepting physician name was documented. On January 7, 2025, at 12:35 p.m., a review of the facility document titled, “Progress Note-Nurse”, dated November 18, 2024, at 10:23 p.m., indicated, “...[Name of facility] transport team at bedside at 2122 [9:22 p.m.], leaving with pt off unit at 2145 [9:45 p.m.]...” On January 7, 2025, at 1 p.m., an interview was conducted with the QS. The QS indicated, “...there was no transfer form found in the patients’ medical record...or documentation of accepting physician in the physician notes...” On January 9, 2025, at 10 a.m., a review of the facility P&P document titled, “[Name of Facility]...Transfer - To Higher or Lateral Level of Care, Rehabilitation, or Skill Nursing Facility,” dated June 10, 2024, indicated, “...Physician signature will be obtained on transfer summary and a copy given to patient and/or patient’s legal representative...The sending physician obtains an accepting physician. The physician must have a physician-to-physician report...A transfer report will be completed by the Registered Nurse on the discharging unit. A copy stays with chart...””

“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 (P&P) were implemented, for five of 30 sample patients (Patients 6, 19, 22, 24 and 29), when: 1. For Patient 6, Oxygen therapy (treatment that provides extra oxygen to aide in breathing) was administered without a physician order; 2. For Patient 22, a central venous catheter (a thin, flexible tube that is inserted into a vein in the neck, chest, arm, or groin and threaded into a large vein above the heart) was inserted without a physician order; 3. For Patient 29, a lumbar puncture (procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid) was administered without a physician order; 4. For Patients 6 and 24, Translation Services were not utilized for the non-English speaking patient; 5. For Patients 6 and 29, Universal Protocol (UP, a process used to identify the correct patient, the correct procedure, the correct proceduralist and the correct site) was not completed prior to an invasive procedure (a medical treatment where tools such as needles, tubes, or surgical instruments are used to diagnose or treat a condition); 6. For Patient 19, discharge paperwork placed in the medical record was missing a required signature from a witness. These failures had the potential to cause a delay in patient care and harm to the patients. Findings: 1. On January 7, 2025, at 12 p.m., a concurrent interview and review of Patient 6’s record was conducted with the Manager of the Orthopedic Program (MO). A facility document titled, “History and Physical,” dated September 14, 2024, indicated Patient 6 was admitted to the facility for shortness of breath and pneumonia (lung infection). The facility documents titled, “Clinical Info - Respiratory,” from September 14, 2024, to September 24, 2024, were reviewed. The documents indicated Patient 6 had oxygen therapy every day. No physician order was found for the administration of oxygen. On January 7, 2025, at 3:20 p.m., an interview was conducted with the Quality Supervisor (QS). The QS stated patients require a physician order for oxygen therapy. The QS stated there was not an order for oxygen therapy for Patient 6 and further stated there should have been an order for oxygen therapy entered by the physician for Patient 6, however, this was not done. On January 8, 2025, at 8:45 a.m., an interview was conducted with the Director of Medical/Surgical/Telemetry (DMST). The DMST stated patients require an active order from the physician for oxygen therapy. A review of a Policy and Procedure (P&P), titled, “[Name of Facility] Criteria of Care for the ICU [Intensive Care Unit], PCU [Progressive Care Unit], Medical Surgical, Cardiac Telemetry Patient,” dated November 2024, was conducted. The P&P indicated, “...Oxygen therapy...delivery device as ordered by physician...” 2. On January 7, 2025, at 3:30 p.m., a concurrent interview and record review of Patient 22’s record was conducted with the QS and the Cardiac Services Manager (CSM). A review of the facility document titled, “Procedure Note”, dated October 24, 2024, at 9:46 a.m., by [Name of Medical Doctor 2] indicated “...Right Internal Jugular Vein Central Venous Catheter...” was placed. There was no indication per documentation that the procedure was performed on an emergent basis.. On January 7, 2025, at 3:45 p.m. an interview was conducted with the QS. The QS stated, “...an order for a central line should have been placed in the patient’s chart per policy...” On January 8, 2025, at 1:30 p.m., a review of the facility P&P document titled, [Name of Facility] Central Venous Catheters- Insertion, Care, Maintenance, and Removal”, revised June 10, 2024, indicated, “...Central Venous Catheters (CVC)...Must have a physician’s order documented in the patients medical record to access or remove any central venous access device for any purpose...” 3. On January 8, 2025, at 9:30 a.m., a concurrent interview and record review of Patient 29’s record was conducted with the QS and the CSM. A facility document titled, “ED [Emergency Department] Physician Record”, dated January 1, 2025, at 1:49 p.m., indicated a lumbar puncture was completed by MD 1. The document further indicated, “...the second attempt, the needle was advanced into the spinal canal and clear CSF [Cerebral Spinal Fluid] was obtained...” There was no indication of emergent status documented for Patient 29.. On January 8, 2025, at 9:35 a.m., an interview of the QS was conducted. The QS stated, “...there was no order for a lumbar puncture procedure found in the patient’s chart.” The QS further stated, “An order should have been documented in the patient’s chart per policy...” On January 8, 2025, at 9:45 a.m., a review of the facility’s P&P document titled, “[Name of Facility] Universal Protocol,” dated April 28, 2024, indicated, “...Prior to initiating the bedside procedure...The bedside pre-verification will at a minimum include...Procedure confirmed with order in medical record...” 4a. On January 8, 2025, at 10:30 a.m., a concurrent interview and review of Patient 6’s record was conducted with the MO. A facility document titled, “Progress Note-Physician,” dated October 2, 2024, was reviewed, and indicated, “...RN messaged me to come to patient’s bedside to assist with translation...team was placing a central line [tube placed into a large vein used to give medications, fluids or nutrients directly into the bloodstream]...” The MO stated, the RN should have utilized the interpreter line and not called the Physician to interpret for the patient. A review of the P&P, titled, “[Name of Facility] Interpreter - Language Access for Limited English Proficient (LEP) and Hearing- Impaired Patients,” dated October 2022, was conducted. The P&P indicated, “...The hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients, and their surrogate decision makers for those with LEP and/or sensory impairments to ensure they have services provided to them in their primary language or have interpreter services provided to them during the delivery of healthcare services...If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations, conveying/ receiving simple messages, or for basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent [permission for a medical procedure after understanding risks, benefits, and alternatives] requires the use of a qualified medical interpreter available through the contracted language services provider...” 4b. On January 7, 2025, at 10:00 a.m., a concurrent interview and review of Patient 24’s record was conducted with the QS and the CSM. A facility document titled, “Face Sheet”, dated January 5, 2025, at 9:50 a.m., indicated Patient 24’s language was Spanish. On January 7, 2025, at 10:10 a.m., a review of the facility undated document titled, “Preferred Mode of Communication for Health Care Discussions”, indicated Patient 24 preferred a Language Interpreter for communication. On January 7, 2025, at 10:15 a.m., a review of the facility document, “History and Physical”, dated January 4, 2025, at 8:45 p.m., indicated “...spoke with patient’s granddaughter over the phone due to patient’s mainly Spanish speaking...” No indication of interpreter usage for translation was documented. On January 7, 2025, at 10:30 a.m., an interview was conducted with the QS. The QS stated Patient 24 preferred using a Spanish interpreter and no interpreter was used during this visit. A review of P&P, titled, “[Name of Facility] Interpreter - Language Access for Limited English Proficient (LEP) and Hearing- Impaired Patients,” dated October 2022, was conducted. The P&P indicated, “...The hospital shall provide reasonable accommodations as required by law to ensure effective communication between care providers, patients, and their surrogate decision makers for those with LEP and/or sensory impairments to ensure they have services provided to them in their primary language or have interpreter services provided to them during the delivery of healthcare services...If the staff or the physician speaks the same language as the patient, no interpreter is necessary for social conversations, conveying/ receiving simple messages, or for basic questions and/or general instructions (i.e., instructing patient that you wish to bathe them, telling them the medicine is for treating their pain, etc.). Any interpretation that requires asking or giving of detailed medical information and/or informed consent [permission for a medical procedure after understanding risks, benefits, and alternatives] requires the use of a qualified medical interpreter available through the contracted language services provider...” 5a. On January 8, 2025, at 10:30 a.m., a concurrent interview and review of Patient 6’s record was conducted with the MO. A facility document titled, “Procedure Note,” dated September 30, 2024, was reviewed, and indicated, Patient 6 underwent a thoracentesis (a procedure where a needle is used to remove fluid from around the lungs). A facility document titled, “Preprocedure Checklist,” dated September 30, 2024, was reviewed, and indicated, “...Procedural Forms...Procedural Consent Signed...[blank]” not completed. The MO stated the Preprocedure Checklist was not properly completed and the UP documentation was not found in Patient 6’s medical record. On January 8, 2025, at 2:35 p.m., an interview was conducted with the QS. The QS stated UP should have been followed and documented before the thoracentesis was performed on Patient 6 and a consent for the thoracentesis should have been obtained and this was not done. A review of P&P titled, “[Name of Facility] Universal Protocol,” dated April 2024, was conducted. The P&P indicated, “...UP consists of three distinct steps: Pre procedure, Site Marking, and Time Out...Prior to the initiation of an operative or invasive procedure, UP must be followed and documented...Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process...Pre-Procedure Verification- Prior to initiating the operative procedure, the following verification of the correct patient, site, procedure, and proceduralist occurs and must involve the patient or surrogate decision maker when possible...The patient’s nurse and proceduralist verify the site and procedure through independent review of the medical records including but not limited to the H&P, consent, radiographs, schedule and/or LP’s [Licensed Practitioner] order...If the patient is non-English preferred speaking a credentialed and internal interpreter or remote interpreting service should be used...” 5b. On January 8, 2025, at 9:30 a.m., a concurrent interview and record review of Patient 29’s record was conducted with the QS and the CSM. The facility document titled, “ED Physician Record,” dated January 1, 2025, at 1:49 p.m., indicated a lumbar puncture was performed by MD 1. The document further indicated, “...the second attempt, the needle was advanced into the spinal canal and clear CSF [Cerebral Spinal Fluid] was obtained...” There was no indication of emergent status documented for Patient 29.. On January 8, 2025, at 9:35 a.m., an interview with the QS was conducted. The QS stated, “ ...there was no Universal Protocol procedure documented. The QS stated, “...It should have been done per policy...” On January 8, 2025, at 9:40 a.m., a review of P&P titled, “[Name of Facility] Universal Protocol [UP],” dated April 2024, was conducted. The P&P indicated, “...UP consists of three distinct steps: Pre procedure, Site Marking, and Time Out...Prior to the initiation of an operative or invasive procedure, UP must be followed and documented...Missing information or discrepancies are to be resolved by the team during any point of the procedure verification process...Pre-Procedure Verification- Prior to initiating the operative procedure, the following verification of the correct patient, site, procedure, and proceduralist occurs and must involve the patient or surrogate decision maker when possible...The patient’s nurse and proceduralist verify the site and procedure through independent review of the medical records including but not limited to the H&P, consent, radiographs, schedule and/or LP’s order...” 6. On January 7, 2025, at 9:30 a.m., a concurrent interview and review of Patient 19’s record was conducted with the QS and the CSM. A review of the facility document titled, “ED Physician Record,” dated November 26, 2023, at 5:15 a.m., indicated Patient 19 was stable for discharge. On January 7, 2025, at 9:35 a.m., a review of the document titled, “[Name of Facility] Confirmation of Receipt of Instructions”, dated November 26, 2023, indicated a signature from Patient 19, but no signature from the nurse or a hospital witness. On January 7, 2024, at 1:30 p.m., an interview was conducted with the Emergency Department Director (EDD). The EDD stated, “...there should have been a signature from the Emergency Room Nurse on the discharge signature page...It is expected that every nurse follows the policy...” On January 7, 2025, at 1:35 p.m., a review of the facility P&P document titled, “[Name of Facility] Discharge Criteria: Emergency Department,” dated November 12, 2018, indicated, “...No patient is discharged without discharge instructions, which is signed, dated and witnessed...””

“DISCHARGE PLANNING-QUALIFIED PERSONNEL CFR(s): Any discharge planning evaluation or discharge plan under this paragraph must be developed by or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel. This Standard is not met as evidenced by: 50122 Based on interview and record review, the facility failed to ensure adequate discharge assessments and planning were completed by a Qualified Social Worker for one of 30 sampled patients (Patient 20). This had the potential for patients to not be assessed for psychosocial needs, care setting needs, functional status, discharge planning, and prioritizing of patient care needs. Findings: On January 7, 2025, at 1:30 p.m., a concurrent interview and record review was conducted with the Quality Supervisor (QS) and the Quality Clinical Effectiveness Coordinator. A review of the facility document titled, “History & Physical”, dated October 30, 2024, at 8:39 a.m., indicated Patient 20 was admitted for a fall and weakness with a history of tongue cancer and thyroid disease. On January 7, 2025, at 1:45 p.m., a review of the facility document titled, “Order”, dated November 2, 2024, at 1:06 p.m., indicated a consult to Social Services was ordered by Medical Doctor (MD) 4. The document further indicated the order was placed “due to staff concerns regarding wife making medical decisions, wife not competent to make decisions.” On January 7, 2025, at 1:50 p.m., a review of the facility document titled, “Progress Note - Care Manage/Social Work,” dated November 6, 2024, at 11:50 a.m., by Case Manager 1 (CM 1) indicated, “...APS [Adult Protective Services] was here to meet w/pt [patient] and wife...[APS Social Worker-APS SW] spoke with Patient 20 privately without wife. APS SW asked Patient 20 if he would be willing to transfer to [Name of Facility] and he nodded “no”. Patient 20 acknowledged that the only facility he was willing to go to was [Name of Facility]...” On January 7, 2025, at 1:50 p.m., an interview was conducted with the Case Management Director (CMD). The CMD stated, “...We had no Social Worker [SW] on site or in house...They would defer Social Worker consults or try and get assistance from sister facilities, Adult Protective Services, or Behavioral health...There was no SW for about three months...For this patient, they had risk and ethics involved and wife was removed from the facility for impeding care...” The CMD further indicated they hired a SW in mid-November 2024. CMD further stated, “...they had lots of interviews, staffing hired three travel SW, but they never came to the facility...if it was something that the nursing or CM couldn’t handle, they would escalate...” On January 7, 2025, at 2 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, “...If a Social worker was not readily available, they would follow the COC [chain of command]...” On January 8, 2025, at 9:30 a.m., a review of the facility document titled, “[Name of Facility] Annual Performance Evaluation-Staff- Licensed Clinical Social Worker [LCSW]”, dated March 6, 2023, indicated, “Position Specific Standards...Assessment: Performs psychosocial assessment according to hospital/unit policy and procedure...Performs initial assessments appropriate to functional status, diagnosis, care setting, age, development level, psychosocial, cultural, and religious orientation in a timely manner...Identifies and prioritizes the need for further assessment based on the patient’s clinical presentation/diagnosis, care setting, desire for care and responses to any previous care ...Provides resource information and referrals for follow-up of psychosocial and discharge planning needs...Maintains LCSW licensure...” On January 9, 2025, at 9 a.m., a review of the facility policy and procedure document titled, “[Name of Facility] Transfer - To Higher or Lateral Level of Care, Rehabilitation, or Skilled Nursing Facility,” dated June 10, 2024, indicated, “...Supportive counseling by a Social Worker will be available as necessary to patients and families working through the emotional and psychosocial issues surrounding placement process...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 48776 Based on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) when patient belongings were not properly inventoried, stored, and returned on discharge for 11 of 31 sampled patients (Patients 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). These failures resulted in patients not having their personal items returned to them prior to discharge and could have resulted in a breach in confidentiality and impact the overall quality of patient care. Findings: On September 16, 2024, at 10:55 a.m., a tour of Unit A was conducted with the Director of Medical/Surgical Unit (DMS 1), and the Nurse Educator (NE). During the tour of Unit A, in the soiled utility room, two bins labeled “PATIENT BELONGINGS was observed. Inside the bins, multiple bags labeled with patient’s names and some without labels were found in the bins including loose items such as clothing, dentures, wallets (identification, credit cards, insurance cards, bank cards, social security card, and miscellaneous cards), medications (from home and from the facility), an original advance directive, jewelry, cell phone, car key fob, discharge instructions, life alert lanyard, prescription glasses, and sun glasses. On September 16, 2024, at 11:05 a.m., an interview was conducted with DMS 1. DMS 1 stated she did not know how or why the bins labeled “PATIENT BELONGINGS” were placed in the soiled utility room. DMS 1 stated these bins should not be in this room and was not sure how long they have been there. DMS 1 stated patient belongings and medications should never be stored in the soiled utility room. On September 16, 2024, at 11:25 a.m., an interview was conducted with Environment Services (EVS). EVS stated he was not the one who placed the bins in the soiled utility room, but they were present on September 15, 2024. On September 16, 2024, at 11:32 a.m., an interview was conducted with the Director of EVS (DEVS). DEVS stated the bins do not belong in the soiled utility room and did not know how or why the bins were placed in this room. a. A review of Patient 21’s medical record was conducted on September 16, 2024, at 1:45 p.m., with the Orthopedic Program Manager (OPM) and the Clinical Effectiveness Coordinator (CEC). During the tour of the soiled utility room, a belonging bag was observed to have the following medications in it with Patient 21’s name on them; Pantopazolone sodium 40 mg (a medication used to treat gastroesophageal reflux disease) 6 tablets, Pantopazolone sodium 40 mg 13 tablets, Atorvastatin 10 mg (a medication used to decrease cholesterol) 15 tablets, Glimepiride 4 mg (a medication used to treat diabetes) 3 tablets, Aspirin 81 mg one tablet, Metformin 500 mg (a medication used to treat diabetes) 23 tablets, Lisinopril 20 mg (a medication used to treat high blood pressure) 15 tablets. A review of the facility’s document titled, “History and Physical (H&P)”, indicated Patient 21 was admitted to the facility on March 21, 2023, for aspiration pneumonia (an infection of the lungs), swelling of the lower legs, and acute kidney injury. A review of the facility’s document titled, “Valuables/Belongings,” dated March 21, 2023, indicated Patient 21 did not have any medications. A review of the facility’s document titled, “Progress note-Nurse,” dated April 3, 2023, authored by the House Supervisor (HS). was conducted. This documented indicated, “...Personal Belongings...Called emergency contact number [family phone number] to let the family know this patient left some of his personal belongings in the room...This HS left a message with a return contact phone number to reach me at. Will hold belongings at the charge desk...” On September 18, 2024, at 10:45 a.m., an interview with the Director of Pharmacy (DOP) was conducted. The DOP stated patients home medications are never stored at the bedside and should not be in the soiled utility room. The DOP stated home medications are inventoried (tablets counted) and sent to the pharmacy. The DOP further stated there was no record that Patient 21’s home medications were stored in the pharmacy. b. During the tour of Unit A, a patient’s belonging bag was observed in the soiled utility room which contained an original “Advance Health Care Directive [legal document that expresses medical wishes]” form and other articles of clothing with Patient 22’s label on the bag. A review of facility’s document titled, “H&P,” dated May 4, 2024, indicated Patient 22 was admitted to the facility on May 5, 2024, with a syncopal (fainting) episode. A review of the facility’s document titled, “Valuables/Belongings,” dated May 5, 2023, indicated Patient 22 did not have the original “Advance Health Care Directive” on the inventory list. On September 16, 2024, at 12:02 p.m., an interview with DMS 1 was conducted. DMS 1 stated the original “Advance Health Care Directive” should have been given back to the family member after a copy was made for the Electronic Medical Record (EMR). DMS 1 further stated, the articles of clothing should have been returned to Patient 22 on discharge. c. During the tour of Unit A, a biohazard bag (a bag used to collect wastes products containing tissue and blood) in the soiled utility room was observed with a silver-colored watch and with Patient 23’s label on the bag. A review of facility’s document titled, “H&P,” dated May 25, 2023, indicated, Patient 23 was admitted to the facility on May 25, 2023, with encephalopathy (disease of the brain that can cause altered level of consciousness), and hyponatremia (low sodium levels). A review of facility’s document titled, “Valuables/Belongings,” dated May 28, 2023, indicated, “...watch At bedside...Returned upon Discharge...” A review of the facility’s document titled, “Progress note-Nurse,” dated May 28, 2023, indicated, “...Going over D/C [discharge] with Night Shift RN [nurses name], went over belongings list and no watch found at bedside. RN went through belongings bag and no watch found...” On September 16, 2024, at 12:02 p.m., an interview with DMS 1 was conducted. DMS 1 stated the watch should have been placed in the safe when found and the patient/family should have been called to pick it up and this was not done. d. During the tour of Unit A, a biohazard bag was observed in the soiled utility room which contained a cell phone and a brown wallet and with Patient 24’s label on the bag. A review of facility’s document titled, “H&P,” dated September 16, 2023, indicated, Patient 24 was admitted to the facility on September 16, 2023, with a subdural hematoma (blood to the brain), Chronic Obstructive Pulmonary Disorder (COPD, a lung disease that makes it difficult to breath), and Hypertension (elevated blood pressure). A review of facility’s document titled, “Valuables/Belongings,” dated October 6, 2023, indicated, Patient 24 did not have a cell phone or a wallet on the inventory list. On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the cell phone belonged to Patient 24, and his wife was notified of this on September 17, 2024, and she would be in to pick it up. DMS 1 stated the wallet belonged to another patient the patient’s family was notified on September 17, 2024, and would be in to pick it up. DMS 1 stated both items should have been placed in the safe and patient’s notified when items were found, and this was not done. e. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a pair of prescription glasses and with Patient 25’s label on the bag. A review of facility document titled, “H&P,” dated April 20, 2022, indicated, Patient 25 was admitted to the facility on April 22, 2022, with hypertension, impaired ambulation (walking), and lower extremity edema (swelling). A review of facility’s document titled, “Valuables/Belongings,” dated April 24, 2022, indicated the patient did not have eyeglasses on the inventory list. On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the glasses and this was not done. f. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a brown wallet and with Patient 26’s label on the bag. A review of facility document titled, “H&P,” dated November 14, 2023, indicated, Patient 26 was admitted to the facility on November 15, 2023, with Congestive Heart Failure and lower extremity edema (swelling). On September 18, 2024, at 9:30 a.m., a concurrent interview and record review were conducted with the Clinical Effectiveness Coordinator (CEC). The CEC stated an admission belongings inventory was not completed. The CEC further stated document titled, “Valuables/Belonging,” dated November 16, 2023, indicated, “...No Data Available...” On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated a patient belongings inventory list should have been completed on admission and the wallet should have been sent to the safe. DMS 1 stated the P&P was not followed. g. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a container containing lower dentures in water and with Patient 27’s label on the bag. A review of facility document titled, “H&P,” dated August 7, 2023, indicated Patient 27 was admitted to the facility on August 7, 2023, with COPD, weakness, and coronary artery disease (blocked arteries due to build up). A review of facility’s document titled, “Valuables/Belongings,” dated August 10, 2023, indicated, Patient 27 “...with upper dentures, lower dentures...” was listed on the inventory list. On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the dentures when they were found. DMS 1 further stated Patient 27’s care giver will be in to pick the dentures up this week. h. During the tour of Unit A, a biohazard bag was observed in the soiled utility room with a pair of prescription glasses and with Patient 28’s label on the bag. A review of facility document titled, “H&P,” dated July 30, 2023, indicated, Patient 28 was admitted to the facility on July 31, 2023, with hypertension, coronary artery disease and syncopal episode. A review of facility document titled, “Valuables/Belongings,” dated July 31, 2023, indicated the patient did not have eyeglasses on the inventory list. On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the glasses when they were found, and this was not done. i. During the tour of Unit A, a biohazard bag was observed in the soiled utility room which contained three boxes of eye drops, Timolol, Maleate, Prednisolone Acetate, Ketorolac (eye drops used to treat glaucoma, a chronic eye disease caused by damage to the optic nerve) and with Patient 29’s label on each of the medication boxes. A review of the facility document titled, “H&P,” dated May 22, 2023, indicated, Patient 29 was admitted to the facility on May 22, 2023, with a syncopal episode and abdominal pain and has a history of glaucoma. On September 16, 2024, at 12:02 p.m., an interview with DMS 1 was conducted. DMS 1 stated the eye drops came from the facility and should not be stored at the bedside or in the soiled utility room. On September 16, 2024, at 1:30 p.m., an interview with the Quality Supervisor (QS) was conducted. The QS stated the facility does not have an outpatient pharmacy. The QS stated the eye drops for Patient 29 should not have be given to her since these were medications provided by the hospital pharmacy to be administered while admitted. On September 18, 2024, at 10:45 a.m., an interview with DOP was conducted. The DOP stated the eye drops were dispensed by the hospital pharmacy and should not have been placed in the patient belongings bin. They should have been returned to the pharmacy. The DOP further stated medications should not have been stored in the soiled utility room. j. During the tour of Unit A, a biohazard bag was observed in the soiled utility room which contained a life alert lanyard and with Patient 30’s label and a note “...[Room number], discharged 10/24/23 [October 24, 2023]...” A review of the facility’s document titled, “H&P,” dated October 19, 2023, indicated, Patient 30 was admitted to the facility on October 19, 2023, with altered mental status and anemia (condition that occurs with blood loss). A review of facility’s document titled, “Valuables/Belongings,” dated October 19, 2023, indicated Patient 30 did not have a life alert lanyard on the inventory list. On September 18, 2024, at 11:15 a.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the life alert lanyard when it was found, and this was not done. k. During the tour of Unit A, a belonging bag was observed in the soiled utility room which contained a urinary catheter drainage kit and a key fob with Patient 31’s label on it. A review of the facility’s document titled, “H&P,” dated March 19, 2023, indicated Patient 31 was admitted to the facility on March 19, 2023, with possible pneumonia (infection of lung) versus pulmonary edema (fluid in lung). A review of the facility’s document titled, “Valuables/Belongings,” dated March 20, 2024, indicated, “...Other...At bedside, Returned upon Discharge, key...” On September 17, 2024, at 12:50 p.m., an interview with DMS 1 was conducted. DMS 1 stated the patient should have been called to retrieve the key fob and her items when they were found. DMS 1 stated Patient 31 was contacted and came in on September 17, 2024, to pick up the key fob. On September 16, 2024, at 1:30 p.m., an interview was conducted with the QS. The QS stated the P&P for placing valuables in the safe and medications brought from home and dispensed from pharmacy were not followed. On September 17, 2024, at 12:50 p.m., an interview was conducted with DMS 1. DMS 1 stated the P&P for patient belongings, placing items in the safe, and storage of medications were not followed. On September 18, 2024, at 10:45 a.m., an interview was conducted with the QS. The QS stated letters were not sent by security per policy to patients when valuables/property ownership was discovered. The QS stated the P&P for patient valuables was not followed. A review of the facility’s P&P titled, “Discharge Medication Counseling,” dated August 8, 2022, indicated, “...For medications ordered by the physician for the patient upon discharge, the remainder of a multiple dose container of medication previously dispensed to the patient for inpatient use will NOT be provided to the patient to take home...” A review of the facility’s P&P titled, “Patient Valuables and Belongings: Admission Process,” dated October 18, 2018, indicated, “...At the time of admission, inform each patient to have a family member or friend take all the patient’s property or valuables home, However, if this action cannot be accomplished, valuables are placed in a valuables envelop and stored in the safe...Inventory all valuables with patient or patient representative...Found Patient Belongings (Non-valuables)...Patient belongings that are labeled with the patient’s identification and are found or left behind after discharge will be sent to the nursing clinical supervisor’s office. The clinical supervisors will call the patient/family to return to the hospital to pick up the belongings, and document the date contact was made on/inside the bag. Belongings that are not picked up within a week of notification will be discarded or donated. Belongings found without patient identification will be kept for a one week after which time they will be discarded or donated...Found Patient Valuables...Patient valuables found that are unlabeled will be turned in to the Security Office. The Security office will secure the valuable and contact the Patient Advocate to determine if any reports of lost valuable have been made matching the description. If a possible match is made, the Patient Advocate will contact the patient/family. Valuables not claimed will be appropriately discarded or donated after 90 days...” A review of the facility’s P&P titled, “Valuables and Property: Security Process,” dated February 8, 2021, indicated, “...Unclaimed valuables/property found in rooms, parking lots, hospital grounds...found within the hospital facility...if an item has been found within the facility, obtain a patient belongings bag and place the item(s) inside the bag. On the outside of the bag write the patient’s name if known, location/room number, date and time...Contact Security/House supervisor to log items into lost and found cabinet or safe...Security will maintain a Lost Item Log for any items turned into security. Security will access this log for appropriate personnel who call regarding an item which may have been lost. The Security Officer will be responsible for placing the phone calls...A letter will be sent by the hospital if valuables/property ownership can be identified. The letters will be prepared, sent, followed-up on, and retained by the Security Officer/Plant Operations at each facility...” A review of the facility’s P&P titled, “Medications/Devices Brought from Home by Patients,” dated of June 10, 2024, indicated, “...If medications or device cannot be sent home with the family, it shall be sent to the pharmacy for safekeeping. It will not be kept on the nursing floor...Nursing will document on the chart that medications were brought in and sent to the pharmacy and the storage bag tag will be placed in the patient’s chart...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 49214 Based on interview and record review, the facility failed to ensure the facility’s condition of admission (COA - a document that includes provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient’s confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) was provided for three of 31 sampled patients (Patients 4, 12, and 23). This failure had the potential for patients to not be informed of their rights, which may also result in their inability to effectively make decisions regarding care or treatment. Findings: 1. A review of Patient 4’s medical record was conducted on September 17, 2024, at 1:30 p.m., with the Sepsis and Quality Coordinator (SQC). A review of the facility’s document titled, “History and Physical (H&P),” dated August 31, 2024, indicated Patient 4 was admitted on August 31, 2024, for ethyl alcohol (ETOH) cirrhosis (liver damage due to alcohol), acute renal failure (kidneys not working), and gastrointestinal hemorrhage (bleeding in the colon). A review of the facility’s document titled, “Condition of Admission/Registration Treatment Authorization and Financial Responsibility,” dated September 14, 2024, indicated, there was no documented evidence the COA was provided and Patient 4’s emergency contact person was not contacted to complete it. On September 17, 2024, at 2:36 p.m., an interview was conducted with the SQC. The SQC stated Patient 4 did not have a signed COA and the policy was not followed. 2. A review of Patient 12’s medical record was conducted on September 17, 2024, at 1:40 p.m., with the Stroke Program Manager (SPM). A review of the facility’s document titled, “H&P,” dated August 23, 2024, indicated, Patient 12 was admitted on August 22, 2024, at 12:14 p.m., for chronic gerd (a backflow of stomach acid), skin ulcer (open sore on the skin) of lower leg, and schizophrenia (mental disorder). A review of the facility’s document titled, “Conditions of Admission/Registration Treatment Authorization and Financial Responsibility,” dated August 29, 2024, at 2:51 p.m., indicated, “...Unable to sign...Verbal Consent...August 29, 2024...” There was no documented evidence the facility attempted to follow up after the initial attempt with patient or emergency contact. On September 17, 2024, at 2 p.m., an interview was conducted with the SPM. The SPM stated the COA was not signed, and no follow-up was conducted. 3. A review of Patient 23’s medical record was conducted on September 17, 2024, at 1:45 p.m., with the Orthopedic Program Manager (OPM). A review of the facility’s document titled, “H&P,” dated May 5, 2023, indicated, Patient 23 was admitted to the facility on May 25, 2023, for acute encephalopathy (infection or lack of oxygen in the brain), coronary artery disease (arteries blocked due to buildup), status post coronary angioplasty (procedure to open blocked arteries), and chronic kidney disease (damaged kidneys not functioning properly). A review of the facility’s document titled, “Condition of Admission/Registration Treatment Authorization and Financial Responsibility,” dated May 25, 2023, indicated, “...Unable to sign...” On September 18, 2024, at 10:55 a.m., an interview was conducted with the Director of Admissions and Patient Access Services (DAPA). The DAPA stated Patient 23’s COA signature was not obtained, and the family was not notified and should have been. On September 18, 2024, at 3:15 p.m., an interview was conducted with the the DAPA. The DAPA stated if the patient was unable to sign at admission, a follow up should first be made with the patient, and if necessary, with their representative, power of attorney, or emergency contact. The DAPA further stated once the patient is admitted, the facility aims to obtain patient’s signature promptly. A review of the facility’s policy and procedure (P&P) titled, “Consents,” dated May 13, 2024, indicated, “...To set guidelines which define when consent is necessary...Routine hospitals services/activities require the patient or legally authorized representative consent via the signed...Condition of Admission...””

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 42512 Based on observation, interview and record review the hospital’s governing body failed to assume full responsibility for determining, implementing, and monitoring policies governing the facility’s total operation when: 1. For Patient 1, the facility failed to ensure a comprehensive operative report was completed immediately after a surgery in accordance with the facility’s policy and procedure (P&P) (Refer to A0047). 2. For Patients 4 and 7, the facility staff failed to ensure interventions were implemented timely when the patients experienced multiple episodes of low heart rate (Refer to A0083). The cumulative effect of these systemic problems resulted in the facility failure to ensure the governing body was effective in carrying out its responsibilities for the conduct of the facility which resulted in substandard care and death.”

“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: 44871 Based on observation, interview and record review, the facility failed to ensure the facility followed their policy and procedures, for 15 of 30 sampled patients (Patient 1, 4, 5, 7, 8, 9, 10, 11, 12, 18, 24, 27, 28, 29, and 30) when: 1. For Patient 9, 10, 29, and 30 the facility failed to ensure pain was reassessed after medication administration (refer to A398). 2. For Patient 1, 24, and 27 patients did not receive an initial assessment and reassessment by a case manager and social services during hospitalization (refer to A398). 3. For Patient 4, 12 and 30 critical lab values were not reported in a timely manner (refer to A398). 4. For Patients 8, 11, 27, 28, 29, and 30 the facility did not review, sign, date, time and/or place the telemetry strips in the patient’s physical chart (refer to A398). 5. For Patient 5 the facility did not complete a wound consult per physician’s order (refer to A398). 6. For Patient 4 and 7 the facility staff failed to ensure interventions were implemented timely when Patient 4 and 7 had multiple episodes of low heart rate which were not addressed timely (refer to A398). 7. An intravenous contrast was inappropriately stored in the Radiology Department (refer to A398). 8. Two bottles of anesthetics were inappropriately stored in the Minor Procedure Room (refer to A398). 9. For Patient 18, a procedural time out was not performed before an arterial line (a thin, flexible tube that is placed into an artery) placement (refer to A398). 10. For patient 24, 27, 28, and 29 the facility failed to ensure an individualized plan of care was completed (refer to A396). 11. The facility failed to ensure a Registered Nurse (RN) completed yearly required competencies (refer to A397). The cumulative effect of these systemic failures resulted in the patients to not be provided safe and quality care to meet the patient needs and had the potential to delay provision of care and treatment.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to ensure for seven of 30 sampled patients (Patient 1, 3, 11, 22, 23, 26, and 27) an effective and active system-wide infection control program for the prevention, control, and investigation of infections and communicable diseases, including meeting the needs of all patients requiring gastrointestinal services (the study, diagnosis, and treatment of disorders that deal with the digestive system) and the use of flexible endoscopes (a reusable instrument used to inspect and treat interior portions of the body) was implemented when: 1. Operating room temperatures were not maintained per Association of Operating Room Nurses (AORN) guidelines (Refer to A0749). 2. Temperature and humidity were not monitored in the gastrointestinal (GI, related to the stomach and intestines) lab decontamination and clean room (Refer to A0749). 3. Surgical tables and mats in Operating Rooms (OR) 2 and 4 were left wet after cleaning (Refer to A0749). 4. Two IV (intravenous, within the vein) poles were found with chipped paint and rusty color at the base in Operating Rooms 2 and 4 (Refer to A0749). 5. Multiple equipment in the Radiology Department (RD, medical speciality using medical imaging to diagnose diseases and guide treatment) were not appropriately cleaned (Refer to A0749). 6. For Patients 1, 3, 11, 22, 23, 26, and 27 were not provided a CHG (Chlorhexidine gluconate, skin cleaning to help reduce the spread of infections in the hospital especially in intensive care units) bath (Refer to A0750). 7. Management and staff of the GI department were unaware of the standards or guidelines to follow for the processing and storage of flexible scopes (Refer to A772). 8. ANSI/AAMI (American National Standards Institute/ Association for the Advancement of Medical Instrumentation) guidelines were not followed when there was not a two or three compartment sink for processing/cleaning the flexible scopes (Refer to A772). 9. The endoscope storage cabinet did not contain a HEPA (high efficiency particulate air [filter]). This type of air filter can remove dust, pollen, mold, bacteria, and any airborne particles with a size of 0.3 microns (µm - unit of measurement) filter, and preventive maintenance were not performed in accordance with ANSI/AAMI guidelines (Refer to A772). 10. Gray and black particles, and debris were observed scattered at the bottom of the endoscope storage cabinet (Refer to A772). 11. The facility did not have a policy and procedure in place to guide staff on how to process and store the flexible scopes (Refer to A772). 12. Gastrointestinal Technician (GI Tech) staff did not have the certification needed to process endoscopes in accordance with ANSI/AAMI guidelines (Refer to A772). The cumulative effects of these systemic problems resulted in the facility’s inability to provide an effective hospital wide infection control program and to provide patient care in a safe and effective manner. Due to the failure of the GI Techs not being aware of the standards or guidelines to follow for the processing and storage of flexible scopes, the endoscope storage cabinet not containing a HEPA filter, gray and black debris being observed at the bottom of the endoscope storage cabinet, not having policy and procedures in place to guide staff on how to process and store the flexible scopes, and GI Techs did not have certification needed to process endoscopes in accordance with ANSI/AAMI guidelines, the team determined that an IJ (immediate jeopardy) situation existed on May 7, 2024, at 5 p.m., and was communicated to the hospital staff which included the Chief Nursing Officer (CNO), Director of Education (DE), Chief Operating Officer (COO), and the Senior Clinical Effectiveness Coordinator (SCEC). On May 9, 2024, at 4 p.m., the facility provided an acceptable removal plan of immediate action that included the following: 1. Current staff (two GI Techs), and new hires, will follow the AAMI scope cleaning and reprocessing guidelines. The facility developed and published a new policy that follows AAMI guidelines as of May 8, 2024. (2) Staff will be educated to the new endoscopy cleaning and reprocessing policy for processing and storing scopes by May 8, 2024. (3) 1:1 training will be provided by competent staff on how to process and store flexible scopes according to the new policy by May 8, 2024. (4) Employees on a leave of absence will be educated and trained on the date of return to work and prior to cleaning and processing scopes independently. (5) The facility will monitor compliance by conducting weekly audits for three months to achieve a goal of 95% compliance. 2. Facility has approved and published a new scope cleaning and reprocessing policy that follows AAMI guidelines as of May 8, 2024. 3. Facility will ensure all staff responsible for cleaning and reprocessing scopes have been made aware of the process. Education and training will be completed by May 8, 2024. 4. Facility will create and assign education in the Learning Management System (LMS) that includes a copy of the policy, quarterly, and any updates to evidence-based practices by May 9, 2024. 5. Staff will perform an annual competency on scope cleaning and reprocessing. On May 9, 2024, at 5 p.m., the implementation of the removal plan was verified onsite through observation, interview, and record review. The CNO was notified that the immediate jeopardy was removed.”

“MEDICAL STAFF - BYLAWS CFR(s): 482.12(a)(3) [The governing body must] assure that the medical staff has bylaws. This Standard is not met as evidenced by: 42512 Based on interview and record review the facility failed to ensure a comprehensive operative report was completed immediately after a surgery, in accordance with the facility’s policy and procedure (P&P), for one of 30 sampled patients, Patient (1). This failure had the potential to cause a delay of treatment for patients. Findings: On May 8, 2024, at 12:30 p.m., an interview and concurrent record review were conducted with the Cardiac Manager (CM). The facility document titled, “History and Physical (H&P),” indicated Patient 1 was admitted to the facility on April 28, 2024, for shortness of breath and STEMI (a heart attack). Review of a facility document titled, “AUTHORIZATION FOR AND CONSENT TO SURGERY OR SPECIAL DIAGNOSTIC OR THERAPEUTIC PROCEDURES,” dated April 29, 2024, at 7:15 a.m., indicated, “...Coronary Artery Bypass Grafting...Endoscopic vein harvest...” Further review of Patient 1’s record indicated there was no documented evidence an Operative Report was completed for Patient 1, this report was not in the Electronic Medical Record (EMR). An interview was conducted on May 08, 2024, at 12:49 p.m., with the CM. The CM stated there is no Post Operative Report in the chart, the surgery was performed on April 29, 2024, there should have been an Operative Report per hospital policy. An interview and concurrent record review were conducted on May 08, 2024, at 2:40 p.m., with the Director of Health Information Manager (DHIM). The DHIM stated she does not see a Post Operative Report in the chart. The DHIM further stated the expectation would be for the surgeon to have completed the report within 24 hours, or before the patient goes to the next level of care, when the provider is no longer with the patient. An interview and concurrent record review were conducted on May 08, 2024, at 2:51 p.m., with the Director of Medical Staff (DMS). The DMS stated the expectation would be for the surgeon to complete the Operative Report within 24 hours, this chart did not have it. The DMS further stated the Rules and Regulations for documentation post-surgery were not followed in this specific case. A review of facility document titled, “[Name of the facility] Medical Staff General Rules & [and] Regulations,” dated June 10, 2019, was conducted. The document indicated, “...Operative and invasive procedure reports shall be written or dictated within twenty-four (24) hours following the procedure for outpatients as well as inpatients. The report is promptly authenticated by the practitioner and made a part of the patient’s current medical record. An operative/invasive procedure progress note is required to be entered in the medical record immediately after the procedure to provide pertinent information for any individual required to attend the patient...””

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 42512 Based on observation, interview and record review, the facility failed to ensure the facility followed their policy and procedures, for two of 30 sampled patients (Patient 4, and 7) when the facility staff failed to ensure interventions were implemented timely when Patients 4 and 7 experienced multiple episodes of low heart rate. These failures had the potential to delay patient care, and cause harm or death to the patients. a. A review of Patient 4’s record was conducted with the Senior Clinical Effectiveness Coordinator (SCEC) on May 10, 2024, at 12:40 p.m. The History and Physical (H&P), dated April 7, 2024, indicated Patient 4 was admitted to the facility on April 7, 2024, for anemia (low red blood cell count) and gastrointestinal bleed (bleeding that occurs in the large intestines). The facility document titled, “Progress Note-Physician,” dated April 7, 2024, indicated, “...Discussed in detail with the patient in case of emergency in which his heart stops or he is unable to breath the methods of which he would take in order to preserve life...The patient is in full understanding of the risk of benefits of life saving/heroic measures and would like to have DNR/DNI [Do Not Resuscitate] in the event of incapacitation for any reason while in the hospital...” The facility document titled, “Progress Note-Physician,” dated April 8, 2024, at 1741 (5:41 p.m.), authored by Resident (R 1) indicated, “...CODE BLUE was activated on 04/08/2024 [April 8, 2024] at 1521 [3:21 p.m.]. Upon arrival, patient was found laying on the floor of his room with noticeable urinary incontinence and stool. Nursing staff advised that the patient was pulseless and unresponsive and CPR [life saving procedure performed when the heart stops] was in progress at the time of arrival. Had reviewed patient’s CODE STATUS prior to arrival and called off all heroic measures as patient was DNI/DNR. Patient was pronounced at 1522 [3:22 p.m.]. Non responsive to painful stimulus, no initiation of breaths, absent pulse, asystole on monitor, absent heart & breath sounds on auscultation, no pupillary reflex. Updated the wife and daughter at bedside...” The facility document titled, “Progress Note-Physician,” dated April 9, 2024, at 12:24 p.m., authored by, Physician (P 1) indicated, “...Spoke with wife...over the phone today giving our condolences to her and her family and also reached out to see if there is anything that we can do to help. In addition I also disclosed to [name of wife] that there was a period of approximately 25 minutes where her husband’s heart rate gradually declined and stated that in these types of circumstances typically the physician would have been notified but due to unforeseen reasons we were not...” The facility document titled, “Progress Note-Nurse,” dated April 8, 2024, at 1932 (7:32 p.m.), authored by Registered Nurse (RN 1) indicated, “...At approx [approximately] 1520 [3:20 p.m.] tele monitor alerted asystole. Went to check on pt [patient] who was found on the floor unresponsive...Checked for pt pulse not (sic) was found initiated code blue and began chest compression...” The facility document titled, “Telemetry Specific Details,” dated April 8, 2024, at 1517 (3:17 p.m.) indicated, “...at 1517 [3:17 p.m.]...Tele Alert Notification Reason...Bradycardia [slow heart beat], other informational didn’t alarm...at 1521 [3:21 p.m.]...Asystole [hearts electrical system fails and causes heart to stop beating]...Flag Comments by [name of telemetry monitor tech (MT 1)], on April 8, 2024, 1539 [3:39 p.m.] attempted to contact RN, CODE blue called after...” A review of the facility’s EKG (electrocardiogram, test for heart rate and rhythm) strips, dated April 8, 2024, indicated the following: - At 14:59:12 (2:59 and 12 seconds p.m.), Patient 4’s heart rate was 50 beats per minute; - At 14:59:20 (2:59 and 20 seconds p.m.), Patient 4’s heart rate was 41 beats per minute; - At 14:59:29 (2:59 and 29 seconds p.m.), Patient 4’s heart rate was 37 beats per minute; - At 14:59:38 (2:59 and 38 seconds p.m.), Patient 4’s heart rate was 43 beats per minute; - At 15:09:49 (3:09 and 49 seconds p.m.), Patient 4’s heart rate was 46 beats per minute; - At 15:09:58 (3:09 and 58 seconds p.m.), Patient 4’s heart rate was 48 beats per minute; - At 15:14:32 (3:14 and 32 seconds p.m.), Patient 4’s heart rate was 44 beats per minute; - At 15:14:40 (3:14 and 40 seconds p.m.), Patient 4’s heart rate was 50 beats per minute; - At 15:19:38 (3:19 and 38 seconds p.m.), Patient 4’s heart rate was 30 beats per minute; - At 15:19:46 (3:19 and 46 seconds p.m.), Patient 4’s heart rate was 29 beats per minute; - At 15:21:26 (3:21 and 26 seconds p.m.), Patient 4’s heart rate was 20 beats per minute; - At 15:21:28 (3:21 and 28 seconds p.m.), Patient 4’s heart rate was 20 beats per minute; - At 15:21:34 (3:21 and 34 seconds p.m.), Patient 4’s heart rate was 0 beats per minute; and - At 15:21:36 (3:21 and 36 seconds p.m.), Patient 4’s heart rate was 0 beats per minute. An interview and concurrent record review were conducted with the Director of Medsurg/Tele PCU (progressive care unit) (DMTPCU) on May 10, 2024, at 12:55 p.m. The DMTPCU stated there were three level alarms for heart rate parameters and defaulted at heart rate of 50 bpm. The DMTPCU stated alarms gets louder and louder based on the level. The DMTPCU stated the tele machine at 2:59:20 (2:59 and 20 seconds p.m.) started to alarm and the patient was at 41 beats per minute and there was no evidence MT 1 (Monitor-Tech, staff responsible to observe and interpret heart rate and rhythm from the remote monitor) notified RN 1. The DMTPCU stated MT 1 was busy interpreting a tele strip for a newly admitted patient. The DMTPCU stated MT 1 was monitoring 48 patients and at this time there were multiple alarms going off. The DMTPCU stated the alarm was set at 10%, which is deemed low for the day shift due to ambient noise. The DMTPCU stated MT 1 stated Patient 4’s decline in heart rate was an oversight as he did not hear the alarm. There was no documented evidence MT 1 notified RN 1of Patient 4’s low heart rate on April 8, 2024, from 2:59 and 12 seconds p.m., to 3:21 and 36 seconds p.m., (22 minutes and 44 seconds). There was no documented evidence Patient 4 was assessed for physical symptoms related to severe changes in heart rate and rhythm on April 8, 2024, from 2:59 and 12 seconds p.m. to 3:21 and 36 seconds p.m., (22 minutes and 44 seconds), when the patient’s heart rate was low. b. On May 8, 2024, at 1 p.m., an interview and concurrent record review was conducted with the Stroke Program Manager (SPM). A review of Patient 7’s record was conducted. The H&P dated May 2, 2024, indicated Patient 7 was admitted to the facility for dizziness, double vision, and UTI (urinary tract infection). The facility document titled, “Cardiac Rhythm,” dated May 1, 2024, through May 7, 2024, indicated, “...Sinus Bradycardia...05/02/2024 [May 2, 2024]...07:54:00 [7:54 a.m.]...” There was no documented evidence the Monitor Tech [MT 2] notified the RN. The facility document titled, “Communication Log,” dated May 1, 2024, through May 8, 2024, was reviewed. There was no documented evidence a notification was made to the RN on May 2, 2024, for the bradycardic episode of Patient 7. An interview was conducted on May 8, 2024, at 1:25 p.m., with the Director of Medsurg/Tele/PCU (DMTPCU). The DMTPCU stated he was not able to find any communication from MT 2 to the RN for the bradycardia on May 2, 2024. He stated the MT 2 should have called the RN when the heart rate fell below the parameters. The DMTPCU further stated MT 2 should have documented the notification in the EMR. The DMTPCU stated the bradycardia telemetry strip was not in the EMR and it should have been printed and placed in the patient chart. A review of the facility’s policy and procedure (P&P) titled, “Cardiac/Telemetry Monitoring in the Telemetry Units,” dated May 9, 2022, was conducted. The P&P indicated, “...To provide skilled cardiac monitoring to patients who require continuous telemetry...An evaluation of the patient will occur by the RN...with any changes in rhythm, heart rate, or conduction. The physician will be notified as appropriate...All life-threatening rhythms require physician notification...The Telemetry Monitor Technician will notify the RN...any time there is a change in rhythm or concern about the patient. The Telemetry Monitor Technician will also document these changes in the EMR (electronic medical record)...The Telemetry Monitor Technician will log the call to the RN...in the EMR...The Telemetry Monitor Technician will maintain a report on all telemetry monitored patients...Heart rate alarms and the arrhythmia analysis function must be turned ON at all times...””

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure patients or their representative, were informed in advance of their rights to appeal discharge, for three of 30 sampled patients (Patient 2, 9, and 18). These failures had the potential to result in the patient not being informed of their rights to appeal discharge. Findings: 1. On May 9, 2024, at 10:29 a.m., a concurrent interview and record review were conducted with the Cardiac Manager (CM). A review of Patient 2’s record was conducted. The “History and Physical (H&P),” dated May 3, 2024, at 7:27 p.m., indicated, Patient 2 was admitted to the facility for a NSTEMI (heart attack). The facility document titled, “Discharge Request,” dated May 8, 2024, at 9:22 a.m., indicated Patient was discharged on May 8, 2024. There was no documented evidence that an Important Message from Medicare (IMM) was given and signed by Patient 2, 48 hours prior to discharge. An interview was conducted with the CM on May 9, 2024, at 10:48 a.m. The CM stated “I can not find an Important Message from Medicare in (computer program name) or the physical chart.” The CM further stated the patient should have been given the IMM 48 hours before discharge. 2. On May 9, 2024, at 9:30 a.m., a concurrent interview and record review with Clinical Supervisor (CS) was conducted. A review of Patient 9’s record was conducted. The “H&P,” dated April 19, 2024, indicated, Patient 9 was admitted to the facility on April 19, 2024, for weakness and UTI (urinary tract infection). The facility document titled, “Discharge Summary,” dated May 7, 2024, at 12:38 p.m., was reviewed. The document indicated Patient 9 was discharged home on May 7, 2024. The facility document titled, “IMM,” dated April 23, 2024, was reviewed. The document indicated, “PT [patient] medically unable to sign 04/23/24 [April 23, 2024] 2:06 p.m.” There was no documented evidence the IMM was provided to Patient 9 or Patient 9’s representative prior to discharge. An interview with the CS was conducted on May 9, 2024, at 10:15 a.m. The CS stated the IMM was only presented to Patient 9 on April 23, 2024. The CS stated the IMM should have been presented to the patient or the patient’s family 48 hours prior to the discharge date of May 7, 2024. 3. A review of Patient 18’s chart was conducted on May 9, 2024, at 9:37 a.m., with the Wound Care Program Manager (WCPM). A review of the facility’s document titled, “H&P,” dated, May 4, 2024, indicated, Patient 18 was admitted on May 4, 2024, with a diagnosis of respiratory failure and Renal failure (Acute Kidney Injury). There was no documented evidence that an IMM was given and signed by Patient 18 on admission. A review of the facility’s policy and procedure (P&P) titled, “Important Message from Medicare,” dated February 13, 2023, was conducted. The P&P indicated, “...In the event the patient or the patient [sic] representative did not sign the IMM, it becomes the responsibility of the PAS (Patient Access Staff) Department to attempt to obtain a signature prior to discharge...Attempts will be made daily until a signature has been obtained...Completing the IMM...Upon admission to an impatient status...If not delivered on inpatient admission, must be delivered within 2 calendar days of admission...PAS staff must explain the form and ensure that the beneficiary or responsible party comprehends...The form must be signed and dated by beneficiary or responsible party...Care Coordination staff or their designee must deliver a follow-up copy of the Important Message (IMM) as far in advance as possible before discharge, but no more than 2 calendar days before the day of discharge...””

“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: 47071 Based on interview and record review, the facility failed to ensure an individualized plan of care were completed, for four of 30 sampled patients (Patient 24, 27, 28, and 29). This failures had the potential to delay patient care, patient services, and cause patient harm. Findings: a. A concurrent interview and record review were conducted with the Clinical Effective Coordinator (CEC) on May 8, 2024, at 3:20 p.m. A review of Patient 24’s record was conducted. The facility document titled, “History and Physical (H&P),” indicated, Patient 24 was admitted to the facility on May 8, 2024, for right hip pain and a right total hip replacement. During an interview with the CEC on May 8, 2024, at 3:20 p.m., the CEC stated she was unable to find a patient specific care plans for risk for infection and skin integrity relating to the post-surgical patient that were developed and implemented for the patient in the EMR (electronic medical record). She stated the patient should have had an individualized care plan started with in 24 hours of admission. b. A concurrent interview and record review were conducted with the CEC on May 9, 2024, at 1:06 p.m. A review of Patient 27’s record was conducted. The facility document titled, “H&P,” indicated, Patient 27 was admitted to the facility on May 5, 2024, for worsening chest pain, NSTEMI (non ST elevated myocardial infarction) heart attack. A review of the facility document titled, “Document In Plan,” dated May 9, 2024, indicated there was no evidence of a care plan for pain documented in the Patient 27’s electronic medical record (EMR). An interview was conducted with the CEC on May 9, 2024, at 1:47 p.m. The CEC stated there was no documented individualized care plans for pain in the Patient 27’s EMR. She stated Patient 27 should have had a care plan for pain. c. A concurrent interview and record review were conducted with the CEC on May 9, 2024, at 2:09 p.m. A review of Patient 28’s record was conducted. The facility document titled, “H&P,” indicated, Patient 28 was admitted to the facility on May 5, 2024, for blood in stools. A review of the facility document titled, “Document In Plan,” dated May 9, 2024, indicated there was no evidence an individualized care plan was developed or implemented in Patient 28’s EMR. An interview was conducted with the CEC on May 9, 2024, at 2:24 p.m. The CEC stated there was no individualized care plans in Patient 28’s EMR. She stated Patient 28 should have had a care plan developed and implemented. An interview was conducted with the Emergency Room Manager (ERM) on May 9, 2024, at 2:28 p.m. The ERM stated Patient 28 should have had care plans implemented. The ERM stated the “Quality Team” helps review the care plans, helps make sure the care plans are completed, and assists to complete the care plans when needed. d. A concurrent interview and record review were conducted with the CEC on May 10, 2024, at 9:50 a.m. A review of Patient 29’s record was conducted. The facility document titled, “H&P,” indicated, Patient 29 was admitted to the facility on May 3, 2024, for cough, generalized weakness, and urinary tract (bladder) infection. A review of the facility document titled, “Document In Plan,” dated May 9, 2024, indicated, Patient 29’s care plans were not reviewed each shift after implementation. The individualized care plans were missing risk for urinary tract infection, and sepsis. An interview was conducted with the CEC on May 10, 2024, at 10:12 a.m. The CEC stated there was no individualized care plan for sepsis and urinary tract infection. The CEC stated it would be expected for the patient to have had an individualized care plan for sepsis and urinary tract infection. She stated based on her understanding of the policy, nurses should address the patient’s care plan every shift per policy. A review of the facility’s Policy and Procedure (P&P) titled, “Assessment-Reassessment of the Patient,” dated November 28, 2021, was conducted. The document indicated, “...The Registered Nurse will develop an Individualized Plan of Care this will be implemented and documented with target dates on all inpatients...Within 24 hours of admission...Each shift by addressing goals...””

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 44871 Based on interview and record review the facility failed to ensure a Registered Nurse (RN) completed yearly required competencies. This failure had the potential to cause harm to patients by an unqualified RN providing the care and treatment. Findings: A review of the facility document titled, “Student Assignment Completion Report,” was conducted. The document indicated, “...DELINQUENT...Cardiac Rhythms and Dysrhythmias...12/31/2023 [December 31, 2023]...PAST DUE...Cardiac Rhythms and Dysrhythmias...4/30/2024 [April 30, 2024]...” A review of the facility document titled, “ANNUAL PERFORMANCE EVALUATION - STAFF,” dated 2024, was conducted. The document indicated, “...Able to interpret cardiac arrhythmia’s, intervene as appropriate and alert physician of any significant changes...” An interview and record review were conducted with the Director of Medical /Surgical /Telemetry and Infection Preventionist (DMST&IP) on May 10, 2024, at 9:30 a.m. The DMST&IP stated Registered Nurse (RN 1) did not complete her competencies per requirements. An interview and record review were conducted with the Chief Nursing Officer (CNO) on May 10, 2024, at 9:49 a.m. The CNO stated the nurse did not complete her required competencies and she was not disciplined per facility policy. A review of the facility Policy and Procedure (P&P), titled, “Competency Assessment,” dated February 12, 2024, was conducted. The document indicated, “...Competency assessment occurs upon hire during the orientation period, on an ongoing basis, and at a minimum, annually...” A review of the facility P&P titled, “Performance Evaluation,” dated February 12, 2024, was conducted. The document indicated, “...Employees are required to complete each of the following items during the year as scheduled; however, no later than May 31st...Annual Self-Paced Orientation/Post Tests (LMS assignments)...The annual evaluation is not finalized until each of the following requirements have been completed...Annual Self-Paced Orientation / Post Test LMS Transcript...” A review of the P&P titled, “Corrective Action Process,” dated February 13, 2024, was conducted. The document indicated, “...Corrective action may be initiated for many reasons, including, but not limited to, violations of [Name of the Facility] work rules or policies, poor job performance, attendance, unauthorized disclosure of patient and/or employee health information, etc. The severity of the action generally depends on the nature of the offence and the employee’s work record. Corrective action may range from a preventative counseling session to immediate employment termination. The usual process for the corrective action process is...Preventive Counseling...Written Warning...Final Written Warning...Employment Termination...The counseling process should be timely and follow the incident requiring the corrective action as closely as possible...””

“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: 44871 Based on observation, interview and record review, the facility failed to ensure the facility followed their policy and procedures (P&P), for 15 of 30 sampled patients (Patient 1, 4, 5, 7, 8, 9, 10, 11, 12, 18, 24, 27, 28, 29, and 30) when: 1. For Patient 9, 10, 29, and 30 the facility failed to ensure pain was reassessed after medication administration. 2. For Patient 1, 24, and 27, patients did not receive an initial assessment and reassessment by a case manager and social services during hospitalization. 3. For Patient 4, 12 and 30, critical lab values were not reported in a timely manner. 4. For Patient 8, 11, 22, 27, 28, 29, and 30, the facility did not review, sign, date, time and/or place the telemetry strips in the patients physical chart. 5. For Patient 5, the facility did not complete a wound consult per physician’s order. 6. For Patient 4 and 7, the facility staff failed to ensure interventions were implemented timely when Patients 4 and 7 experienced multiple episodes of low heart rate. 7. An intravenous contrast was inappropriately stored in the Radiology Department. 8. Two bottles of anesthetics were inappropriately stored in the Minor Procedure Room. 9. For Patient 18, a procedural time out was not performed before an arterial line (a thin, flexible tube that is placed into an artery) placement. These failures had the potential to delay patient care, cause harm, medical errors such as wrong-site or wrong-procedure, or death to the patients. Findings: 1a. On May 9, 2024, at 9:30 a.m., a concurrent interview and record review with the Clinical Supervisor (CS) were conducted. A review of Patient 9’s record was conducted. The “History and Physical (H&P),” dated April 19, 2024, indicated Patient 9 was admitted to the facility on April 19, 2024, for weakness and UTI (urinary tract infection). Review of an untitled document, dated April 26, 2024, at 0:40 (12:40 a.m.), indicated, “...hydrocodone-acetaminophen [Norco 5 mg, unit of measurement]-325 mg oral tablet...Frequency...q4h [every four hours]...PRN [as needed]...Pain 4-6 [Moderate]...” The facility document titled, “Medications,” indicated Patient 9 was administered Norco on the following dates: -May 2, 2024, at 11:30 a.m.; -May 4, 2024, at 6:38 a.m.; and -May 4, 2024, at 11:44 a.m. There was no documented evidence Patient 9’s pain was reassessed after the pain medication Norco was administered on the above dates. 1b. On May 9, 2024, at 11 a.m., a concurrent interview and record review with the Clinical Supervisor (CS) were conducted. A review of Patient 10’s record was conducted. The “H&P,” dated May 5, 2024, indicated Patient 10 was admitted to the facility on May 6, 2024, for chest discomfort, bilateral shoulder pain, numbness to left hand, dizziness, and weakness. Review of an untitled document, dated May 5, 2024, at 4:18 a.m., indicated, “...oxyCODONE...10 mg...Frequency...q6H [every six hours]...PRN [as needed]...” The facility document titled, “Medications,” indicated Patient 10 was administered OxyCODONE on May 5, 2024, at 22:59 (10:59 p.m.). There was no documented evidence Patient 10’s pain was reassessed after the pain medication oxyCODONE was administered. An interview with the CS was conducted on May 9, 2024, at 11:10 a.m. The CS stated there was no documented evidence Patients 9 and 10’s pain was reassessed after pain medication was given on the above dates and times. The CS further stated the registered nurse (RN) should have reassessed Patients 9 and 10’s pain one hour after the medication was given. The CS stated the RN should have documented the patient’s pain in the EMR (Electronic Medical Record) to ensure the pain medication was effective. 1c. On May 10, 2024, at 10:40 a.m., a concurrent interview and record review with Clinical Effective Coordinator (CEC) were conducted. A review of Patient 29’s record was conducted. The facility document titled “H&P,” indicated Patient 29 was admitted to the facility on May 3, 2024, for cough, generalized weakness, and urinary tract (bladder) infection. The facility document titled, “Patient Flow Sheet ,” indicated Patient 29’s pain was assessed on the following dates: -May 5, 2024, at 2016 (8:16 p.m.) numeric scale 6/10. -May 6, 2024, at 5:28 p.m., numeric scale 4/10 (pain screening tool using 0-10); Review of an untitled document, dated May 4, 2024, at 1:04 p.m., indicated, “...acetaminophen [Tylenol] 650 mg oral tablet...Frequency...q6h...PRN...Fever/Pain 1-3 (Mild)...” The facility document titled, “Medications,” indicated Patient 29 was administered Acetaminophen on the following dates: -May 4, 2024, at 0117 (1:17 a.m.); -May 5, 2024, at 2017 (8:17 p.m.); -May 5, 2024, at 0529 (5:29 a.m.); and -May 6, 2024, at 1550 (3:50 p.m.). There was no documented evidence Patient 29’s pain was reassessed after the pain medication Tylenol was administered. An interview was conducted with the CEC on May 10, 2024, at 9:50 a.m. The CEC stated there was no documentation the nurse notified the physician about the pain being greater than 3. The nurse gave the Acetaminophen for pain greater than 1-3/10. The CEC stated the nurse did not follow the physician’s orders. The CEC stated the nurse should have requested medication for the pain and the assessed level. She further stated there was no documentation that the pain was reassessed. 1d. On May 9, 2024, at 10:40 a.m., a concurrent interview and record review with Clinical Effective Coordinator (CEC) were conducted. A review of Patient 30’s record was conducted. The facility document titled “H&P,” indicated Patient 30 was admitted on May 5, 2024, for seizure like activity, confusion, and fell out of the bed. The facility document titled, “Patient Flow Sheet,” indicated Patient 30’s pain was assessed on the following dates: -February 5, 2024, at 0730 (7:30 a.m.), FLACC (Face, Legs, Activity, Cry, Consolability) pain scale 6/10; -February 5, 2024, at 0830 (8:30 a.m.), FLACC pain scale 6/10; -February 5, 2024, at 1030 (10:30 a.m.), FLACC pain scale 2/10; -February 5, 2024, at 1523 (3:23 p.m.), FLACC pain scale 5/10; and -February 5, 2024, at 2100 (9:00 p.m.), FLACC pain scale 2/10. The facility untitled document, dated February 5, 2024, at 12:34 p.m., indicated, “...acetaminophen 650 mg OG-Tube [thin soft tubed placed through the mouth and into the stomach]...Frequency...q4h...PRN... /Pain 1-3...Fever...” The facility untitled document, dated February 5, 2024, at 12:34 p.m., indicated, “...acetaminophen 650 mg Supp [suppository] Rectal Frequency...q4h...Once PRN... /Pain 1-3...Fever...” The facility document titled, “Medications,” indicated Patient 30 was administered Acetaminophen on the following dates: - February 5, 2024, at 0155 (1:55 a.m.), OG-Tube; and - February 5, 2024, at 1259 (12:59 p.m.), supp/Rectal. There was no documented evidence Patient 30’s pain was reassessed after the pain medication Tylenol was administered. An interview was conducted with the CEC on May 10, 2024, at 11:44 a.m. The CEC stated based on the assessment the patient should have been given pain medication. The medication given was not an appropriate medication to be given based on the physician’s order. The nurses used the FLACC pain scale to assess the patient’s pain. A review of the P&P titled, “Medication Administration and Monitoring,” dated April 8, 2024, was conducted. The P&P indicated, “...Medications will be administered in safe, accurate, and consistent manner...Medications Not Eligible for Scheduled Dosing Times include...PRN medications...The response of the patient to medication will be monitored by the administering nurse...according to the clinical needs of the patient...The patient’s own perceptions of the efficacy...will be gathered...Relevant information in the medical record will be taken into consideration, such as relevant...clinical response, and medication profile...” 2a. A review of Patient 1’s record was reviewed with the Cardiac Manager (CM) on May 8, 2024, at 12:30 p.m. Patient 1’s H&P indicated, Patient 1 was admitted to the facility on April 28, 2024, for shortness of breath and STEMI (a heart attack). The facility document titled, “Consult to Case Management (Case Management Consult),” was reviewed. There was no documented evidence an initial case management assessment was completed during Patient 1’s hospitalization. An interview and record review were conducted with the Case Management Manager (CMM) on May 8, 2024, at 3:13 p.m. The CMM stated this patient should have had an initial assessment and then a reassessment prior to discharge and it was not done. 2b. A concurrent interview and record review were conducted with the CEC on May 9, 2024, at 9:59 a.m. A review of Patient 24’s record was conducted. The facility document titled, “H&P,” indicated Patient 24 was admitted to the facility on May 7, 2024, for right hip pain and had a right total hip replacement. A review of the facility document titled, “Orders,” was reviewed. The document indicated a case management referral was ordered May 7, 2024 at 10:10 a.m. There was no documented evidence an initial case management assessment was completed during Patient 24’s hospitalization. An interview and record review were conducted with the CMM on May 9, 2024, at 9:59 a.m. The CMM stated a case manager was working on the discharge assessment, currently there was no admissions assessment in the electronic health record. 2c. A concurrent interview and record review were conducted with the CEC on May 9, 2024, at 1:06 p.m. A review of Patient 27’s record was conducted. The facility document titled, “H&P,” indicated Patient 27 was admitted to the facility on May 5, 2024, for worsening chest pain, NSTEMI (non ST elevated myocardial infarction) heart attack. A review of a document titled, “Orders,” indicated a case management referral was ordered May 9, 2024, at 12:19 p.m. There was no documented evidence an initial case management assessment was completed during Patient 27’s hospitalization. An interview and record review were conducted with the CMM on May 9, 2024, at 9:59 a.m. The CMM stated there was no documentation a case management initial assessment was completed as ordered by the physician. A review of the P&P titled, “[Facility Name] Physician’s Orders,” undated, was reviewed. The documented indicated, “...Licensed personnel may carry out orders for which there is a hospital Policy/Procedure and for which they have been trained...Provider orders will be accurately processed and promptly followed...” 3a. On May 9, 2024, at 9:17 a.m., a record review and concurrent interview were conducted with the CM. A review of Patient 4’s record was conducted. The H&P, dated April 7, 2024, indicated Patient 4 was admitted to the facility on April 7, 2024, for anemia (low red blood cell count) and gastrointestinal (inside the intestine) bleed. A review of Patient 4’s labs indicated, CO2 (Carbon dioxide) 48 mEq/L (unit of measurement) (critical) (Normal Range 23-29 mEq/L) on April 8, 2024, at 8:08 a.m. The pharmacy documented Registered Nurse (RN 1), was notified at 9:48 a.m. There was no documented evidence RN 1 called the physician to give the critical lab results. An interview was conducted with the CM on May 9, 2024, at 9:32 a.m. The CM stated if there were critical lab values the nurse was supposed to notify the provider within 30 minutes, and if there was no response, the nurse should have followed the escalation process. The CM further stated there was no notification in the chart per policy. 3b. On May 9, 2024, at 3:15 p.m., a record review and concurrent interview were conducted with the CS. The CS stated Patient 12 was admitted on May 3, 2024, for chest pain and shortness of breath. A review of Patient 12’s labs indicated his white blood cell count was critically low on the following dates: -May 3, 2024, at 1.8 g/dL (unit of measurement) (normal white blood cell count between 4.5 - 11.0 g/dL); and -May 6, 2024, at 1.8 g/dL. There was no documented evidence the critical values were reported to the physician. An interview was conducted with the CS on May 9, 2024, at 3:45 p.m. The CS stated there was no documented evidence the lab values above were reported to the physician. The CS stated any lab values that are critical should have been reported to the physician right away. 3c. A concurrent interview and record review were conducted with the CEC on May 9, 2024, at 1:06 p.m. A review of Patient 30’s record was conducted. The facility document titled, “H&P,” indicated Patient 30 was admitted on May 5, 2024, for seizure like activity and confusion, following a fall out of the bed. A review of Patient 30’s labs indicated Troponin (protein in heart cells) 1,514.5 ng/mL (unit of measurement) (critical) (Normal Range 0 and 0.04 ng/mL) on February 5, 2024, at 3.33 a.m. There was no documented evidence the RN called the physician to give the critical results. An interview was conducted with the CEC on May 10, 2024, at 11:11 a.m. The CEC stated the labs were not reported to the physician. A review of the P&P titled, “Critical Results,” dated April 8, 2024, was conducted. The document indicated, “...All Registered Nurses...in clinical departments that report critical results...Critical results apply to all diagnostic tests, including...laboratory tests...Critical results are those that fall significantly outside the normal range and may present life-threatening values...The results may reflect a pathological state which, if left untreated, poses an imminent threat to life...The time frame for communicating critical results to a physician is to be within sixty (60) minutes...Carbon dioxide...Critical Low < 10 mmol/L...Critical High...> (greater than)...40 mmol/L...Troponin...female....>51.4 ng/L (unit of measurement)...Hemoglobin...Critical Low...<(less than) 10.0 g/dL...When the reporting department calls the physician, the first and last name of the patient should be used...Documentation...The reporting clinician (i.e., nurse...) will document physician notification in the patient’s medical record...” 4a. On May 8, 2024, at 1 p.m., an interview and concurrent record review with the Stroke Program Manager (SPM) were conducted. A review of Patient 8’s record was conducted. The “H&P,” dated May 6, 2024, indicated Patient 8 was admitted to the facility on May 6, 2024, for left sided facial tingling and numbness. A review of the facility’s document titled, “Vitals Quick View,” dated May 6, 2024, was reviewed. The document indicated Patient 8 was on telemetry (continuous tracking of your heartbeat). The document further indicated Patient 8’s telemetry strip interpretation on May 6, 2024, at 1800 (6 p.m.) was missing. There was no documented evidence Patient 8’s telemetry strip was placed in his chart. An interview and concurrent record review was conducted on May 8, 2024, with the Stroke Program Manager (SPM). The SPM stated at a minimum, one telemetry strip should be interpreted, printed, signed, and dated every shift. She further stated Patient 8’s May 6, 2024, strip interpretation was incomplete, and the strip was missing from the patient’s chart. 4b. On May 9, 2024, at 1:30 p.m., an interview and concurrent record review with the CS were conducted. Patient 11’s H&P indicated he was admitted to the facility on May 2, 2024, for shortness of breath (SOB), increased cough and rhonchi (coarse rattling lung sounds). A review of the facility’s document titled, “Vitals Quick View,” dated May 4, 2024, was conducted. The document indicated Patient 11 was on telemetry. The document further indicated Patient 11’s telemetry strip interpretation on May 4, 2024, was missing. There was no documented evidence Patient 11’s telemetry strip was placed in his chart. An interview and concurrent record review was conducted on May 9, 2024, at 1:30 p.m., with the CS. The CS stated a telemetry strip should have been printed every shift when a patient was on telemetry. She stated the telemetry strip for May 4, 2024, was missing and not in the chart. She further stated there was no documented evidence in the EMR a May 4, 2024, telemetry strip was interpreted, printed, signed and dated. 4c. A concurrent interview and record review were conducted with the Wound Care Program Manager (WCPM) on May 9, 2024, at 2:45 p.m. A review of Patient 22’s record was conducted. The facility document titled, “H&P, “ indicated, Patient 22 was admitted to the facility on November 26, 2023, for transaminitis (high levels of a particular type of enzyme in your blood, called a transaminase) and proctitis (inflammation of the rectum and anus). During a review of Patient 22’s record, the following telemetry strips were reviewed: -November 27, 2023, at 4:33 a.m., there was no documented evidence of time, date, printed name, and signature of RN or monitor tech (MT) documented on the strip; -November 27, 2023, at 8:20 a.m., there was no documented evidence of time, date, printed name and signature of RN or MT was documented on the strip; -November 27, 2023, at 7:09 p.m., there was no documented evidence of time, date, printed name and signature of RN or MT was documented on the strip; -November 28, 2023, day shift (7 a.m. to 7 p.m.), there was no documented evidence a telemetry strip was printed and interpreted; -November 28, 2023, at 10:14 p.m., there was no documented evidence of time, date, printed name and signature of RN or MT was documented on the strip; -November 29, 2023, day shift, there was no documented evidence a telemetry strip was printed and interpreted; -November 29, 2023, at 8:45 p.m., there was no documented evidence of time, date, printed name and signature of RN or MT was documented on the strip; -November 30, 2023, at 12:16 a.m., there was no documented evidence of time, date, printed name and signature of RN or MT was documented on the strip; and -November 30, 2023, at 7:23 a.m., there was no documented evidence of time, date, printed name and signature of RN or MT was documented on the strip. An interview on May 9, 2024, at 3:45 p.m., with the WCPM was conducted. The WCPM stated the policy for telemetry strip documentation was changed to reflect the new process, however, when the policy was received from the hospital, the WCPM stated the policy was not followed. 4d. A concurrent interview and record review were conducted with the Clinical Effective Coordinator (CEC) on May 9, 2024, at 1:06 p.m. A review of Patient 27’s record was conducted. The facility document titled, “H&P,” indicated, Patient 27 was admitted to the facility on May 5, 2024, for worsening chest pain, NSTEMI (non ST elevated myocardial infarction) heart attack. A review of facility documents titled, “Caliper Measurement,” was conducted. There was no documented evidence the six second telemetry strips were completed with full printed, signed name, date, and time of interpretation on the following dates: -May 4, 2024, day shift (7 a.m. to 7 p.m.) or night shift (7 p.m. to 7 a.m.); -May 5, 2024, day shift or night shift; -May 6, 2024, day shift or night shift; -May 7, 2024, day shift or night shift; -May 8, 2024, day shift or night shift; and -May 9, 2024, day shift. An interview and record review were conducted with the CEC on May 9, 2024, at 2 p.m. The CEC stated she was aware of the policy for the telemetry strips to include the nurse’s full printed and signed name, date, and time of interpretation and to place the strips in the patient’s chart. An interview and record review were conducted with the Director of Medsurg/Tele PCU (DMTPCU) on May 9, 2024, at 2:10 p.m. The DMTPCU stated the policy was to run the six second telemetry strip, interpret the strip, and sign. The DMTPCU stated the strips were incomplete and the nurses were not following their policy. 4e. A concurrent interview and record review were conducted with the CEC on May 9, 2024, at 3:09 p.m. A review of Patient 28’s record was conducted. The facility document titled, “H&P,” indicated, Patient 28 was admitted to the facility on May 5, 2024, for blood in stools for months. A review of facility documents tilted, “Caliper Measurement,” was conducted. There was no documented evidence the six second telemetry strips were completed with full printed, signed name, date, and time of interpretation on the following dates: -May 4, 2024, night shift; -May 5, 2024, day shift, missing strip in the medical record; -May 5, 2024, night shift; and -May 6, 2024, day shift. An interview and record review were conducted with the CEC on May 9, 2024, at 3:51 p.m. The CEC stated she was unable to find the telemetry strip for May 5, 2024 a.m. shift. The CEC also stated that the telemetry strips were not printed, signed and dated. 4f. A concurrent interview and record review were conducted with the CEC on May 10, 2024, at 8:40 a.m. A review of Patient 29’s record was conducted. The facility document titled, “H&P,” indicated, Patient 29 was admitted to the facility on May 3, 2024, for cough, generalized weakness, and urinary tract (bladder) infection. A review of the facility documents tilted, “Caliper Measurement,” was conducted. There was no documented evidence the six second telemetry strips were completed with full printed, signed name, date, and time of interpretation on the following dates: -May 3, 2024, night shift; -May 4, 2024, day shift or night shift; -May 5, 2024, day shift or night shift; -May 6, 2024, day shift or night shift; -May 7, 2024, day shift or night shift; and -May 8, 2024, day shift or night shift. An interview and record review were conducted with the CEC on May 10, 2024, at 9:39 a.m. The CEC stated the telemetry strips were not complete as per policy. 4g. A concurrent interview and record review were conducted with the CEC on May 8, 2024, at 3:20 p.m. A review of Patient 30’s record was conducted. The facility document titled, “H&P,” indicated, Patient 30 was admitted on May 5, 2024, for seizure like activity, confusion, and fell out of the bed. A review of the facility documents tilted, “Caliper Measurement,” was conducted. There was no documented evidence the six second telemetry strips were complete with full printed, signed name, date, and time of interpretation on the following dates: -February 5, 2024, 1550 (3:50 p.m.); -February 5, 2024, 2112 (9:12 p.m.); -February 5, 2024, 2145 (9:45 p.m.); -February 6, 2024, 1200 (12:00 a.m.); -February 6, 2024, 0200 (2:00 a.m.); -February 6, 2024, 0227 (2:27 a.m.); and -February 6, 2024, 0246 (2:46 a.m.). An interview and record review were conducted with the CEC on May 10, 2024, at 10:50 a.m. The CEC stated the telemetry strips were not complete as per policy. A review of the facility’s P&P titled, “Cardiac/Telemetry Monitoring in the Telemetry Units,” dated May 09, 2022, was conducted. The P&P indicated, “...To provide skilled cardiac monitoring to patients who require continuous telemetry...A six second (minimum) telemetry strip will be run a minimum of once per shift...A strip will also be run anytime dysrhythmias are noted...The strip (s) will be placed into the patient’s Chart after evaluation/documentation has been completed...Telemetry Monitor Technician responsibility for strip documentation...Documentation is to include a complete strip interpretation...PR, QRS, QT, rhythm type, heart rate...It is the endorsed Nurse’s responsibility to chart the Rhythm interpretation in the EMR...Strip evaluation and documentation on the strip for telemetry monitored patient in the Telemetry Units is done by the designated Telemetry Monitor Technician...The strip will include the nurse’s Full Printed and Signed name, Date, and Time of interpretation and place the strip in the patient’s chart...” 5. On May 10, 2024, at 9:19 a.m., an interview and concurrent record review was conducted with the Senior Clinical Effectiveness Coordinator (SCEC). Patient 5’s H&P indicated she was admitted to the facility on May 4, 2024, for pneumonia (lung inflammation caused by bacterial or viral infection). A review of the facility’s document titled, “Wound Care Consult,” dated May 5, 2024, at 6:18 a.m., was conducted. The documented indicated, “...Reason for Consult...Stage 4 pressure on sacral [tail bone] area...Special instructions...Eval and Treat...” There was no documented evidence that a wound consult was completed for Patient 5. An interview and concurrent record review was conducted on May 10, 2024, at 9:53 a.m., with the SCEC. The SCEC stated there was no documented evidence in the chart a wound consult was completed per physican order. An interview and concurrent record review were conducted on May 10, 2024, at 9:58 a.m., with the WCPM. The WCPM stated she did not see any evidence the wound consult was done. The WCPM further stated, “I did not do it, I was assisting with the survey”. The WCPM stated she was the only wound care nurse at this time. A review of the P&P titled, “[Facility Name] Physician’s Orders,” undated, was conducted. The documented indicated, “...Licensed personnel may carry out orders for which there is a hospital Policy/Procedure and for which they have been trained...Provider orders will be accurately processed and promptly followed...” 6a. A review of Patient 4’s record was conducted. The History and Physical (H&P), dated April 7, 2024, indicated Patient 4 was admitted to the facility on April 7, 2024, for anemia and gastrointestinal bleed. The facility document titled, “Progress Note-Physician,” dated April 7, 2024, indicated, “...Discussed in detail with the patient in case of emergency in which his heart stops or he is unable to breath the methods of which he would take in order to preserve life...The patient is in full understanding of the risk of benefits of life saving/heroic measures and would like to have DNR/DNI [do not resuscitate/do not intubate] in the event of incapacitation for any reason while in the hospital...” The facility document titled, “Progress Note-Physician,” dated April 8, 2024, at 1741 (5:41 p.m.), authored by Resident (R 1) was reviewed. The document indicated, “...CODE BLUE was activated on 04/08/2024 [April 8, 2024] at 1521 [3:21 p.m.]. Upon arrival, patient was found laying on the floor of his room with noticeable urinary incontinence and stool. Nursing staff advised that the patient was pulseless and unresponsive and CPR [life saving procedure performed when the heart stops] was in progress at the time of arrival. Had reviewed patient’s CODE STATUS prior to arrival and called off all heroic measures as patient was DNI/DNR. Patient was pronounced at 1522 [3:22 p.m.]. Non responsive to painful stimulus, no initiation of breaths, absent pulse, asystole on monitor, absent heart & breath sounds on auscultation, no pupillary reflex. Updated the wife and daughter at bedside...” The facility document titled, “Progress Note-Physician,” dated April 9, 2024, at 12:24 p.m., authored by, Physician (P 1) was reviewed. The document indicated, “...Spoke with wife...over the phone today giving our condolences to her and her family and also reached out to see if there is anything that we can do to help. In addition I also disclosed to [name of wife] that there was a period of approximately 25 minutes where her husband’s heart rate gradually declined and stated that in these types of circumstances typically the physician would have been notified but due to unforeseen reasons we were not...” The facility document titled, “Progress Note-Nurse,” dated April 8, 2024, at 1932 (7:32 p.m.), authored by RN 1 was reviewed. The document indicated, “...At approx.[approximately] 1520 [3:20 p.m.] tele [telemetry] monitor alerted asystole [heart ceases to beat]. Went to check on pt [patient] who was found on the floor unresponsive...Checked for pt pulse not (sic) was found initiated code blue and began chest compression...” The facility document titled, “Telemetry Specific Details,” dated April 8, 2024, at 1517 (3:17 p.m.) was reviewed. The document indicated, “...at 1517 [3:17 p.m.]...Tele Alert Notification Reason...Bradycardia, other informational didn’t alarm...at 1521 [3:21 p.m.]...Asystole...Flag Comments by [name of telemetry monitor tech, MT 1], on April 8, 2024, 1539 [3:39 p.m.] attempted to contact RN, CODE blue called after...” Review of the facility’s EKG (electrocardiogram, [test for heart rate and rhythm]) strips, dated April 8, 2024, indicated the following: - At 14:59:12 (2:59 and 12 seconds p.m.), Patient 4’s heart rate was 50 beats per minute; - At 14:59:20 (2:59 and 20 seconds p.m.), Patient 4’s heart rate was 41 beats per minute; - At 14:59:29 (2:59 and 29 seconds p.m.), Patient 4’s heart rate was 37 beats per minute; -At 14:59:38 (2:59 and 38 seconds p.m.), Patient 4’s heart rate was 43 beats per minute; - At 15:09:49 (3:09 and 49 seconds p.m.), Patient 4’s heart rate was 46 beats per minute; - At 15:09:58 (3:09 and 58 seconds p.m.), Patient 4’s heart rate was 48 beats per minute; -At 15:14:32 (3:14 and 32 seconds p.m.), Patient 4’s heart rate was 44 beats per minute; - At 15:14:40 (3:14 and 40 seconds p.m.), Patient 4’s heart rate was 50 beats per minute; - At 15:19:38 (3:19 and 38 seconds p.m.), Patient 4’s heart rate was 30 beats per minute; - At 15:19:46 (3:19 and 46 seconds p.m.), Patient 4’s heart rate was 29 beats per minute; - At 15:21:26 (3:21 and 26 seconds p.m.), Patient 4’s heart rate was 20 beats per minute; - At 15:21:28 (3:21 and 28 seconds p.m.), Patient 4’s heart rate was 20 beats per minute; - At 15:21:34 (3:21 and 34 seconds p.m.), Patient 4’s heart rate was 0 beats per minute; and - At 15:21:36 (3:21 and 36 seconds p.m.), Patient 4’s heart rate was 0 beats per minute. An interview and concurrent record review were conducted with the DMTPCU on May 10, 2024, at 12:55 p.m. The DMTPCU stated there were three level alarms for heart rate parameters and defaulted at heart rate of 50. The DMTPCU stated alarms get louder and louder based on the level. The DMTPCU stated the tele machine at 2:59:20 (2:59 and 20 seconds p.m.) started to alarm and the patient was at 41 beats per minute and there was no evidence MT 1 notified RN 1. The DMTPCU stated MT 1 was busy interpreting a tele strip for a newly admitted patient. The DMTPCU stated MT 1 was monitoring 48 patients and at this time there were multiple alarms going off. The DMTPCU stated the alarm was set at 10% volume, which is deemed low for the day shift due to ambient noise. The DMTPCU stated MT 1 stated Patient 4’s decline in heart rate was an oversight as he did not hear the alarm. There was no documented evidence MT 1 notified RN 1 of Patient 4’s low heart rate on April 8, 2024, from 2:59 and 12 seconds p.m. to 3:21 and 36 seconds p.m., (22 minutes and 44 seconds). There was no documented evidence Patient 4 was assessed for physical symptoms related to severe changes in heart rate and rhythm on April 8, 2024, from 2:59 and 12 seconds p.m. to 3:21 and 36 seconds p.m., (22 minutes and 44 seconds), when the patient’s heart rate was low. 6b. On May 8, 2024, at 1 p.m., an interview and concurrent record review were conducted with the SPM. A review of Patient 7’s record was conducted. The H&P dated May 2, 2024, indicated, Patient 7 was admitted to the facility for dizziness, double vision, and UTI (urinary tract infection). The facility document titled, “Cardiac Rhythm,” dated May 1, 2024, through May 7, 2024, was reviewed. The document indicated, “...Sinus Bradycardia...05/02/2024 [May 2, 2024]...07:54:00 [7:54 a.m.]...” There was no documented evidence the Monitor Tech (MT 2) notified the RN. The facility document titled, “Communication Log,” dated May 1, 2024, through May 8, 2024, was reviewed. There was no documented evidence a notification was made to the RN on May 2, 2024, for the bradycardic episode of Patient 7. An interview was conducted on May 8, 2024, at 1:25 p.m., with the DMTPCU. The DMTPCU stated he was not able to find any communication from MT 2 to the RN for Patient 7’s bradycardia on May 2, 2024. He stated the MT 2 should have called the RN when the heart rate fell below the parameters. The DMTPCU further stated MT 2 should have documented the notification in the EMR. The DMTPCU stated the bradycardia telemetry strip was not in the EMR and it should have been printed and placed in the patient’s chart. A review of the P&P titled, “Cardiac/Telemetry Monitoring in the Telemetry Units,” dated May 9, 2022, was conducted. The P&P indicated, “...To provide skilled cardiac monitoring to patients who require continuous telemetry...An evaluation of the patient will occur by the RN...with any changes in rhythm, heart rate, or conduction. The physician will be notified as appropriate...All life-threatening rhythms require physician notification...The Telemetry Monitor Technician will notify the RN...any time there is a change in rhythm or concern about the patient. The Telemetry Monitor Technician will also document these changes in the EMR...The Telemetry Monitor Technician will log the call to the RN...in the EMR...The Telemetry Monitor Technician will maintain a report on all telemetry monitored patients...Heart rate alarms and the arrythmia analysis function must be turned ON at all times...” 7. A tour of the computed tomography (CT) room #1 was conducted on May 6, 2024, at 3:26 p.m., with the Radiology Director (Rad. Dir.), Radiology Supervisor (Rad. Sup.) and WCPM. During a concurrent observation and interview on May 6, 2024, at 3:39 p.m., with the Rad. Dir, Rad. Sup., and the WCPM, in CT room #1, one unattended intravenous contrast Lopamidol (contrast agent) injection bottle was observed in a drawer of the supply cart. The Rad. Dir. stated it should not be there and should have been in the Pyxis (automated medication dispensing unit) because the medication was sensitive to light. During a review of the manufacturer’s instruction for use titled, “[Brand Name] Imaging Bulk Package,” dated April 2023, indicated, “...Storage: Store at 20-25° C (68-77° F). (See USP [United States Pharmacopoeia]). Protect from light.” A review of the P&P titled, “Secure Medication Storage and Access to Medications,” dated April 8,2024, indicated, “...No medication may be kept on the person of the healthcare provider...Medications will be obtained from the appropriate storage and promptly administered to the patient...Medications will be kept in approved containers up to the actual dispensing to the patient...Medication removed for administration to a patient and not administered must be returned to the properly designated storage area as soon as possible...” 8. A tour of the Minor Procedure Room was conducted on May 7, 2024, at 9:40 a.m., with the Interim Operating Room Director (IORD), Gastrointestinal Technician (GI Tech) and the WCPM. During a concurrent observation and interview on May 7, 2024, at 9:43 a.m., with the IORD, GI Tech, and the WCPM in the minor procedure room, two bottles of 0.25% Bupivacaine Hcl injection, solution (indicated for the production of local or regional anesthesia or analgesia for surgery, dental and oral surgery procedures, diagnostic and therapeutic procedures, and for obstetrical procedures) was observed unattended, on an open shelf in the room. The IORD stated the medication should not have been left unattended and should have been locked or returned to the pharmacy if not used. A review of the P&P titled, “Secure Medication Storage and Access to Medications,” dated April 8, 2024, indicated, “...All controlled drugs will be kept in individual pockets in a Pyxis Med [medication] Station (e.g., “cubie” drawers)...To prevent diversion, controlled drugs must be stored in locked areas accessible to authorized personnel only...No medication shall be left out in any other unsecured area, including operating rooms...” 9. On May 8, 2024, at 9:37 a.m., a review of Patient 18’s record was conducted with the WCPM. A review of Patient 18’s facility document titled, “H&P,” dated May 4, 2024, indicated, Patient 18 was admitted for respiratory failure, renal failure, shock and urinary tract infection. A review of Patient 18’s facility document titled, “Procedure Note (Physician),” dated May 4, 2024, indicated, “Procedure performed: Right Arterial Line Placement.” There was no documented evidence that a procedural time-out was conducted prior to the procedure on May 4, 2024. During a concurrent interview and record review on May 8, 2024, at 9:46 a.m., conducted with the CS, Patient 18’s record was reviewed. There was no documented evidence that a a procedural time out was performed before the arterial line placement. The CS stated, per the facility policy a procedural time out should have been performed prior to the procedure but was not. A review of the P&P titled, “Universal Protocol,” dated April 08, 2024, indicated, “...A universal protocol is a process used to identify the correct patient, the correct procedure, the correct proceduralist and the correct site. Prior to the initiation of an operative or invasive procedure, UP (universal protocol) must be followed and documented...Time Out Process...Procedural time out - a time out is conducted immediately before the start of an operative or invasive procedure to provide a final verification of the patient, site, procedure and proceduralist...””

“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: 45431 Based on observation, interview and record review, the facility did not follow the infection control plan to maintain the cleanliness of the facility environment when: 1. Operating room temperatures were not maintained per Association of Operating Room Nurses (AORN) guidelines. 2. Temperature and humidity were not monitored in the gastrointestinal (GI, related to the stomach and intestines) lab decontamination and clean room. 3. Surgical tables and mats in Operating Rooms (OR) 2 and 4 were left wet after cleaning. 4. Two IV (intravenous, within the vein)) poles were found with chipped paint and rusty color at the base in Operating Rooms 2 and 4. 5. Multiple equipment in the Radiology Department (RD, medical speciality using medical imaging to diagnose diseases and guide treatment) were not appropriately cleaned. These failures placed all patients receiving services in these areas, at risk for infection and to not receive quality health care. Findings: 1. On May 6, 2024, at 1:23 p.m., a tour of Operating Rooms 1, 2, 3, 4, and 5 was conducted with the Interim Operating Room Manager (IORD) and the Clinical Effective Coordinator (CEC). During the tour in Operating Room (OR) 4, the temperature monitor mounted on the back wall was observed at 65.5 degrees Fahrenheit. A review of facility document titled, “OR DAILY REPORT,” indicated, the temperatures in the Operating Rooms were as followed: -May 6, 2024, at 65 degrees Fahrenheit in Operating Room 1; -May 5, 2024, at 65 degrees Fahrenheit in Operating Room 1; -May 4, 2024, at 64.9 degrees Fahrenheit in Operating Room 1; -May 3, 2024, at 65 degrees Fahrenheit in Operating Room 1; -May 2, 2024, at 65.4 degrees Fahrenheit in Operating Room 1; -May 1, 2024, at 64.9 degrees Fahrenheit in Operating Room 1; -April 30, 2024, at 65.4 degrees Fahrenheit in Operating Room 1; -April 29, 2024, at 67.0 degrees Fahrenheit in Operating Room 1; -May 6, 2024, at 67.7 degrees Fahrenheit in Operating Room 2; -May 4, 2024, at 67.9 degrees Fahrenheit in Operating Room 2; -May 2, 2024, at 67.7 degrees Fahrenheit in Operating Room 2; -May 1, 2024, at 67.8 degrees Fahrenheit in Operating Room 2; -May 6, 2024, at 67.8 degrees Fahrenheit in Operating Room 3; -May 4, 2024, at 67.3 degrees Fahrenheit in Operating Room 3; -May 3, 2024, at 67.7 degrees Fahrenheit in Operating Room 3; -May 2, 2024, at 67 degrees Fahrenheit in Operating Room 3; -May 1, 2024, at 67.2 degrees Fahrenheit in Operating Room 3; -April 30, 2024, at 67.4 degrees Fahrenheit in Operating Room 3; -April 29, 2024, at 67.6 degrees Fahrenheit in Operating Room 3; -May 6, 2024, at 66.5 degrees Fahrenheit in Operating Room 4; -May 5, 2024, at 65.8 degrees Fahrenheit in Operating Room 4; -May 4, 2024, at 66.2 degrees Fahrenheit in Operating Room 4; -May 3, 2024, at 65.1 degrees Fahrenheit in Operating Room 4; -May 1, 2024, at 65.7 degrees Fahrenheit in Operating Room 4; -April 30, 2024, at 65.2 degrees Fahrenheit in Operating Room 4; -April 29, 2024, at 66.3 degrees Fahrenheit in Operating Room 4; -May 6, 2024, at 64.8 degrees Fahrenheit in Operating Room 5; -May 5, 2024, at 65.3 degrees Fahrenheit in Operating Room 5; -May 4, 2024, at 65.1 degrees Fahrenheit in Operating Room 5; -May 3, 2024, at 64.9 degrees Fahrenheit in Operating Room 5; -May 2, 2024, at 65.7 degrees Fahrenheit in Operating Room 5; -May 1, 2024, at 64.5 degrees Fahrenheit in Operating Room 5; -April 30, 2024, at 64.7 degrees Fahrenheit in Operating Room 5; and -April 29, 2024, at 64.9 degrees Fahrenheit in Operating Room 5. An interview and concurrent record review were conducted on May 7, 2024, at 1:23 p.m., with the Director of Plant Operations (DPO). The DPO stated he reviewed the temperature and humidity policy, and it indicated OR temperature should be between 64-75 degrees Fahrenheit. The DPO stated the information was from the AORN guidelines they follow however, he was unable to state which version of the guidelines they were following. A follow up interview was conducted on May 8, 2024, at 11:15 a.m., with the DPO. The DPO stated they follow the 2021 AORN guidelines that indicated the OR room temperature should be between 68-75 degrees Fahrenheit. He stated they were not meeting the guidelines. On May 8, 2024, a review of the document titled, “AORN eGUIDELINES,” dated 2024, was conducted. The document indicated “...Temperature...OR’s should be designed to maintain space temperature between 68-75 degrees Fahrenheit...” 2. A tour of the GI decontamination room was conducted on May 7, 2024, at 9:45 a.m., with the IORD, GI technician (GI tech) and Wound Care Program Manager (WCPM). During a tour of the GI decontamination room on May 7, 2024, at 9:54 a.m., a thermostat mounted on the wall was observed. During an interview on May 7, 2024, at 10:02 a.m., with the GI tech, the GI Tech stated the room temperature and humidity was not being monitored. On May 7, 2024, at 10:02 a.m., the facility was unable to provide the requested temperature and humidity logs for the GI decontamination and clean room. There was no documented evidence the temperature and humidity was being monitored in the GI decontamination and clean rooms. A review of the AORN eGuideline titled, “AORN Guidelines Summary: Processing Flexible Endoscopes [an instrument which can be introduced into the body to view internal parts],” undated, indicated, “...Maintain relative humidity and temperature within the heating, ventilation, and air conditioning (HVAC) design parameters. Processing flexible endoscopes in an area where temperature, humidity, environmental cleaning, surgical attire, traffic patterns, and security are managed may improve efficiency, help maintain functionality of flexible endoscopes, reduce the risk of cross contamination, and provide a safe work environment...” 3. On May 6, 2024, at 2:30 p.m., a tour of OR 2 and 4 was conducted with the IORD and the CEC. During the tour on May 6, 2024, at 2:30 p.m., in Operating Room 2, the underside of the mats and the surgical table were observed to be wet. An interview was conducted on May 6, 2024, at 3:15 p.m,. with the IORD. The IORD stated the table and mats were wet and they should not have been wet. The mats and table should have been dry depending on the dwell time. The mats should have been dried before they were placed on the surgical table. During the tour on May 6, 2024, at 3:25 p.m., in Operating Room 4, the underside of the mats and the surgical table were observed to be wet. An interview was conducted on May 6, 2024, at 3:25 p.m., with the Environmental Services (EVS) 1. The EVS 1 stated the underside of the mats and table were wet. EVS 1 stated the mats should not have been wet. EVS 1 stated the turnover of the room was quick and there was no time to wait for it to dry. EVS 1 stated they cleaned with VIREX Plus (a cleaning solution). EVS 1 stated the VIREX Plus was to stay on the surface for two minutes. EVS 1 stated the rag might have been too wet when cleaning the table. EVS 1 further stated the table should have only been wet for 2 (two) minutes. An interview was conducted on May 7, 2024, at 1:36 p.m., with the Environmental Services (EVS) 2. The EVS 2 stated the process was to take the bucket to the Doverseu Quattroselect (dispenser used to mix the Virex Plus and water) and choose the type of cleaner, Virex Plus or the Crew Na SC (cleaning solution). The EVS 2 stated the cleaner that was used in the OR was the Virex Plus. The EVS 2 stated the dispenser would automatically mix the solution with the water. EVS 2 further stated she changed the soap solution at least two or three times in eight hours. The EVS 2 stated they were to leave the solution on the surgical table and mats for 2-3 minutes. An interview was conducted on May 8, 2024, at 10:56 a.m., with the Environmental Services Supervisor (EVSS). The EVSS stated the carts were set up with the Virex Plus in the buckets. The EVSS stated the rag should be wet enough to stay wet for the duration of the dwell time. The EVSS stated the dwell time was three minutes. If the equipment was still wet, they were to dry with another rag. The EVSS stated the room turn over time was 10-15 minutes depending on the type of surgical case. The EVSS stated competencies were done every year and placed in the employee’s file. The EVSS stated two minutes was not the correct dwell time. EVSS stated the correct dwell time was three minutes. The EVSS reviewed the picture of OR 4 surgical table, and mats, and stated the table was wet and should not be. EVSS further stated that either the rag was too wet, or the staff did not allow for dry time. A review of the undated, Virex Plus instructions, was conducted on May 8, 2024, at 1:38 p.m. The instructions indicated, “...Directions for use...Contact Time: Leave surface wet for 1 minute for HIV-1(Human Immunodeficiency Virus, a virus that attacks calls that help the body fight infection) and three minutes for HBV (Hepatitis B Virus, an infection of the liver) and HCV (Hepatitis C Virus, viral infection that causes liver inflammation, or swelling) with a 1/2 ounce per gallon use-solution use contact time indicated on the label for disinfection against all other viruses bacteria and fungi...” A review of Policy and Procedure titled, “Equipment- Cleaning Schedule,” dated May 9, 2022, was conducted. The policy indicated “...Equipment will be cleaned with hospital approved germicide after each patient use on a regular schedule...The manufacture’s recommendation for use will be followed...Equipment cleaning responsibilities are listed in the table that follows...EQUIPMENT...Beds (all hospitals owned)...WHO...EVS...HOW...Hospital-approved disinfectant...WHEN...All surfaces upon patient discharge...” 4. On May 6, 2024, at 2:35 p.m., a tour of OR 2 was conducted with the IORD and the CEC. During the tour on May 6, 2024, at 2:35 p.m., in Operating Room 2, an IV pole was observed to have chipped paint and a rusty color at the base of the pole. During the tour on May 6, 2024, at 3:45 p.m., in Operating Room 4, an IV pole was observed to have chipped paint and a rusty color at the base of the pole. An interview was conducted on May 7, 2024, at 1:43 p.m., with the Clinical Supervisor (CS). The CS stated the IV poles were removed from OR 2 and OR 4 due to equipment being damaged. The CS further stated that sometimes the equipment will come from other units and the damage was missed when in the OR. An interview was conducted on May 7, 2024, at 2:16 p.m., with the Senior Clinical Effective Coordinator (SCEC). The SCEC stated upon review of the picture of the IV pole from the OR, the pole would be considered damaged equipment and should have been removed from the OR. A review of Policy and Procedure titled, “Mechanical Safety,” dated August 7, 2021, was conducted. The policy indicated, “...All mechanical devices shall be inspected and approved prior to use in patient care areas...Staff members are to report any malfunctioning or damaged equipment to their supervisor immediately...Check all...broken platforms...Report any malfunction to your Supervisor or Director, placing an out of order red ticket on the device...” 5. A tour of the Radiology Department was conducted on May 6, 2024, at 2:15 p.m., with the Radiology Director (Rad Dir), Radiology Supervisor (Rad Sup) and WCPM. During a concurrent observation and interview on May 6, 2024, at 2:52 p.m., with the Rad Dir, Rad Sup, and WCPM, in the Fluoroscopy (medical imaging procedure that uses an X-ray beam to create a continuous X-ray image on a monitor in real time) room, a dried brown smear on the black pad attached to the panel beside the MBS (Modified Barium Swallow, a non-invasive, quick, radiographic procedure that allows a doctor to examine a patient’s swallowing anatomy) chair was observed. The Rad Sup wiped down the smear and stated it was dirt or possible body fluid from the last patient that was in this room. The Rad Dir stated the panel should have been wiped down after each patient use. During an interview on May 6, 2024, at 3:08 p.m., with the Environmental Services Supervisor (EVSS 2), the EVSS 2 stated the room is terminally cleaned (a thorough cleaning and disinfection procedure used in healthcare facilities) when requested and daily at night. The EVSS 2 further stated cleaning included high dusting, removal of trash, and mopping the floors. During a tour on May 6, 2024, at 3:10 p.m., in the Fluoroscopy room, gray fuzzy matter was observed all over the [Equipment Name] cart, and the [Equipment Name] device. During an interview on May 6, 2024, at 3:12 p.m., with the EVSS 2, the EVSS 2 stated the device, and the cart should have been cleaned and dusted daily but were not. During a concurrent observation and interview on May 6, 2024, at 3:15 p.m., with the Rad Dir, Rad Sup and WCPM, in the X-Ray room, gray and black particles on the surfaces of the X-ray tube and “Wall Bucky” were observed. The Rad Dir stated it should have been dusted by EVS when they cleaned at night. During a concurrent observation and interview on May 6, 2024, at 3:26 p.m., with the Rad Dir, the Rad Sup and WCPM, in the Computed Tomography Room (CT#1, computerized X-ray imaging procedure in which a narrow beam of X-rays is aimed at the patient and quickly rotated around the body), accumulated gray, black and fuzzy particles on top of the suction canister at the side of the crash cart and on the surface and screen of the defibrillator were observed. The Rad Dir stated it should have been dusted by EVS when they cleaned at night. A review of the facility’s policy and procedure titled, “Imaging Rooms,” dated October 10, 2022, indicated, “...Procedure...Perform the Standard 7 Step Process...Complete the High Dust process...Inspection Standards 1. Ceilings, ledges, countertops, furniture, and cabinets are clean and free of dust...””

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 42512 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 patients were not provided a Chlorhexidine Gluconate (CHG, bathing product that kills germs and reduces the spread of infections in hospitals) bath, in accordance with the facility’s Policy and Procedure (P&P), for seven of 30 sampled patients (Patient 1, 3, 11, 22, 23, 26, and 27). These failures had the potential to result in the transmission and spread of pathogens (bacteria, virus, or other microorganism) which could cause disease/s to the patients receiving care in the facility. Findings: a. A concurrent interview and record review were conducted with the Cardiac Manager (CM) on May 8, 2024, at 1:13 p.m. Patient 1’s History and Physical (H&P) indicated Patient 1 was admitted to the facility on April 28, 2024, for shortness of breath and STEMI (a heart attack). There was no documented evidence Patient 1 was allergic to CHG. A facility document titled, “Order,” dated April 28, 2024, at 2:33 a.m., was reviewed. The document indicated, “...Level of Care...Critical Care...” The Central Line flow sheet dated April 28, 2024, at 5:06 p.m., was reviewed. The document indicated a central line was inserted. The Function and Safety flow sheets, from April 28, 2024, to May 8, 2024, were reviewed. There was no documented evidence Patient 1 was provided a CHG bath on May 1, 2024, May 4, 2024, and May 6, 2024. An interview was conducted with the CM on May 8, 2024, at 1:47 p.m. The CM stated the three days listed above were missing CHG baths. The CM further stated the patient had a central line and was admitted to Critical Care level of care and should have had a daily CHG bath per facility policy. b. Patient 3’s H&P indicated he was admitted to the facility on April 2, 2024, for syncope (fainting) and pneumonia (bacterial or viral infection in the lungs). There was no documented evidence Patient 3 was allergic to CHG. The Central Line flow sheet dated April 15, 2024, at 10:02 a.m., was reviewed. The document indicated a central line was inserted. The Function and Safety flow sheets, from April 15, 2024, to May 8, 2024, were reviewed. There was no documented evidence Patient 3 was provided a CHG bath on April 26, 2024, May 1, 2024, May 4, 2024, May 5, 2024, and May 6, 2024. An interview was conducted with the CM on May 8, 2024, at 1:58 p.m. The CM stated the five days listed above were missing CHG baths. The CM further stated the patient had a central line in place and should have had a daily CHG bath per policy. c. An interview and record review were conducted with the Clinical Supervisor (CS) on May 9, 2024, at 9:45 a.m. The following records were reviewed: Patient 11’s H&P indicated he was admitted to the facility on May 2, 2024, for shortness of breath (SOB), increased cough and rhonchi (low pitched and rattling breath sounds). There was no documented evidence Patient 11 was allergic to CHG. The Urinary Catheter (Foley Protocol) sheet dated May 4, 2024, was reviewed. The document indicated Patient 11 had a Foley Catheter (a semi flexible plastic tube that is inserted into the bladder to drain urine). There was no documented evidence Patient 11 was provided a CHG bath on May 4, 2024, May 5, 2024, and May 6, 2024. An interview was conducted with the CS on May 9, 2024, at 2:55 p.m. The CS stated Patient 11 had a Foley catheter and should have had a CHG bath daily. The CS stated there was no documented evidence Patient 11 received a CHG bath on May 4, 2024, through May 6, 2024. d. An interview and record review were conducted with the Wound Care Program Manager (WCPM) on May 9, 2024, at 2:45 p.m. The following records were reviewed: A review of Patient 22’s record was conducted. The facility document titled, “H&P,” indicated, Patient 22 was admitted to the facility on November 26, 2023, for Transaminitis (high levels of a particular type of enzyme in your blood, called a transaminase) and Proctitis (inflammation of the rectum and anus). This document further indicated Patient 22 had a foley catheter on admission. There was no documented evidence Patient 22 was allergic to CHG. The Function and Safety flow sheets, from November 26, 2023, through November 31, 2023, were reviewed. There was no documented evidence Patient 22 was provided a CHG bath from November 26, 2023, through November 31, 2023. An interview was conducted with the WCPM on May 9, 2024, at 3:04 p.m. The WCPM stated the patient should have had a CHG bath per the hospital CAUTI (Catheter Associated Urinary Tract Infection) protocol. e. An interview and record review were conducted with the Clinical Effective Coordinator (CEC) on May 8, 2024, at 12:30 p.m. The following records were reviewed: A review of Patient 23’s record was conducted. The facility document titled, “H&P,” indicated, Patient 23 was admitted to the facility on May 1, 2024, for painless abdominal cramping. There was no documented evidence Patient 23 was allergic to CHG. A facility document titled, “Preprocedural Checklist,” dated May 6, 2024, was reviewed. The document indicated, “...Chlorhexidine Bath...Completed...NO...Chlorhexidine Shower completed...NO...Chlorhexidine wipes completed...NO...Chlorhexidine 2% wipe of surgical site Completed...NO...” An interview was conducted with the CEC on May 8, 2024, at 1:10 p.m. The CEC stated she was unable to find documentation the CHG bath was given prior to the surgical procedure. The CEC stated if unable to find in the documentation in the Electronic Medical Record (EMR) then one can assume the CHG bath was not given. f. An interview and record review were conducted with the CEC on May 9, 2024, at 10 a.m. The following records were reviewed: A review of Patient 26’s record was conducted. The facility document titled, “H&P,” indicated, Patient 26 was admitted to the facility on May 7, 2024, for cardioversion (procedure to return heartbeat to normal rhythm). There was no documented evidence Patient 26 was allergic to CHG. A facility document titled, “Preprocedural Checklist,” dated May 7, 2024, was reviewed. The document indicated, “...Chlorhexidine Bath...Completed...Blank...Chlorhexidine Shower completed...Blank...Chlorhexidine wipes completed...Blank...” An interview was conducted with the CEC on May 9, 2024, at 10:57 a.m. The CEC stated the patient should have had a CHG bath prior to the procedure. The CEC stated the CHG bath was not documented in the preprocedural check list or the EMR. g. An interview and record review were conducted with the CEC on May 9, 2024, at 10 a.m. The following records were reviewed: A review of Patient 27’s record was conducted. The facility document titled, “H&P,” indicated, Patient 27 was admitted to the facility on May 5, 2024, for worsening chest pain, NSTEMI (non ST elevated myocardial infarction) heart attack. There was no documented evidence Patient 27 was allergic to CHG. The Function and Safety flow sheets, from May 4, 2024, to May 9, 2024, were reviewed. There was no documented evidence Patient 26 was provided a CHG bath on May 4, 2024, May 5, 2024, May 6, 2024, May 7, 2024, May 8, 2024, and May 9, 2024. An interview was conducted with the CEC on May 9, 2024, at 1:20 p.m. The CEC stated there was no documentation that the patient had a CHG bath in the EMR. The CEC stated the patient should have had a CHG bath once per shift. The review of the facility’s P&P titled, “Central Venous Catheters- Insertion, Care, Maintenance and Removal,” dated July 13, 2020, was conducted. The document indicated, “...Ongoing documentation for the patient with a central venous catheter should include the location of the catheter, number of lumens and catheter size, type of dressing, site assessment, presence of any complications, and any actions taken...Daily CHG bath...” The review of the facility’s P&P titled, “Preventing Catheter Associated Urinary Tract Infections (CAUTI),” dated May 10, 2021, was conducted. The document indicated, “...To reduce the incidence of hospital acquired, catheter associated urinary tract infections...Urinary tract infections can result in sepsis, prolonged hospitalization and mortality...Perineal/meatal care should be performed at least every shift and the patient will receive a daily CHG bath as needed utilizing hospital approved peri-wash products and bath wipes...” The review of the facility’s P&P titled, “Prevention of Surgical Site Infections,” dated October 10, 2022, was conducted. The document indicated “...Patient will be bathed preoperatively with an antimicrobial product (Chlorhexidine gluconate preferred) the evening before and the morning of surgery...””

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to ensure the needs of all patients requiring gastrointestinal (GI) services (the study, diagnosis and treatment of disorders that deal with the digestive system) including the use of flexible endoscopes (a reusable instrument used to inspect and treat the interior portions of the body) were met when: 1. Management and staff of the GI department were unaware of the standards or guidelines to follow for the processing and storing of flexible scopes. 2. ANSI/AAMI (American National Standards Institute/ Association for the Advancement of Medical Instrumentation) guidelines were not followed when there were not a two or three compartment sink for processing/cleaning the flexible scopes. 3. The endoscope storage cabinet did not contain a HEPA (high efficiency particulate air [filter]). This type of air filter can remove dust, pollen, mold, bacteria, and any airborne particles with a size of 0.3 microns (µm - unit of measurement) filter and preventive maintenance were not performed in accordance with ANSI/AAMI guidelines. 4. Gray and black particles, and debris were observed scattered at the bottom of the endoscope scope storage cabinet. 5. The facility did not have a policy and procedure in place to guide staff on how to process and store the flexible scopes. 6. Gastrointestinal Technicians (GI Techs) did not have the certification needed to process endoscopes in accordance with ANSI/AAMI guidelines. These failures placed all patients receiving services in these areas, at risk for infection and to not receive quality health care. Findings: 1. A tour of the GI decontamination room was conducted on May 7, 2024, at 9:45 a.m., with the Interim Operating Room Director (IORD), GI technician (GI tech) and Wound Care Program Manager (WCPM). During an interview on May 7, 2024, at 9:54 a.m., with the IORD and GI tech, both were unable to articulate the standards or guidelines they follow for the processing and storage of the facility’s endoscopes. 2. During a concurrent observation and interview on May 7, 2024, at 9:55 a.m., with the GI Tech, in the GI Decontamination room, one compartment sink was observed being used to process scopes. The GI tech stated, this was the set up in place when he started in April 2023, and has been using one sink to process and clean all the endoscopes used in the GI department. During an interview with the IORD on May 7, 2024, at 12:51 p.m., in the conference room, the IORD stated the hospital followed the following nationally recognized guidelines: ANSI/AAMI ST91:2021 (2022) (American National Standards/Association for the Advancement of Medical Instrument, standards development organizations) Flexible and Semi Rigid endoscope processing in healthcare facilities. During a concurrent interview and record review on May 7, 2024 at 12:51 p.m., with the IORD, the facility document titled, “ANSI/AAMI ST91 flexible and semi-rigid endoscope processing health care facilities,” dated 2022, was reviewed. The ANSI/AAMI ST91 flexible and semi-rigid endoscope processing health care facilities indicated, “...Design of endoscope processing area...Physical Facilities...General space requirements...Space requirements in the decontamination area...decontamination sink for manual cleaning...sink...for leak testing...if the facility anticipates for manual high-level-disinfection or manual liquid chemical sterilization [a two-part process that uses a liquid chemical germicide to sterilize reusable medical devices that are sensitive to heat]...separate sink for rinsing...” The IORD stated they did not follow these guidelines. During an interview on May 9,2023, at 10:30 a.m., with the Respiratory Therapy Director (RTD). The RTD stated they processed and clean their bronchoscopes (a thin tube-like instrument with a light and lens that allows a medical professional to examine the insides of the lungs, trachea, and bronchi) in the GI Department. 3. During a concurrent observation and interview on May 7, 2024, at 10:05 a.m., with the IORD, GI tech and WCPM, in the GI clean room, the scope storage cabinet containing 20 scopes, did not have a HEPA filter. The IORD stated she did not know if the cabinet had a HEPA filter or if Biomed (a facility department) was monitoring this storage cabinet. The GI Tech stated the cabinet was a regular storage cabinet that did not have a HEPA filter and was not being monitored by the Biomed department. During an interview on May 7, 2024, at 10:14 a.m., the Biomed Engineer stated the endoscope storage cabinet in the GI clean room did not have a HEPA filter and was not being monitored by their department. During a record review on May 7, 2024, at 12:57 p.m., with the IORD, the facility document titled, “ANSI/AAMI ST91:2021 flexible and semi-rigid endoscope processing health care facilities”, dated 2022, indicated, “...Endoscope drying cabinets. Endoscope drying cabinets are closed cabinets designed for storage of flexible endoscopes that circulate HEPA-filtered or instrument air through the cabinet and each endoscope channel at continuous positive pressure...Conventional drying cabinets. Conventional cabinets are closed cabinets that enable circulation of HEPA-filtered or instrument air through the cabinet at passively or via continuous positive pressure, but do not include forced air through endoscope channels...” 4. During a concurrent observation and interview on May 7, 2024, at 10:05 a.m., with the IORD, and GI tech, in the GI clean room, 20 scopes were observed hanging freely in the cabinet and were labeled, “Clean”. Gray and black particles, and debris were observed scattered throughout the bottom of the cabinet where the scopes were stored. The IORD stated the expectation is for the cabinet to be cleaned daily but it was not. The GI tech stated he oversaw the cleaning of the storage cabinet daily however, he stated he had not done it daily as expected. During a concurrent interview and record review on May 7, 2024, at 12:55 p.m., with the IORD, the facility document titled, “ANSI/AAMI ST91:2021 flexible and semi-rigid endoscope processing health care facilities,” dated 2022, was reviewed. The ANSI/AAMI ST91:2021 flexible and semi-rigid endoscope processing health care facilities indicated, “...Storage of processed endoscopes...Storage of high level disinfected or liquid chemical sterilized endoscopes...Endoscopes are to be stored in an area that is clean, well-ventilated, and dust-free in order to keep the endoscopes dry and prevent exposure to potentially hazardous microbial contamination...” A review of the ANSI/AAMI guidelines, titled, “ANSI/AAMI ST91:2021 flexible and semi-rigid endoscope processing health care facilities,” dated 2022, indicated, “...Environmental Cleaning...Other surfaces, such as walls, storage shelves, endoscope storage cabinets, and registers and duct diffusers, should be cleaned and disinfected on a regularly scheduled basis and more often if needed...” 5. During the tour of the GI area on May 7, 2024, at 9:45 a.m., with the IORD, GI tech and WCPM, the policies and procedure for processing flexible scopes were requested. The IORD stated the facility did not have a policy in place to provide guidance to staff specific to processing flexible scopes. The review of ANSI/AAMI guidelines, titled, “ANSI/AAMI ST91:2021 flexible and semi-rigid endoscope processing health care facilities,” dated 2022, indicated, “...Quality control...General considerations...This section covers aspects of establishing policy and procedures, product identification and traceability, documentation and record-keeping, verification, and monitoring of the cleaning process, monitoring of high-level disinfection and sterilization processes, product recalls, and quality process improvement...Establishing policy and procedures for quality assurance and safety program. The health care facility should establish a multidisciplinary, comprehensive, written quality assurance and safety program for all aspects of endoscope processing...” 6. A review of the GI tech’s employee file was conducted on May 10, 2024, at 9:44 a.m., with the Human Resources Director (HRD). The HRD stated there was no documented evidence the GI tech was certified to process flexible scopes according to the guidelines. An interview was conducted on May 9, 2024, at 10 a.m., with the GI Tech. The GI Tech stated, Bronchoscopes used by the Respiratory Department are processed and cleaned in the GI area. The GI Tech further stated on occasion a staff member from the Respiratory Department will process the bronchoscopes when they (GI techs) are not working. An interview was conducted on May 10, 2023, at 10:30 a.m., with the RTD. The RTD stated, GI techs did the processing of their bronchoscopes but sometimes a designated Respiratory Therapist (RT) who served as a back up would process the scopes. The RTD was unsure if the RT was certified in processing flexible scopes. The RTD further stated her department followed AAMI - ST 91 for processing scopes. A review of the ANSI/ AAMI guidelines, titled, “ANSI/AAMI ST91:2021 flexible and semi-rigid endoscope processing health care facilities,” dated 2022, was conducted with the RTD. It indicated, “...Education, training, and competency verification...General considerations...All personnel performing processing of endoscopes should be certified in flexible endoscope processing within two years of employment and should maintain that certification throughout their employment...” A review of RT’s employee file was conducted on May 10, 2024, at 12:40 p.m. with the HRD. The HRD stated there was no documented evidence the RT was certified to process flexible scopes according to the guidelines. Due to the failures of the GI lab staff not being aware of the standards or guidelines to follow for the processing and storage of flexible scopes, the endoscope storage cabinet not containing a HEPA filter, gray and black debris being observed at the bottom of the endoscope storage cabinet, the facility not having a policy and procedures in place to guide staff on how to process and store the flexible scopes, and two GI Techs did not have certification needed to process endoscopes in accordance with the ANSI/AAMI guidelines, the survey team determined that an IJ (immediate jeopardy) situation existed on May 7, 2024, at 5 p.m., and was communicated to the hospital staff which included the Chief Nursing Officer (CNO), Director of Education (DE), Chief Operating Officer (COO), and the Senior Clinical Effectiveness Coordinator (SCEC). On May 9, 2024, at 4 p.m., the facility provided an acceptable removal plan of immediate action that included the following: 1. The facility approved and published a new scope cleaning and reprocessing policy as of May 8, 2024. 2. The facility will ensure all staff responsible for cleaning and reprocessing scopes have been made aware of the process. Education and training will be completed by May 8, 2024. 3. The facility will create and assign education in the Learning Management System (LMS) that includes a copy of the policy quarterly, and any updates to evidence-based practices. 4. Staff will perform an annual competency on scope cleaning and reprocessing. 5. A second sink will be installed on May 8, 2024. 6. A drying cabinet with a HEPA filter will be installed on May 8, 2024. On May 9, 2024, at 5 p.m., the implementation of the removal plan was verified onsite through observation, interview, and record review. The CNO was notified that the immediate jeopardy was removed.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 33972 Based on observation, interview, and record review, the facility failed to remove expired drugs from stock. This failure had the potential for patients to receive expired Intravenous (IV) solution (liquid injected into a person’s vein) and could potentially have an adverse outcome. Findings: On February 7, 2024, at 10 a.m., an unannounced visit was conducted at the facility to conduct a revisit for a previous complaint validation survey. On February 7, 2024, at 12:10 p.m., a tour of the Intensive Care Unit (ICU) Supply room was conducted. The following expired medications were observed: -one (1) 1000 ml (unit of measurement) bag of 5% Dextrose Lactated Ringers IV solution expired 01/23 (January 2023), -one (1) 1000 ml (unit of measurement) bag of 5% Dextrose Lactated Ringers IV solution expired 05/23 (May 2023), and; -one (1) 1000 ml (unit of measurement) bag of 5% Dextrose Lactated Ringers IV solution expired 12/23 (December 2023). On February 7, 2024, at 12:15 p.m., an interview with the Director of ICU (D-ICU) was conducted. The D-ICU stated the expectation for the unit is not to have any expired medications available for use. She stated Supply Chain Staff checks expiration dates when they stock the unit. The D-ICU stated the drugs should have been removed from patient availability. The D-ICU stated if expired, the item should be removed from the supply room. On February 7, 2024, at 12:20 p.m., an interview with the Director of Supply Chain (DSC) and the Materials Handler (MH) was conducted. The MH stated he is responsible for checking expired items in the ICU supply room. He stated he checked expiration dates when refilling that item. He stated the 5% Dextrose Lactated Ringers IV Solution should not be expired. He further stated any expired products should be removed from the supply room and disposed. He stated there should be no expired products available for use in the supply room. A review of the policy and procedure (P&P) titled, “Disposal of Containers of Empty, Discontinued, or Expired Medications,” dated August 8, 2022, was conducted. The P&P indicated, “...To provide for appropriate disposition of medication...Medications that are discontinued, unused, deteriorated, or expired will be disposed of appropriately...””

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 44871 Based on interview and record review the facility failed to provide surgical services in accordance with acceptable standards of practice when Patient 5’s planned exploratory laparotomy (surgical procedure, abdomen is opened and examined) with colostomy (colon diverted to an artificial opening in the abdominal wall) was performed incorrectly. This failure resulted in Patient 5 having another surgical procedure on January 4, 2023, for an exploratory laparotomy and ostomy revision (a surgical procedure performed to modify or repair an existing colostomy). In addition, this failure resulted in Patient 5 suffering from surgical complications such as infection, pain, delay in recovery and could have led to the deterioration of medical condition and/or the death of the patient. Findings: On December 11, 2023, an unannounced visit was conducted at the facility. On December 12, 2023, a review of Patient 5’s record was conducted with the Cardiac Program Manager (CPM) and the Senior Clinical Effectiveness Coordinator (SCEC). The facility document titled, “ED [Emergency Department] Physician Record,” dated December 25, 2022, at 9:39 p.m., indicated, “...Patient 5 was brought in via EMS [Emergency medical services, ambulance service]...complaining of abdominal pain with vomiting which began suddenly...” The facility document titled, “CT [computed tomography (an imaging test)] Abdomen/Pelvis w/o [without] Contrast [iodine base liquid],” dated December 25, 2022, at 11:30 p.m., indicated, “...Peritoneum [cavity of the abdomen]: Small ascites. Minimal pneumoperitoneum [presence of air or gas in the abdominal cavity], which may represent perforated viscus in the absence of recent intervention. Recommend clinical correlation...” The facility document titled, “History & [and] Physical,” dictated by Surgeon 1 on December 26, 2022, at 4:53 a.m., indicated, “...Assessment: Perforated viscus [the wall of the gastrointestinal tract ruptures and the enteric contents leak into the abdominal cavity], peritonitis [inflammation of the abdominal cavity]...will proceed with exploratory laparotomy...” The facility document titled, “Operative Report,” dictated by Surgeon 1 on December 26, 2022, at 8:07 a.m., indicated, “...the piece of the colon [part of the large intestine] with perforation was resected proximally [near the point of origin] and distally [furthers way from the center] with GIA 75, mesentry [sic] [attaches your intestines to the wall of your stomach] taken down with ligature [tying or binding]. The distal stump was over sawn [sic] with 2-0 silk and covered with omentum [a fold connecting stomach with other abdominal organs] in an attempt to prevent stump blow out (full of hard rock stool). The proximal colon mobilized with ligatured device to obtain adequate length. Abd [abdomen] irrigated with multiple liters of fluid until clear...the descending colon delivered via the stoma [an opening]...” The facility document titled, “Progress note-Physician,” dictated by Physician 1 dated December 28, 2022, at 5:41 p.m., indicated, “...Gastrointestinal...colostomy bag on left side-minimal output, bowel sound sluggish...” The facility document titled, “Progress note- Physician,” dictated by Physician 2 dated January 2, 2023, at 9:41 a.m., indicated, “...WBC rose overnight to 17.4...colostomy bag on left side-minimal output-stool present, bowel sounds sluggish...viscus perforation with peritonitis with sepsis [microorganisms in the blood] S/P [status post] exploratory laparotomy with colostomy...” The undated facility document titled, “Lab View,” indicated, “...December 27, 2022, at 2:26 a.m., WBC [white blood cells] 9.6...December 28, 2022, at 5:16 a.m., WBC 14.4...December 29, 2022, at 3:41 a.m. WBC 11.6...December 30, 2022, at 12:13 p.m., WBC 9.9...December 31, 2022, at 6:22 a.m., WBC 10.2...January 1, 2023, at 4:10 a.m., WBC 11.5...January 2, 2023, at 6:03 a.m., WBC 17.4...January 3, 2023, at 5:55 a.m., WBC 15.8...January 3, 6:26 a.m., WBC 16...” The facility document titled, “CT Abdomen/Pelvis w/o Contrast,” dated January 3, 2023, at 10:41 p.m., indicated, “...Indication...Abdominal Distention/Intestinal Obstruction [blockage]; eval [evaluation] colostomy- distal vs proximal colon...Impression...CONTRAST FROM OSTOMY LIES IN THE DESCENDING COLON AND RECTUM...” The facility document titled, “Consult - General Surgery,” dictated by Surgeon 2 dated January 4, 2023, at 9:47 a.m., indicated, “...plan for exploratory laparotomy today at 1 PM [after noon] for ostomy revision...” The facility document titled, “Operative Reports,” dictated by Surgeon 2 on January 4, 2023, at 3:12 p.m., indicated, “...CT of the abdomen pelvis with contrast through the ostomy was in the descending colon extending down to the rectum suggestive that the distal colon was brought up as the ostomy. Patient requires an exploratory laparotomy, possible bowel resection, with new ostomy creation...Findings...Previous colostomy was distal transverse colon stump resected, new colostomy brought up to right abdomen...” An interview and record review were conducted on December 12, 2023, at 1:40 p.m. with Surgeon 2. Surgeon 2 stated feces was getting backed up in the patients gut for two days. Surgeon 2 further stated, the proximal part of the colon should have been brought up to the ostomy, but the distal end was brought up instead. An interview and record review were conducted on December 13, 2023, at 9:36 a.m. with Physician 3. Physician 3 stated, “ ...The surgeon did not follow his normal routine, and there was a little bit of a rush, because the patient was sick ...Instead of the proximal portion of the bowel, that should have been diverted, brought out the rectal portion of the bowel, he brought out the wrong side ...” Physician 3 further stated, “ ...this is an unusual occurrence, that when you do an open colectomy (exploratory laparotomy) you can automatically see what is going on. You can see the intestine vs [versus] when you do a laparoscopic surgery where you can’t clearly see where everything is. When done laparoscopic a lot of surgeons will put little tabs on different parts of the intestine to orient themselves. In this case it was open, he had a full view of the anatomy of the abdomen, so this becomes a very rare event when it is an open surgery...” During a review of the facility’s policy and procedure (P&P) titled, “Universal Protocol,” dated April 24, 2023, the P&P indicated, “...Universal protocol is the process used to identify the correct patient, the correct procedure, the correct [sic] and the correct site...The team members providing care for the patient are accountable for patient safety...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 44871 Based on interview and record review, the facility failed to implement, and maintain an effective, ongoing, hospital-wide data driven quality program for following adverse events when the facility failed to ensure Patient 5’s planned exploratory laparotomy (surgical procedure, abdomen is opened and examined) with colostomy (colon diverted to an artificial opening in the abdominal wall) was performed correctly. This failure resulted in Patient 5 having another surgical procedure on January 4, 2023, for an exploratory laparotomy and ostomy revision (a surgical procedure performed to modify or repair an existing colostomy). In addition, this failure resulted in Patient 5 suffering from surgical complications such as infection, pain, delay in recovery and could have led to the deterioration of medical condition and/or the death of the patient. Findings: On December 11, 2023, an unannounced visit was conducted at the facility. On December 12, 2023, a review of Patient 5’s record was conducted with the Cardiac Program Manager (CPM) and the Senior Clinical Effectiveness Coordinator (SCEC). The facility document titled, “ED [Emergency Department] Physician Record,” dated December 25, 2022, at 9:39 p.m., indicated, “...[name of patient 5] was brought in via EMS [Emergency medical services, ambulance service]...complaining of abdominal pain with vomiting which began suddenly...” The facility document titled, “CT [computed tomography (an imaging test)] Abdomen/Pelvis w/o [without] Contrast [iodine base liquid],” dated December 25, 2022, at 11:30 p.m., indicated, “...Peritoneum [cavity of the abdomen]: Small ascites. Minimal pneumoperitoneum [presence of air or gas in the abdominal cavity], which may represent perforated viscus in the absence of recent intervention. Recommend clinical correlation...” The facility document titled, “History & [and] Physical,” dictated by Surgeon 1 on December 26, 2022, at 4:53 a.m., indicated, “...Assessment: Perforated viscus [the wall of the gastrointestinal tract ruptures and the enteric contents leak into the abdominal cavity], peritonitis [inflammation of the abdominal cavity]...will proceed with exploratory laparotomy...” The facility undated document titled, “Lab View,” indicated, “...December 27, 2022, at 2:26 a.m., WBC [white blood cells] 9.6...December 28, 2022, at 5:16 a.m., WBC 14.4...December 29, 2022, at 3:41 a.m. WBC 11.6...December 30, 2022, at 12:13 p.m., WBC 9.9...December 31, 2022, at 6:22 a.m., WBC 10.2...January 1, 2023, at 4:10 a.m., WBC 11.5...January 2, 2023, at 6:03 a.m., WBC 17.4...January 3, 2023, at 5:55 a.m., WBC 15.8...January 6:26 a.m., WBC 16...” The facility document titled, “Operative Report,” dictated by Surgeon 1 on December 26, 2022, at 8:07 a.m., indicated, “...the piece of the colon [part of the large intestine] with perforation was resected proximally [near the point of origin] and distally [furthers way from the center] with GIA 75, mesentry [sic] [attaches your intestines to the wall of your stomach] taken down with ligature [tying or binding]. The distal stump was over sawn [sic] with 2-0 silk and covered with omentum [a fold connecting the stomach with other abdominal organs] in an attempt to prevent stump blow out (full of hard rock stool). The proximal colon mobilized with ligatured device to obtain adequate length. Abd [abdomen] irrigated with multiple liters of fluid until clear...the descending colon delivered via the stoma [an opening]...” The facility document titled, “Progress note-Physician,” dictated by Physician 1 dated December 28, 2022, at 5:41 p.m., indicated, “...Gastrointestinal...colostomy bag on left side-minimal output, bowel sound sluggish...” The facility document titled, “Progress note- Physician,” dictated by Physician 2 dated January 2, 2023, at 9:41 a.m., indicated, “...WBC rose overnight to 17.4...colostomy bag on left side-minimal output-stool present, bowel sounds sluggish...viscus perforation with peritonitis with sepsis [microorganisms in the blood] S/P [status post] exploratory laparotomy with colostomy...” The facility document titled, “CT Abdomen/Pelvis w/o Contrast,” dated January 3, 2023, at 10:41 p.m., indicated, “...Indication...Abdominal Distention/Intestinal Obstruction [blockage]; eval [evaluation] colostomy- distal vs proximal colon...Impression...CONTRAST FROM OSTOMY LIES IN THE DESCENDING COLON AND RECTUM...” The facility document titled, “Consult - General Surgery,” dictated by Surgeon 2 dated January 4, 2023, at 9:47 a.m., indicated, “...plan for exploratory laparotomy today at 1 PM [after noon] for ostomy revision...” The facility document titled, “Operative Reports,” dictated by Surgeon 2 on January 4, 2023, at 3:12 p.m., indicated, “...CT of the abdomen pelvis with contrast through the ostomy was in the descending colon extending down to the rectum suggestive that the distal colon was brought up as the ostomy. Patient requires an exploratory laparotomy, possible bowel resection, with new ostomy creation...Findings...Previous colostomy was distal transverse colon stump resected, new colostomy brought up to right abdomen...” An interview and record review were conducted on December 12, 2023, at 1:40 p.m. with Surgeon 2. Surgeon 2 stated feces was getting backed up in the patients gut for two days. Surgeon 2 further stated, the proximal part of the colon should have been brought up to the ostomy, but the distal end was brought up instead. An interview and record review were conducted on December 12, 2023, at 3:15 p.m. with the DMS and the SCEC. The DMS and the SCEC both stated the event was not discussed in the Quality Improvement Committee in January or February meetings due to California Code, 1157, this is confidential and protected. An interview and record review were conducted on Decemeber 13, 2023, at 9:36 a.m. with Physician 3. Physician 3 stated, “...The surgeon did not follow his normal routine, and there was a little bit of a rush, because the patient was sick...Instead of the proximal portion of the bowel that should have been diverted and brought out the rectal portion of the bowel, he brought out the wrong side...” A review of the facility document titled, “QI (Quality Improvement) Plan,” was conducted with Physician 3 and the SCEC. Physician 3 and the SCEC both stated that the policy included sentinel events to be discussed in Quality Improvement Plan and this incident was not. There is no documented evidence that this sentinel event was discussed at the Quality Improvement Committee’s January and February 2023 meetings. A review of the facility’s policy and procedure (P&P) titled, “QI (Quality Improvement) Plan,” dated August 8, 2022, was conducted. The P&P indicated, “...Initiatives are intended to attain optimal patient outcomes and patient family experience, enhance appropriate utilization and minimize risks and hazards of care...IDENTIFICATION & PRIORITIZATION OF OPPORTUNITIES AND INITIATIVES...Balancing the ongoing desire for improvement in multiple areas with the reality of limited resources requires criteria for determining which initiatives to prioritize...Quality Improvement Committee uses the following criteria to identify and prioritize quality initiatives in the organization:...b. Sentinel Events...” A review of the facility’s P&P titled, “Event Reporting,” dated August 8, 2022, was conducted. The P&P indicated, “...The following severity classification shall be used...H- Event occurred that required intervention necessary to sustained life (Sentinel event)...I- Event contributed or cause death (Sentinel event)...The results of this activity shall be reported to appropriate peer review and Performance Improvement Committees...””