John C Fremont Healthcare District

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 45929 Based on interview and record review, the hospital failed to ensure nursing staff followed hospital policies and procedures when: 1. Patient (Pt) 3’s care plan (a written, step-by-step guide made for a person who needs medical, nursing, or daily living support) did not include Pt 3’s interventions for pain when Pt 3’s chief complaint was abdominal pain. 2. Pt 4’s pain was not reassessed after Pt 4 was administered hydromorphone (a strong prescription opioid pain medication). These failures placed Pt 3 and Pt 4 at risk for inadequate pain relief. Findings: 1. During a concurrent interview and record review on 8/6/26 at 11:10 a.m. with Nurse Manager (NM) 1, Pt 3’s “History &Physical (H&P)”, dated 8/4/26, was reviewed. The H&P indicated Pt 3 presented “ ... to the emergency department from his primary care provider’s office for evaluation of worsening abdominal pain ... Plan: Admit for further evaluation and symptom management ...”. During a concurrent interview and record review on 8/6/26 at 11:25 a.m. with NM 1, Pt 3’s “Care Plan (CP)”, dated 8/6/26, was reviewed. The CP included interventions for fall risk, skin integrity, and decreased cardiac output (volume of blood pumped out of the heart). NM 1 stated the CP did not include interventions for abdominal pain which was Pt 3’s chief complaint for coming in the acute care hospital. During an interview with the Chief Nursing Officer (CNO) on 8/7/26 at 11:58 a.m., the CNO stated the CP purpose was for individual care and meeting the needs of the patient’s main concern. The CNO stated it was her expectation the main diagnosis should be addressed in the CP. During a review of the hospital’s policy & procedure (P&P) titled, “Pain Assessment, Reassessment and Management”, dated 12/20/24, the P&P indicated, “ ... Policy ... An individualized pain management plan shall be developed based on the patient’s current medical condition, medical history and specific pain management goals ...”. During a review of the hospital’s P&P titled, “Care Plans”, dated 1/13/25, the P&P indicated, “ ... PURPOSE: To ensure appropriate nursing evaluation of and response to each hospitalized patient’s physical and psychosocial needs ...PROCEDURE ... 3. Care plans for both Inpatient and Swing patients will be re-evaluated every shift and updated as patient condition and/or needs require. a. Care plans shall include at least one care plan on: i. Acute problem from admission ii. Fall risk iii. Skin integrity iv. Pain, for patients receiving pain medications v. Infection, for patients receiving antibiotics or antifungals ...”. 2. During a concurrent interview and record review on 8/6/26 at 11:26 a.m. with NM 1, Pt 4’s H&P, dated 8/4/26, the H&P indicated Pt 4’s chief complaint was nausea, vomiting and abdominal pain. During a concurrent interview and record review on 8/6/26 at 11:30 a.m. with NM 1, Pt 4’s “Pain Flowsheet (PF)” and “Medication Administration Record (MAR)”, dated 8/6/26, NM1 stated the PF indicated Pt 4’s pain level was was rated an 8 (on a scale of 0-10, 10 being the worst pain and 0 indicating no pain) at 3:53 a.m. and was not reassessed on the pain flowsheet. NM 1 stated pain reassessment was recorded on the MAR. The MAR indicated hydromorphone was administered intravenously (IV, in the vein) to Pt 4 at 3:53 a.m. NM 1 stated the reassessment was blank and therefore was not done. During an interview on 8/7/26 at 11:58 a.m. with the CNO, the CNO stated it was her expectation that pain be reassessed after medication per policy. During a review of the hospital’s P&P titled, “Pain Assessment, Reassessment and Management”, dated 12/20/24, the P&P indicated, “ ... PROCEDURE: It shall be the responsibility of all clinical staff to screen all patients expeditiously for the presence or absence of pain, and avoid delays related to testing, diagnostics or consultations. When pain is present, it shall be the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain, and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality (i.e. character, frequency, location and duration of pain), and responses to treatment ... DOCUMENTATION ... The patient shall undergo reassessment of pain per the schedule below: Intravenous [IV] administration of medications: within 15-30 minutes after administration ... IM [intramuscular, in the muscle] Medication: within 30-60 minutes after administration ... Oral pain medications: within 60 minutes after administration ... Notify the primary provider promptly if pain is unrelieved. Document actions taken and any provider instructions. Escalate care if the patient exhibits acute deterioration ...”.”

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 37529 Based on interview and record review, the hospital failed to meet the requirements at CFR 485.627, Organizational Structure, when: 1. No systems were in place to ensure members of the medical staff were appointed and/or reappointed and granted privileges in accordance with the medical staff bylaws, policies, and credentialing and privileging standards. (Refer to C-0962, finding 1) 2. No systems were in place to ensure contracted services were evaluated for compliance with contract terms, and services provided met the needs of the patient and/or hospital. (Refer to C-0962 finding 2)) The cumulative effect of these systemic failures resulted in the hospital’s inability to provide quality healthcare in a safe setting.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 37529 Based on observation, interview and record review, the hospital’s governing body (GB) failed to take full responsibility for the operation of the hospital when: 1. No systems were in place to ensure members of the medical staff were appointed and/or reappointed and granted privileges in accordance with the medical staff bylaws, policies, and credentialing and privileging standards. These failures resulted in privileges being granted to approximately 41 medical staff without initial or ongoing evaluation of physician competence and members of the medical staff with lapsed appointments providing care and had the potential to result in patient harm and not providing quality healthcare in a safe setting. 2. No systems were in place to ensure contracts and/or agreements that provided hospital services, such as the contracted radiology group, were assessed to ensure the needs of the patient and/or hospital were met, and contracted services were not evaluated for compliance with terms of the contract. The terms of the contracts were not reviewed to ensure they were current and complied with Medical Staff Bylaws and Rules and Regulations. These failures resulted in the hospital not holding the contracted radiology group accountable for the terms of the contract and resulted in physicians who did not meet contract criteria providing contracted services and possibly negatively affecting the quality and safety of patient care. Findings: 1. During a concurrent observation and interview on 12/9/25 at 3:20 p.m. with Emergency and Acute Care Department Manager (EAM), the acute care unit was observed. The EAM stated the patients admitted to the acute care unit are medical-surgical patients, some with telemetry monitoring, and some of the acute care beds are “ swing “ beds being used for skilled nursing level care. The EAM stated the current patient census was nine, with three of those being “ swing “ patients. The EAM stated during the day from 8 a.m. until 8 p.m. seven days a week, the hospitalist (a physician who specializes in the care of patient admitted to the hospital) is responsible for all of the patients (med-surg, telemetry, and skilled nursing [ “ swing “ ]) on the acute care unit, and starting at 8 p.m., the ED physician working in the emergency department is also responsible for the patients on the acute care unit until the following morning at 8 a.m.. During an interview on 12/10/25 at 10 a.m. with the Chief Executive Officer (CEO), the CEO stated she was officially appointed as the CEO a little over a month, after being the interim CEO for a month before that. Prior to that she was the director of quality for the district (the hospital and the clinics) for less than one year. The CEO stated she became aware there were issues with credentialing of medical staff soon after she started working for the district. The CEO stated she was not surprised there were issues identified with medical staff credentialing, privileging, or with contracts because there had not been an organized system in place to process appointments and reappointments. The CEO stated staff turnover in her position and other leadership positions in addition to staff turnover and/or lack of qualifications in the medical staff coordinator role had resulted in the hospital ’ s current non-compliance situation. During a concurrent interview and record review on 12/10/25 at 2 p.m. with the Medical Staff Coordinator (MSC), the MSC stated she just recently accepted this position. The MSC stated over the past few years there have been several people in the MSC position with varying levels of knowledge about medical staff processes and because of this some of the work was not done. The MSC stated in some cases the timelines for medical staff reappointment were not met resulting in lapsed reappointments for some physicians. The MSC stated some of the credential files are electronic and some are paper, and not well organized, making it more difficult to quickly identify what is missing. The MSC stated there was not a process for ongoing professional practice evaluation (OPPE- the ongoing assessment of a physician ’ s clinical competence and professional behavior based on department specific metrics [measurements used to track and compare performance]. OPPE information is used in the decision to maintain, modify, or revoke existing clinical privileges). During a concurrent interview and record review on 12/10/25 at 2:05 p.m. with the MSC, MD 3 ’ s credential file was reviewed. The file indicated MD 3 was a physician working in the ED who was first appointed to the medical staff on 1/15/25. When the record of MD 3 ’ s proctoring (an objective evaluation by an experienced peer [the proctor] to confirm the doctor’s competence for specific procedures or non-procedural skills) was requested, the MSC responded that MD 3 was not proctored. The MSC stated that “ None of the physicians [appointed to the medical staff] have been proctored. “ The MSC did not have an explanation for why proctoring did not occur. When the record of MD 3 ’ s background check (a screening process that looks for criminal history and other problems) was requested, the MSC stated no criminal background check was done on MD 3. The MSC stated the hospital just started doing background checks in September 2025, so no one appointed to the medical staff prior to that time had a background check performed. Review of MD 3 ’ s malpractice insurance verification indicated “ Coverage is limited to work on behalf of [Name of Company], “ not the company currently contracted with Hospital A. The MSC stated that is the only proof of insurance in his file. Review of MD 3 ’ s appointment letter dated 1/15/25 indicated MD 3 was granted privileges in Emergency Medicine and Internal Medicine. Review of MD 3 ’ s privilege forms indicated on 9/22/24, MD 3 completed the “ Emergency Department Privilege List, “ placing a check mark in the space indicating “ REQUESTED “ next to 52 privileges including nine identified only as “ Other. “ The spaces next to each requested privilege indicating “ APPROVED “ or “ DENIED “ were all blank, and the form was signed only by MD 3. The three other signature lines were blank. The MSC stated this is the only ED privilege form in MD 3 ’ s file. The file indicated on 10/22/24, MD 3 completed a privilege form for Internal Medicine (a medical specialty focused on preventing, diagnosing, and treating diseases in adults) and requested all 15 privileges on the list. The spaces next to the privilege to approve or deny the privilege were all left blank and the form was signed only by MD 3. Neither privilege form indicated the privilege to admit patients to the hospital. Neither privilege form identified the required qualifications that must be met for education, training or experience in order to apply for the privileges. The MSC stated the reason MD 3 requested Internal Medicine privileges was because the ED physicians were responsible for the hospitalized acute care patients each day from 8 p.m. until the following day at 8 a.m. The MSC stated there was no information in MD 3 ’ s credential file regarding his education, training or experience in managing hospitalized acute care and skilled nursing patients. During a review of the patient census on the acute care unit dated 12/10/25 indicated MD 3 was the admitting physician for Patient 2. During a concurrent interview and record review on 12/10/25 at 2:15 p.m. with the MSC, the credential file for MD 10, a cardiologist (a doctor who specializes in diagnosing and treating diseases or conditions of the heart and blood vessels), indicated MD 10 ’ s last reappointment to the medical staff was 8/30/23. The MSC stated the medical staff members are supposed to be reappointed every two years, and MD 10 ’ s reappointment was due 8/30/25, and the reappointment process had not been initiated yet, meaning the application and privilege request form had not been sent to MD 10 yet, and the National Practitioner Data Bank (NPDB- information from multiple sources on adverse actions, convictions, judgments involving healthcare practitioners) had not been queried since 4/18/23. The MSC stated MD 10 was the only cardiologist on the medical staff and the procedures he performed included interpretation of echocardiograms (a test which uses sound waves to create pictures of the heart) and electrocardiograms (EKG/ECG -a test to measure the heart ’ s rhythm and electrical activity), and performing transesophageal echocardiograms (TEE- an echocardiogram is performed by inserting a probe down the esophagus), and implantation of a Loop recorder (A device placed under the skin of the chest to continuously monitor the heart rate and rhythm). Review of the file indicated for the 2023 reappointment, no privilege form was completed. The MSC stated the most recent privilege form for MD 10 was completed for his reappointment in 2021. The MSC stated for every appointment and reappointment all physicians are required to indicate on the privilege form which privileges they are requesting, and then each of those privileges would need to be either approved or denied by whomever is responsible for that decision by making a check mark indicating approved or denied next to each requested privilege. The privilege forms have signature lines for approval for the Medical Director (an appointed physician responsible for the overall clinical care provided by a hospital, department or service), one for the Chief of Staff (the elected physician leader of the medical staff), and one for the Chairman of the Board of Directors. The MSC stated this form is completed with a physician ’ s initial application for appointment to the medical staff and every two years as part of the reappointment process. The MSC stated this process did not happen for MD 10 in 2023 and it should have. There were no education, training or experience requirements listed on the form for either the initial request for privileges or for the request to renew privileges. When asked what the requirements were for reappointment as far as ongoing evaluation of practice specific to the physician ’ s privileges, the MSC stated there was no process in place to do that for any physician. The MSC confirmed that no ongoing evaluation of MD 10 ’ s performance had been done. During a concurrent interview and record review on 12/10/25 at 2:30 p.m. with the MSC, the credential file for MD 14, a neurologist (a doctor specializing in diagnosing, treating, and managing disorders of the brain and nervous system), indicated MD 14 ’ s last reappointment to the medical staff was 3/30/23. The MSC stated MD 14 ’ s reappointment was due on 3/30/25 and the reappointment process had not been initiated yet. MD 14 was the only neurologist on the medical staff. Review of the file indicated for the last reappointment in 2023, MD 14 requested privileges for Evaluation of Patients who have unstable Pathology and Physiology, Independent Management of Patients who have Complex Neurologic Pathology and Physiology, Interpret Electroencephalograms (EEG- a test that records the brain’s electrical activity to help diagnose neurological issues), Performance and Interpretation of Electromyograms (a diagnostic test that records the electrical signals from muscles and nerves), Performance and Interpretation of Nerve Conduction Studies (a diagnostic test that measures how quickly electrical impulses move through peripheral nerves). Review of the 2023 privilege form indicated no one approved any of the requested privileges and no one other than MD 14 signed the form. The MSC stated that since the reappointment process had not been started for the reappointment that was due on 3/30/25, the hospital had not verified current malpractice insurance or current medical license. The MSC confirmed that no ongoing evaluation of MD 14 ’ s performance had been done. During an interview on 12/11/25 at 10:40 a.m. with the Quality Nurse Specialist (QNS) and the Risk and Patient Safety Manager (RPSM), the RPSM stated they don ’ t have a process in place to collect physician specific performance data for the purpose of on-going evaluation of the physician ’ s professional practice. The QNS stated that the hospital is not doing chart reviews for each physician or gathering and reporting any data specific to each physician. The QNS and RPSM stated that one of the reasons there was not a system in place to do ongoing physician specific data collection and evaluation is the turnover of the Chief Executive Officer (CEO) position in the hospital over the past several years. Without stability in the leadership position it was difficult to make needed changes and add needed resources. The QNS stated there had been more than seven different CEOs in the past three years. The RPSM stated the only peer review that was done is when someone submits an incident report and it relates to a physician it will get sent to a physician to review, and if needed it will get discussed at the Medical Executive Committee (MEC) which is also the Peer Review Committee (PRC). When asked to recall an incident that was reported involving a physician, the RPSM stated in August there was a patient who came in to the emergency department (ED) complaining of pain and an x-ray was done. The RPSM stated the ED physician read (interpreted) the x-ray himself and interpreted it as normal, rather than waiting for the radiologist ’ s interpretation, and discharged the patient, but when the radiologist read the x-ray a fracture was noted. The QNS and RPSM stated they thought the case was referred to the medical director for peer review but stated they did not know what the outcome of the peer review was. During an interview on 12/11/25 at 4:50 p.m. with the Chief Nursing Officer (CNO), the CNO stated the case involving the fracture that was missed on the x-ray did not get referred to peer review, but it would be now. During an interview on 12/11/25 at 12 p.m. with the Chief of Staff (MD 9), MD 9 stated there have been challenges the last few years regarding the hospital ’ s ability to support the process for medical staff appointment and reappointment and peer review. MD 9 stated there has been significant turnover in the CEO position as well as the staff in the medical staff coordinator role and it has been difficult to meet the timeframes for appointment and reappointment. MD 9 stated because of this the hospital ends up granting temporary privileges for a period of a month at a time for several months in a row until the reappointment process can get completed. MD 9 stated he was aware that ongoing evaluation of physician performance was not being done. MD 9 stated in the past they were doing chart reviews as a way to assess the physician ’ s practice but that has not been done recently either. MD 9 stated they do not have a system in place to assess the physicians ’ professional practice on an ongoing basis so they can use that information at the time of reappointment for the purpose of informing privilege decisions. During a concurrent interview and record review on 12/12/25 at 9:30 a.m. with the MSC, the credential file for MD 13, a gastroenterologist (a doctor specializing in the digestive system), indicated MD 13 ’ s last reappointment to the medical staff was 1/17/23. The MSC stated MD 13 ’ s reappointment was due on 1/17/2025, however the reappointment process had not been initiated yet and the NPDB had not been queried since 1/17/23. The MSC stated MD 13 was the only gastroenterologist on the medical staff and the procedures he performed were colonoscopies (a procedure using a flexible tube with a camera to examine the large intestine [colon] to screen for cancer, and detect other gastrointestinal problems) and esophagogastroduodenoscopies (EGD-a procedure using a flexible tube with a camera to examine the lining of the esophagus, stomach, and the first part of the small intestine to diagnose and/or treat problems in the upper digestive tract). Both procedures are done using moderate sedation (medications given to relax the patient and keep them comfortable). Review of the file indicated for the 2023 reappointment, no privilege forms for either gastroenterology privileges, or for moderate sedation privileges were completed. The MSC stated that in 2021 a privilege form for gastroenterology was completed but not for moderate sedation. The MSC confirmed that no ongoing evaluation of MD 13 ’ s performance had been done. During a concurrent interview and record review on 12/12/25 at 9:45 a.m. with the MSC, the credential file for MD 16, a pulmonologist (a physician who specializes in diagnosing and treating diseases of the lungs) was reviewed. The file indicated MD 16 was last reappointed in 9/2023 and his reappointment was due in 9/2025. The MSC stated the reappointment was overdue and the reappointment process had not been initiated yet, and the NPDB had not been queried since 8/23/21. Review of MD 16 ’ s last reappointment in 2023 indicated the privilege request form was completed by MD 16 on 9/8/23, however the form was signed only by MD 16 and none of the requested privileges had been marked as approved or denied. The MSC stated MD 16 was the only pulmonologist on the medical staff. During a concurrent interview and record review on 12/12/25 at 10:30 a.m. with the MSC, MD 22 ’ s credential file was reviewed. The MSC stated that MD 22 was a pathologist (a physician who examines bodies and body tissues and performs lab tests on body tissues) who was last reappointed on 11/15/23. The MSC stated MD 22 was overdue for reappointment. Review of the file indicated the privilege list for MD 22 for the 2023 reappointment had not been completed. The MSC confirmed that no ongoing evaluation of MD 22 ’ s performance had been done. During a concurrent interview and record review on 12/12/25 at 10:45 a.m. with the MSC, MD 7 ’ s credential file was reviewed. The MSC stated MD 7 was last reappointed 5/17/23 with Emergency and Acute Care privileges. The MSC stated MD 7 was overdue for reappointment (due 5/17/25) and had been granted temporary reappointment several times for a month at a time. Review of MD 7 ’ s 2023 Emergency Department privilege list indicated on 3/8/23, MD 7 check marked most of the privileges on the list indicating his request, and there were also three additional privileges written on the ED form by an unknown person, including one for “ Admitting “ and one for “ Acute hospitalist. “ The MSC stated there are two hospitalists on the medical staff and the privilege form that the hospitalists complete is the “ Internal Medicine “ privilege request form. There is not a specific single privilege known as “ acute hospitalist. “ The privilege form MD 7 completed in 2023 was signed only by MD 7 and the spaces to indicate “ Approved “ or “ Denied “ were left blank. Review of MD 7 ’ s malpractice insurance verification indicated “ Coverage is limited to work on behalf of [Name of Company], “ not the company currently contracted with Hospital A. The MSC stated that is the only proof of insurance in his file. Review of the board certification verification for MD 7 indicated MD 7 was not board certified in Emergency Medicine and his board certification in Family Medicine lapsed in 2013. The MSC stated if the physician is not board certified in Emergency Medicine the hospital requires that the physician has current Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS) certification. Review of MD 7 ’ s file indicated he had current PALS but not ACLS. The MSC confirmed that no ongoing evaluation of MD 7 ’ s performance had been done. During a concurrent interview and record review on 12/12/25 at 11:15 a.m. with the MSC, MD 2 ’ s credential file was reviewed. The file indicated MD 2 was board certified in Emergency Medicine and had been appointed to the medical staff on 12/18/24 and given privileges for “ ED, Acute and Internal Medicine. “ Review of the privilege forms for ED and Internal Medicine indicated there were no admitting privileges. The MSC stated the reason he was given the Acute and Internal Medicine privileges was because the ED physicians were responsible for the hospitalized acute care patients each day from 8 p.m. until 8 a.m. The MSC stated there was no information in MD 2 ’ s credential file regarding his education, training or experience in managing hospitalized acute care and skilled nursing patients. The MSC confirmed that MD 2 had not been proctored. Review of MD 2 ’ s malpractice insurance verification indicated “ Coverage is limited to work on behalf of [Name of Company], “ not the company currently contracted with Hospital A. The MSC stated that is the only proof of insurance in his file. The MSC confirmed that a criminal background check had not been performed when MD 2 was appointed to the medical staff. The MSC confirmed that no ongoing evaluation of MD 2 ’ s performance was being done. Review of the patient census on the acute care inpatient unit dated 12/9/25, indicated MD 2 was the admitting physician for two acute care patients in observation status, and one acute care inpatient. During a concurrent interview and record review on 12/12/25 at 12 p.m. with the MSC, MD 1 ’ s credential file was reviewed. The file indicated MD 1, an ED physician, was last reappointed to the medical staff in 8/2023 and was overdue for reappointment. The MSC stated his reappointment is in process however there was no application or privilege request form completed yet. Review of MD 1 ’ s privileges from 2023 indicated on 5/16/23, MD 1 completed the ED privilege request form, requesting almost all of the privileges on the list. The form was signed only by MD 1 and the approved and denied spaces next to each requested privilege were left blank. Review of MD 1 ’ s malpractice insurance verification indicated “ Coverage is limited to work on behalf of [Name of Company], “ not the company currently contracted with Hospital A. The MSC confirmed that no ongoing evaluation of MD 1 ’ s performance had been done. During a concurrent interview and record review on 12/12/25 at 12:10 p.m. with the MSC, the privileges for MD 11 and MD 12 (both hospitalists) were reviewed. MD 11 and MD 12 were appointed to the medical staff in 6/2025 both had privileges in Internal Medicine. Review of the Internal Medicine privilege form indicated there were no privileges to request for admitting patients or performing history and physical examinations. The MSC stated she was unaware that the privilege form did not have privileges to admit patients. The MSC confirmed that neither MD 11 nor MD 12 were proctored. During a review of the hospital district Bylaws dated 10/23/24, and signed 12/10/25, the Bylaws indicated, “ ...General Powers - The Board of Directors, hereafter called the Board, is the governing body of the District. The Board shall have authority to set goals, determine policies, direct operational affairs, control the property of the District, and exercise the powers listed under Healthcare District Law.... Article V: CEO- The Board shall select, employ and compensate a Chief Executive Officer, hereafter called the CEO, who shall report to the Board. He or she shall supervise all employees and be responsible for the overall operation of the District...Article VI Medical Staff: Composition - The Medical Staff consists of physicians, dentists, podiatrists, chiropractors, NP ’ s, PA ’ s, and clinical psychologists who have been granted privileges by the District in accord with the [Name of Hospital] District Medical Staff Bylaws, and with the approval of the Board. Privileges - The Medical Staff sets criteria for its own membership and studies the qualifications of all applicants in the establishment of professional privileges and shall submit recommendations to the Board. Such recommendations shall be considered but shall not be binding on the Board... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...NATURE OF MEDICAL STAFF MEMBERSHIP: Membership on the Medical Staff and/or clinical privileges shall be extended to, and may be maintained by only those professionally competent practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. QUALIFICATIONS FOR MEMBERSHIP: General Qualifications-Only physicians, dentists, podiatrists, and clinical psychologists shall be deemed to possess basic qualifications for membership in the medical staff,... and who: (a) Document their (1) current licensure, (2) Adequate experience, education, and training, (3) current professional competence, (4) good judgment, and (5) current adequate physical and mental health status, so as to demonstrate to the satisfaction of the medical staff that they are professionally and ethically competent and that patients treated by them can reasonably expect to receive quality medical care....BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP- Each member of the Medical Staff shall:...Accept responsibility for participating in Medical Staff proctoring as an obligation of Staff membership... Continuously meet the qualifications for membership as set forth in these Bylaws... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...PROVISIONAL STAFF: The Provisional Staff shall consist of practitioners who are newly appointed to the Medical Staff. Except or as otherwise determined by the Governing Body, all initial appointments except Consulting Staff appointments, shall be to the Provisional category...Each Provisional member shall be proctored in accordance with proctoring requirements established by the Medical Executive Committee, in accordance with the provisions of Section 5.08. A member remains in Provisional status until he/she meets all the qualifications and has successfully completed his/her proctoring program. Provisional appointments are for not less than six months, and ordinarily the Chief of Staff shall certify whether the member has satisfactorily completed the Provisional period to the Medical Executive Committee and the Chief Executive Officer within a year of the member ’ s appointment... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...The Credentials Committee/Medical Executive Committee shall develop policies and procedures (which shall become effective upon approval by the Medical Executive Committee and the Governing Body) to implement the following: (a) All new Staff members shall be appointed to the Provisional Staff and subjected to a period of formal observation and review (except for those appointed to the Consulting Staff). Provisional appointments are ordinarily for a period of from six months to one year, but the Medical Staff Executive Committee may extend the period beyond one year for good cause for a maximum of two additional six month periods. (b) Reappointments to any Staff category shall be for a period of two years. Change in Staff category may be requested at any time during the reappointment period after requirements of Provisional status are met... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...EXERCISE OF PRIVILEGES: Except as otherwise provided in these Bylaws or the Medical Staff Rules and Regulations, every practitioner or other professional providing direct clinical services at this Hospital shall be entitled to exercise only those clinical privileges or services specifically granted to him/her. Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. Requests for clinical privileges shall be evaluated on the basis of the practitioner’s education, training, experience, and demonstrated ability and judgment. The basis for privileges determinations, in connection with periodic reappointment or otherwise, shall include any observed clinical performance and judgment, performance of a sufficient number of procedures each year to develop and maintain the practitioner’s skills and knowledge, and the documented results of the patient care audit and other quality assessment activities required by the Medical Staff Bylaws and Rules and Regulations. Privileges determinations shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and health care settings where a practitioner exercises clinical privileges. This information shall be added to and maintained in the Medical Staff file established for each Staff member. All requests for clinical privileges shall be processed pursuant to the procedures outlined in Article IV and subject to the restrictions regarding proctoring outlined in Section 5.08, if proctoring is required... “ During a review of the hospital ’ s policy and procedure (P&P) titled, “ Physician/ Allied Health Appoint/ Reappoint Procedures, “ dated 05/18/22, the P&P indicated, “ POLICY: Membership on the Medical Staff of [Name of Hospital (Hospital A)] is a privilege, which shall be extended only to professional competent practitioners who are duly licensed and continuously meet qualifications, standards and requirements to provide quality healthcare to Hospital A ’ s patients... Hospital A shall not automatically award appointment, reappointment or privileges to an applicant by virtue of the applicant ’ s inclusion in an exclusivity contract; Hospital A thoroughly reviews every applicant ’ s education, training, experience, and demonstrated current competence. Basic responsibilities of Medical Staff membership is: to provide quality of care to all Hospital A ’ s patients; meeting professional standards of the Medical Staff of Hospital A; abiding by the Medical Staff bylaws and Medical Staff policies and procedures; discharging in a responsible cooperative manner; preparing and completing medical record documentation in an accurate and timely manner... PROCEDURE: Appointment: Each new applicant for Medical Staff appointment and or privileges must complete, sign and submit to the Chief of Staff or his/her designee, the hospital ’ s application for Medical Staff membership and clinical privileges. All physicians must provide and maintain documentation as follows: 4. Current privilege(s) request form for each privilege being requested. Required documentation showing proof of proficiency for all new appointments. Reappointments shall go through a Peer Review process showing proof of proficiency. Verifications: 1. Background checks will be conducted on all practitioners at initial appointment and when deemed necessary by the Medical Staff. 4. National Practitioner Data Bank query will be obtained at initial appointment and reappointment. Medical Executive Committee Action: Upon completion, the appointment/reappointment file will go before the Medical Executive Committee and shall consider all relevant information available to it. The Medical Executive Committee shall then make a recommendation to the Governing Board... Governing Body Action: The Governing Body shall adopt, reject, or modify a favorable recommendation of the Medical Executive Committee, or shall refer the recommendation back to the Medical Executive Committee for further consideration... All new Staff members shall be appointed to Provisional Staff unless they are appointed to the Consulting Staff. All new Medical Staff will be subject to proctoring to assure they meet acceptable quality standards of care. The review will consist of at least 10 charts reviewed and a minimum of six months. Reappointment to any Staff category shall be for a period of two years. Change in Staff category may be requested at any time during the reappointment period after requirements of Provisional status are met. Reappointments: At least 90 days prior to expiration date (presently the Bylaws state “ 150 days “ ) of each staff member ’ s term of appointment, the Chief of Staff or his/her designee shall provide the member with the reappointment form. Completed reappointment form and requested documents shall be returned to the Chief of Staff or his/her designee within 30 days (presently the Bylaws say “ 60 days “ ). Failure, without good cause to return the form shall be deemed a voluntary resignation effective at the expiration of the member ’ s current term. The reappointment forms shall consist of the following: 4. A statement detailing the amounts of malpractice insurance carried. 5. Renewed request for clinical privileges... Continued membership and exercise of clinical privileges shall require at least the following: 1. Documentation of continuing satisfaction of the General Qualifications set forth at Section 2.02-1 of the Medical Staff Bylaws; and insofar as clinical privileges are concerned, with the requirements applicable from time to time to the exercise of such privileges. 2. Satisfactory results in Medical Staff quality assessment reviews, or satisfactory correction of any significant problems identified through such reviews... “ During a review of the hospital ’ s policy and procedure (P&P) titled, “ Peer Review Policy, “ dated 10/14/18, the P&P indicated, “ POLICY: Review of circumstances as outlined in this policy will be conducted by a peer physician(s) acting as agent(s) of the Board of Directors and Medical Staff for purposes of fact finding and forwarded to the medical staff peer review committee for further review and/or action when necessary. PURPOSE: To assist the medical staff in the development of strategies to continually enhance the safety and quality of patient care and professional conduct... CIRCUMSTANCES FOR PHYSICIAN & PRACTIONER PEER REVIEW: A. Any aggregate or individual information derived from generic screens including routine audits, medical staff monitors, adverse or serious adverse events, event notification (incident or occurrence) reports, complaints from patients or staff, third party agencies or other sources of information within the hospital system that suggest possible deviation(s) from accepted standards of patient care, regulatory requirements or other policies that have been approved by the medical staff. B. Performance of clinical procedures that fall outside the boundaries of documented competencies and approved privileges. C. Potential clinical quality issue raised by another medical staff member or other clinicians or staff... G. A minimum of 5 charts quarterly, of practitioner medical charts will be reviewed by a peer to assure competency and quality care is being provided. Results of Peer Review will be returned to the Medical Staff Coordinator within the specified time limits. If this is not being met, the Chief of Staff and administration will be notified. PROCEDURES FOR PHYSICIAN & PRACTIONER CASE REVIEW: A. Patient Safety and Quality Improvement (PSQI) Committee will note circumstances requiring review based upon standards developed by the PSQI personnel in conjunction with applicable medical staff committees... “ 2. During an interview on 12/10/25 at 10 a.m. with the Chief Executive Officer (CEO), the CEO stated oversight by the CEO of contracts providing patient care was necessary in order to ensure they are updated, legally appropriate, and that the services agreed to in the contract are the services being provided and are meeting the needs of patients. During an interview on 12/11/25 at 10:40 a.m. with the Quality Nurse Specialist (QNS) and the Risk and Patient Safety Manager (RPSM), the RPSM stated there had been an issue regarding the turnaround time for radiology studies from the time the test was done until the radiologist interpreted the images and completed the report. The RPSM stated the turnaround time issue had been brought to the attention of the medical director of the radiology group in the past. During an interview on 12/11/25 at 12 p.m. with the Chief of Staff (MD 9), MD 9 stated in the ED, there was an understanding that x-rays would be read by the ED physician rather than sending the images right away to the teleradiologist. The radiologist would interpret the x-ray image later and complete the report. MD 9 stated there have been instances where the radiologist ’ s interpretation ends up being different than the ED physician ’ s however it doesn ’ t occur often. MD 9 stated the ED physician ’ s interpretation is considered preliminary. MD 9 stated this practice occurs only in the case of plain x-rays, not Computed Tomography (CT- a diagnostic procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) scans. During an interview on 12/12/25 at 11 a.m. with the Imaging Manager (IM), the IM stated when imaging tests are ordered the radiology tech completes the tests and then the images are electronically uploaded in order for the teleradiologist to view and interpret the images and complete the official report. The IM stated all imaging test must be interpreted by a radiologist and a report completed. Plain x-rays are not sent right away to the teleradiologist like CT scans are, and the ED physician will usually do a preliminary read but that read is not documented other than in the physicians note in the patient ’ s chart. It is not part of the radiology report. If a physician wants the teleradiologist to interpret the x-ray in a short time frame the physician who ordered the x-ray would need to let the radiology tech know to send it to the radiologist as soon as it is done. Otherwise, the radiologist will review the x-ray and complete the report at a later time. The IM stated CT scans are automatically sent to the radiologist as soon as the radiology tech completes the scan. The IM stated turnaround time is something that is tracked and there have been times when it is longer than they would like it to be. The IM stated there is a teleradiology group that is scheduled during the day until 10 p.m. and that group contracts with another group to cover the night shift after 10 p.m. The IM stated he did not know the details of the terms of the radiology group ’ s contract. The IM stated if there is an issue or concern about turnaround time being too long he informs the medical director. During a review of the contract titled, “ RADIOLOGY COVERAGE AND ADMINISTRATIVE SERVICES AGREEMENT, “ dated 9/25/25, the contract indicated, “ ...1.1 Coverage Services. Group shall be responsible for providing a sufficient number of Physicians to provide remote and on call coverage services as required for patient care and operation of the Department... EXHIBIT C PERFORMANCE ASSESSMENT CRITERIA: Emergency Department and Inpatient Stat orders will be completed within 60(sixty) minutes and 4 hours respectively. All other disciplines will be completed within 24 hours. EXHIBIT D EXCLUSIVE SERVICES During the term of this Agreement, Group shall be the exclusive provider of the professional component of the following Exclusive Services. Modalities: a. CT Scans b. Xray c. Ultrasound d. MRI e. Mammography... “ During a review of the contract between the Teleradiology group (Group 1) (contracted with Hospital A), and Group 2 (the night coverage), dated 12/22/21, the contract indicated, “ ...(c) Response Time: Provider [Group 2] shall use its best efforts to provide a diagnostic reading no more than an average of thirty to forty five (30-45) minutes after receipt of a complete transmission of images of any CT scan, MRI, ultrasound, nuclear medicine study, or plain X-ray and its requisition order. Prior Images and Reports if any exist. Whereas final read should be achieved within sixty (60) minutes...Provider shall provide TeleRadiology Services for the designated hospitals from the hours of 6:00 p.m. to and including 8:00 a.m., seven (7) days per week, including weekends and holidays... “ During an interview on 12/12/25 at 1:45 p.m. with the CNO, the terms of the radiology contract regarding x-rays and turnaround time were discussed. The IM and MD 9 indicated x-rays were not automatically sent to the teleradiologist with the ED physicians doing the preliminary read and the radiologist interpreting the images at a later time, however both contracts indicated x-rays were included in the radiology services with the same time frames for reading as the CT scans and MRIs. The CNO stated she was not aware of the details of the contract. During a concurrent interview and record review on 12/12/25 at 11:45 a.m. with the Medical Staff Coordinator (MSC), the verification records for the board certification status of the eight emergency department (ED) physicians was reviewed. The records indicated five of the eight ED physicians (MD 1, MD 4, MD 5, MD 6, and MD 7) were not board certified in Emergency Medicine. During a review of the contract for the emergency department physicians, dated 8/1/25, the contract indicated, “ ... [Hospital A] is the owner and operator of a general acute care hospital and operates an Emergency Department to provide emergency medical services to persons presenting themselves for care and/or treatment, and Medical Center desires to assure physician coverage for the Department...Group is a duly organized California professional corporation comprised of a single corporate shareholder, director and officer, who is [Name of Physician], and physician independent contractors, each of whom is duly licensed to practice medicine in the State and board certified in the specialty of emergency medicine... “ During a review of the hospital ’ s policy and procedure (P&P) titled, “ Contract/ Agreement/MOU Evaluation, “ dated 12/10/15, the P&P indicated, “ PURPOSE: To assure services provided to [Hospital A] through contractual arrangements meet regulatory standards and are provided in a safe, efficient and competent manner. POLICY: It is the policy of [Hospital A] to maintain a list of all contracts/ agreements/MOUs, etc. both clinical and non-clinical with the scope and nature of services provided. Exceptional care will provided throughout Hospital A whether contracted or provided directly by hospital staff...The Governing Board of Hospital A has final responsibility for all contracts/ agreements/MOUs, etc., policies and procedures at Hospital A... CEO in conjunction with the Chief of Staff are responsible for medical director, medical group and physician evaluations...The Medical Executive Committee will provide an annual review of all clinically based contract services...The Executive Assistant to the CEO in Administration is required to coordinate the renewal and review process... “ During a review of the hospital ’ s policy and procedure (P&P) titled, “ Contracts, “ dated 10/19/22, the P&P indicated, “ ...It is the policy of [Name of Hospital] that all contracts with individuals and/or organizations providing patient care services must be signed exclusively by the Chief Executive Officer (CEO)... The Governing Board will select the individual or organization to which to award the contract based upon consideration of both the Medical Staff and Chief Executive Officer recommendations... “ During a review of the National Law Review article titled, “ Why Every Health Care Organization Needs Accurate, Up-to-Date Contracts, “ dated 12/17/25, the article indicated, “ ...If agreements are missing, expired, unsigned, or inconsistent with actual practice, organizations may inadvertently create compliance vulnerabilities. Well-maintained contract files ensure that leadership and staff understand current obligations, responsibilities, performance metrics, and renewal terms. Outdated or misplaced contracts can lead to billing errors, unmanaged auto-renewals, lapses in required services, lapses in required insurance coverage, or confusion around scope of work--all of which can carry significant financial consequences... “”

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 37529 Based on interview and record review the hospital failed to ensure there was a system in place to assess physician performance and competency, when 41 of 41 physicians (MDs 1 through 41) were not proctored and did not have ongoing review of their professional practice. These failures resulted in the physicians ’ privileges being granted or renewed without having first been evaluated, which had the potential to result in patient harm. Findings: During a review of the medical staff roster, the roster indicated there were 23 physicians on staff providing patient care either in the hospital or the clinics, three physicians providing telemedicine services, and 15 physicians providing teleradiology services, for a total of 41 physicians. During a concurrent interview and record review on 12/10/25 at 2 p.m. with the Medical Staff Coordinator (MSC), the MSC stated she does not have any physicians quality data or peer review. The MSC stated there is not a process in place for ongoing professional practice evaluation (OPPE- the ongoing assessment of a physician ’ s clinical competence and professional behavior based on department specific metrics [measurements used to track and compare performance]. OPPE information is used in the decision to maintain, modify, or revoke existing clinical privileges). During a concurrent interview and record review on 12/10/25 at 2:05 p.m. with the MSC, a record of physician proctoring (an objective evaluation by an experienced peer [the proctor] to confirm the doctor’s competence for specific procedures or non-procedural skills) was requested and the MSC responded that “ None of the physicians have been proctored. “ The MSC did not have an explanation for why proctoring did not occur. During an interview on 12/11/25 at 10:40 a.m. with the Quality Nurse Specialist (QNS) and the Risk and Patient Safety Manager (RPSM), the RPSM stated they don ’ t have a process in place to collect physician specific performance data for the purpose of on-going evaluation of the physician ’ s professional practice. The QNS stated that the hospital is not doing chart reviews for each physician or gathering and reporting any data specific to each physician. The RPSM stated the only peer review that was done is when someone submits an incident report and it relates to a physician it will get sent to a physician to review, and if needed it will get discussed at the Medical Executive Committee (MEC) which is also the Peer Review Committee (PRC). When asked to recall an incident that was reported involving a physician, the RPSM stated in August 2025 there was a patient who came in to the emergency department (ED) complaining of pain and an x-ray was done. The RPSM stated the ED physician read (interpreted) the x-ray himself and interpreted it as normal, rather than waiting for the radiologist ’ s interpretation, and discharged the patient, but when the radiologist read the x-ray a fracture was noted. The QNS and RPSM stated they did not recall who the physician was or any other details of the case, or what the outcome of the peer review was. During an interview on 12/11/25 at 4:50 p.m. with the Chief Nursing Officer (CNO), the CNO stated the case involving the fracture that was missed on the x-ray did not get referred to peer review, but it would be now. During an interview on 12/11/25 at 12 p.m. with the Chief of Staff (MD 9), MD 9 stated he was aware that ongoing evaluation of physician performance was not being done. MD 9 stated in the past they were doing ongoing chart reviews as a way to assess the physician ’ s practice but that has not been done recently either. MD 9 stated they do not have a process in place to assess the physicians ’ professional practice on an ongoing basis so they can use that information at the time of reappointment for the purpose of informing privilege decisions. During a review of the hospital ’ s policy and procedure (P&P) titled, “ Physician/Allied Health Appoint/ Reappoint Procedures, “ dated 05/18/22, the P&P indicated, “ POLICY: Membership on the Medical Staff of [Name of Hospital (Hospital A)] is a privilege, which shall be extended only to professional competent practitioners who are duly licensed and continuously meet qualifications, standards and requirements to provide quality healthcare to Hospital A ’ s patients... Hospital A shall not automatically award appointment, reappointment or privileges to an applicant by virtue of the applicant ’ s inclusion in an exclusivity contract; Hospital A thoroughly reviews every applicant ’ s education, training, experience, and demonstrated current competence. PROCEDURE: Appointment: Each new applicant for Medical Staff appointment and or privileges must complete, sign and submit to the Chief of Staff or his/her designee, the hospital ’ s application for Medical Staff membership and clinical privileges. All physicians must provide and maintain documentation as follows: 4. Current privilege(s) request form for each privilege being requested. Required documentation showing proof of proficiency for all new appointments. Reappointments shall go through a Peer Review process showing proof of proficiency. All new Medical Staff will be subject to proctoring to assure they meet acceptable quality standards of care. The review will consist of at least 10 charts reviewed and a minimum of six months. ... Continued membership and exercise of clinical privileges shall require at least the following: 1. Documentation of continuing satisfaction of the General Qualifications set forth at Section 2.02-1 of the Medical Staff Bylaws; and insofar as clinical privileges are concerned, with the requirements applicable from time to time to the exercise of such privileges. 2. Satisfactory results in Medical Staff quality assessment reviews, or satisfactory correction of any significant problems identified through such reviews... “ During a review of the hospital ’ s policy and procedure (P&P) titled, “ Peer Review Policy, “ dated 10/14/18, the P&P indicated, “ POLICY: Review of circumstances as outlined in this policy will be conducted by a peer physician(s) acting as agent(s) of the Board of Directors and Medical Staff for purposes of fact finding and forwarded to the medical staff peer review committee for further review and/or action when necessary. PURPOSE: To assist the medical staff in the development of strategies to continually enhance the safety and quality of patient care and professional conduct... CIRCUMSTANCES FOR PHYSICIAN & PRACTIONER PEER REVIEW: A. Any aggregate or individual information derived from generic screens including routine audits, medical staff monitors, adverse or serious adverse events, event notification (incident or occurrence) reports, complaints from patients or staff, third party agencies or other sources of information within the hospital system that suggest possible deviation(s) from accepted standards of patient care, regulatory requirements or other policies that have been approved by the medical staff. B. Performance of clinical procedures that fall outside the boundaries of documented competencies and approved privileges. C. Potential clinical quality issue raised by another medical staff member or other clinicians or staff... G. A minimum of 5 charts quarterly, of practitioner medical charts will be reviewed by a peer to assure competency and quality care is being provided. Results of Peer Review will be returned to the Medical Staff Coordinator within the specified time limits. If this is not being met, the Chief of Staff and administration will be notified. PROCEDURES FOR PHYSICIAN & PRACTIONER CASE REVIEW: A. Patient Safety and Quality Improvement (PSQI) Committee will note circumstances requiring review based upon standards developed by the PSQI personnel in conjunction with applicable medical staff committees... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...NATURE OF MEDICAL STAFF MEMBERSHIP: Membership on the Medical Staff and/or clinical privileges shall be extended to, and may be maintained by only those professionally competent practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. QUALIFICATIONS FOR MEMBERSHIP: General Qualifications-Only physicians, dentists, podiatrists, and clinical psychologists shall be deemed to possess basic qualifications for membership in the medical staff,... and who: (a) Document their (1) current licensure, (2) Adequate experience, education, and training, (3) current professional competence, (4) good judgment, and (5) current adequate physical and mental health status, so as to demonstrate to the satisfaction of the medical staff that they are professionally and ethically competent and that patients treated by them can reasonably expect to receive quality medical care....BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP- Each member of the Medical Staff shall:...Accept responsibility for participating in Medical Staff proctoring as an obligation of Staff membership... Continuously meet the qualifications for membership as set forth in these Bylaws... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...The Credentials Committee/Medical Executive Committee shall develop policies and procedures (which shall become effective upon approval by the Medical Executive Committee and the Governing Body) to implement the following: (a) All new Staff members shall be appointed to the Provisional Staff and subjected to a period of formal observation and review (except for those appointed to the Consulting Staff). Provisional appointments are ordinarily for a period of from six months to one year, but the Medical Staff Executive Committee may extend the period beyond one year for good cause for a maximum of two additional six month periods. (b) Reappointments to any Staff category shall be for a period of two years. Change in Staff category may be requested at any time during the reappointment period after requirements of Provisional status are met... “ During a review of the “ Bylaws of the Medical Staff, “ dated 2019, the Bylaws indicated, “ ...EXERCISE OF PRIVILEGES: Except as otherwise provided in these Bylaws or the Medical Staff Rules and Regulations, every practitioner or other professional providing direct clinical services at this Hospital shall be entitled to exercise only those clinical privileges or services specifically granted to him/her. Each application for appointment and reappointment to the Medical Staff must contain a request for the specific clinical privileges desired by the applicant. Requests for clinical privileges shall be evaluated on the basis of the practitioner’s education, training, experience, and demonstrated ability and judgment. The basis for privileges determinations, in connection with periodic reappointment or otherwise, shall include any observed clinical performance and judgment, performance of a sufficient number of procedures each year to develop and maintain the practitioner’s skills and knowledge, and the documented results of the patient care audit and other quality assessment activities required by the Medical Staff Bylaws and Rules and Regulations. Privileges determinations shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and health care settings where a practitioner exercises clinical privileges... “ During a review of the professional reference from the National Association Medical Staff Services (NAMSS), titled, “ CREDENTIALING STANDARDS FOR INITIAL PRACTITIONER APPLICANTS, “ dated 1/24, the reference indicated, “ ...Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide patient-care services in a healthcare setting and credentials verification organizations. Formally credentialing practitioners helps ensure and/or adhere to: Patient safety, Federal and state regulations, Healthcare organization accreditation standards, Risk management, Quality of patient care, Healthcare organization requirements. Federal and state regulations and accrediting organizations stipulate that certain information must be primary source verified and healthcare organizations should make every effort possible to primary source verify all practitioner-credentialing elements whenever possible. If the primary source is unresponsive to material requests, the applicant is responsible for contacting the primary source. The application remains incomplete until it is verified by the primary source. Primary-Source Verification: Obtaining and verifying a credential directly from the original issuing entity. NAMSS ’ best practices for credentialing initial practitioner applicants include an evidence-based evaluation to verify the following 13 criteria from primary sources... 8. CRIMINAL BACKGROUND DISCLOSURE: An applicant ’ s background check includes conducting a County Criminal Search and National Criminal Search to check the applicant ’ s criminal activity within the past seven years, at minimum...Criminal background checks should occur during initial credentialing and can be done ad-hoc at any time. 12. MALPRACTICE: Malpractice Insurance Obtain: A copy of current certificate of insurance. Verify that the applicant holds current professional liability coverage with limits that meet or exceed the organization ’ s requirements. Ensure malpractice coverage is consistent with clinical privileges requested and coverage does not include any exclusions... “ During a review of the American Academy of Family Physicians position titled, “ Clinical Proctoring, “ dated 10/25, the policy indicated, “ ...Clinical Proctoring is an important peer assessment tool for physicians seeking privileges in hospitals and health care organizations. Privileges for procedures and services should be based on training, experience and demonstrated competence... Proctoring is an objective evaluation of a physician’s clinical competence by an experienced physician [the proctor] who represents and is responsible to the hospital or credentialing body. Medical staff members seeking new or expanded privileges are monitored and evaluated by a proctor while performing the service or procedure for which privileges are requested... Three common types of proctoring are prospective, concurrent and retrospective. In prospective proctoring, prior to treatment or performing a procedure, the proctor becomes familiar with details of the case, either by assessing the patient and/or reviewing their chart and then observing. This method of proctoring can be helpful for complex or high-risk procedures. In concurrent proctoring, the proctor observes the physician treating a patient or performing a procedure. This is often used for invasive procedures to verify competence. In retrospective proctoring, the proctor reviews patient charts after treatment, usually sufficient for noninvasive procedures. These types of proctoring are not mutually exclusive. In any request for privileging, a combination of all three may occur.. The proctor shall provide a confidential report using a standardized process to the governing body that determines privileges to assist in the decision to grant the requested privileges. The department ’ s decision should be based on the applicant’s performance during the proctoring period... “ During a review of the professional reference from the American Medical Association (AMA) Policy titled “ Peer Review, “ dated 2024, the policy indicated, “ ...Definition and Purpose of Peer Review. Peer review is the task of self-monitoring and maintaining the administration of patient safety and quality of care, consistent with optimal standards of practice. It is the mechanism by which the medical profession fulfills its obligation to ensure that its members are able to provide safe and effective care. The responsibility assigned to and scope of peer review is the practice of medicine, i.e., professional services administered by a physician and the portion of care under a physician’s direction. Therefore, elements of medical care, which describe the knowledge, skills, attitudes, and educational experiences of physicians and provide the foundation of physician activities, are subject to peer review... Those elements include but are not limited to the following: patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. Activities that comprise medical care are subject to the scope and rigor of peer review... “ During a review of the StatPearls Publishing article titled, “ Credentialing, “ dated 10/24/22, retrieved from <https://www.ncbi.nlm.nih.gov/books/NBK519504/>, the article indicated, “ ... Credentialing is a formal process that utilizes an established series of guidelines to ensure that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. Credentialing also assures patients that they are being treated by providers whose qualifications, training, licensure, and ability to practice medicine are acceptable. Credentialing also ensures that all healthcare workers are held to the same standard... Credentialing is a vital process for healthcare institutions. In simple terms, it is the process of assessing a healthcare provider’s academic qualifications and clinical practice history...All healthcare workers should understand that practicing clinical medicine is a privilege, and it goes hand-in-hand with first being credentialed. After the individual is credentialed, the next step is to address the privileges of practice, which depend on evaluating the provider ’ s clinical qualifications, training, and overall performance... Simply being licensed does not mean healthcare professionals can perform all clinical services...once a license is obtained, they can only perform a function for which they are granted privileges. Privileging occurs when a healthcare worker is authorized to perform a specific set of patient care services based on an evaluation of the individual ’ s credentials and performance... No healthcare worker should be permitted to work before completing the credentialing process. On the other hand, healthcare institutions should promptly perform initial credentialing so that healthcare workers are not left in limbo for months. The governing board should approve the final credentialing. Once the credentialing process is over, the committee must have a process of granting privileges... Granting privileges specific to the healthcare worker ’ s training and experience is important... Once a healthcare worker has been credentialed and his or her privileges are approved, the hospital must have established performance monitoring methods. This may be done with proctoring... “ Review of the article titled, “Credentialing and Privileging Provider Profiling,” dated 2/29/24, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK603712/ indicated, “ ...Profiling for the Ongoing Professional Practice Evaluation (OPPE). Healthcare institutions and the medical staff use Ongoing Professional Practice Evaluation (OPPE) to monitor providers’ continuing performance and competency. Reporting and evaluation intervals for OPPE reports should be more than once every 12 months, with cycle length determined by the institution. The OPPE data for each practitioner should be specific to their specialty, relevant, and valid. It should encompass critical metrics to facilitate ongoing quality improvement for the individual practitioner and the broader department and institution. Measurements of OPPE data can also include periodic chart reviews or audits, direct observation, proctoring, 360° evaluations, simulation, and external peer review ...Both the OPPE and the FPPE processes must be uniform, data-driven, consistent, free from bias, and fairly applied to every provider of every specialty, including physicians, advanced practice providers such as physician assistants and advanced practice registered nurses, midwives, dentists, chiropractors, podiatrists, psychologists, and others ...””

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(3) The CAH maintains a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. This Standard is not met as evidenced by: 37529 Based on interview and record review the hospital failed to maintain a current and accurate list of all patient care services provided under contract when the list of agreements did not identify what services were being provided and where, and by whom, and the list included outdated contracts for services not provided at the hospital. These failures resulted in the hospital’s inability to monitor the services being provided, account for resources spent, ensure contract terms were aligned with the hospital’s goals, and identify gaps in services needed by the community; and could potentially have negative patient outcome. Findings: A list of the hospital ’ s current contracts/agreements to include the name and the purpose (service provided) of the contract was requested on 12/9/25 and provided by the hospital on 12/10/25. Review of the list indicated there were 379 contracts currently in place for services provided to the hospital. The list included only the name of the company, and the purpose of each contract was either left blank or was indicated as “ Service, “ with no further information provided regarding what service was being provided, who was providing it or where in the hospital or clinics the services were provided. During a review of the Professional Services Agreement (PSA) dated 3/1/20 for [Name of group providing anesthesia services], signed by Certified Registered Nurse Anesthetist (CRNA- an advanced practice registered nurse who specializes in administering anesthesia)], the PSA indicated, “ ...The term of this Agreement shall commence on the Effective Date and continue for a period of two (2) years from 3/1/2020-2/28/2022. This Agreement may be renewed for an additional year or multiple years upon mutual Agreement of the parties. In the event the parties continue to perform this Agreement beyond the termination date, the term of the Agreement shall convert to a monthly term... “ During a concurrent interview and record review on 12/10/25 at 4 p.m. with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), the contract list was discussed. The CNO stated the agreement with the CRNA for anesthesia services is not current and the hospital does not have any anesthesia providers on staff. The CNO stated the hospital does not provide anesthesia services and she does not know why the contract was initiated. The CEO stated she had been in the CEO for less than two months, so she was unaware of the purpose of the agreement. The CEO stated the contract list was not current. During a review of the hospital ’ s policy and procedure (P&P) titled, “ Contract/ Agreement/MOU Evaluation, “ dated 12/10/15, the P&P indicated, “ POLICY: It is the policy of [Hospital A] to maintain a list of all contracts/agreements/MOUs, etc. both clinical and non-clinical with the scope and nature of services provided. Exceptional care will be provided throughout Hospital A whether contracted or provided directly by hospital staff...The Governing Board of JCFHD has final responsibility for all contracts/ agreements/MOUs, etc., policies and procedures at JCFHD... “”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49769 Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedure (P&P) titled, “Infection Prevention and Control Plan,” Centers for Disease Control (CDC-a U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) and clinical standards of practice for infection control when: 1. A linen cart was not covered in the clean supply linen room. 2. A grocery bag full of citrus fruit that appeared to have mold growing on them was left on the floor of the pantry room. 3. The patient refrigerator had approximately two inches (unit of measurement) of ice was built up all around the freezer compartment which prevented the freezer door from closing completely. 4. The clean storage room stored 11 expired central line stabilization kits (device used to keep medical tubing in place so it doesn’t get pulled out). 5. The Emergency Department (ED) supply cabinet stored two expired 5.5 mm (millimeters, a unit of measure) endotracheal tubes (ET tube - a plastic tube inserted into the trachea (windpipe) through the mouth or nose to maintain an open airway and facilitate breathing when a patient cannot breathe on their own). 6. The ED supply cabinet stored one expired wound closure strips (adhesive skin closures are used as a non-invasive method to close wounds, including lacerations and surgical incisions) packets were expired in the ED supply cabinet. These failures resulted in the potential risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to patients, visitors, and staff which can lead to infection and diseases. Findings: 1. During a concurrent observation and interview on 3/25/25 at 9:30 a.m. with Nurse Manager (NM), in the clean supply linen room of the medical surgical unit (med/surg - a nursing unit where patients who are not critically ill are cared for), one of one linen cart which stored clean lines was not covered. The NM stated linens should be covered to prevent dust and germs from getting on the linens. The NM stated this is important to avoid spreading infection to patients. The NM stated the linens are used for both med/surg and ED patients. During an interview on 3/26/25 at 2:30 p.m. with the Infection Preventionist (IP), the IP stated the linen cart should be covered to protect it from dust and sources of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) which can be transferred to the patient and had the potential of causing harm. During an interview on 3/26/25 at 2:57 p.m. with the Chief Nursing Officer (CNO), the CNO stated her expectation was for all hospital areas should be monitored frequently, and the linen cart should have been covered to protect the lines from dust and possible sources of cross contamination. The CNO stated dirty linen could harm patients. During a review of the document titled, “CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings” retrieved from, https://www.cdc.gov/infection-control/hcp/core-practices/index.html dated 4/12/24, “ ... Education and Training of Healthcare Personnel on Infection Prevention ...standard precautions (basic level of infection control that is used in patient care) include: ...hand hygiene ...environmental cleaning and disinfection ... Minimizing Potential Exposures References and resources ...Reprocessing of reusable medical equipment between each patient or when soiled...” 2. During a concurrent observation and interview on 3/25/25 at 9:40 a.m. with the NM on the med/surg unit in the pantry room, a grocery store paper bag full of citrus fruit was found on the floor. Some of the fruit had black substance on it. The NM stated the paper bag with citrus fruits should not be in the pantry due to the mold. The NM had the fruits discarded by placing it in a plastic bag and throwing in the garbage bin outside the facility. During an interview on 3/26/25 at 2:30 p.m. with the IP, the IP stated the bag of moldy citrus should not be in the pantry. The IP stated the moldy citrus fruits could get wet and attract insects, which could spread infection. During an interview on 3/26/25 at 2:57 p.m. with the CNO, the CNO stated her expectation was all food in the pantry should be properly contained. The CNO stated any item with mold should be immediately removed because it could harm patients. During a review of a professional reference titled, “Infection Control and Prevention (ICP)” (undated) by the Agency for Healthcare Research and Quality (AHRQ), the “ICP” indicated, “ ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty work areas are used for contaminated equipment ...”. During a review of the professional reference titled, “The role of the surface environment in healthcare-associated infections (RS)”, dated 8/2013, the “RS” indicated, “ ... Hospital surfaces are frequently contaminated with important healthcare-associated pathogens [bacteria]. Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider’s hands or gloves that may result in patient-to-patient transmission of nosocomial [originating from the hospital] pathogens ...”. 3. During a concurrent observation and interview on 3/25/25 at 9:50 a.m. with the NM on the med/surg unit pantry room, the patient refrigerator had two inches of ice buildup in the freezer compartment. The ice was blocking the freezer door from closing completely. The NM stated the freezer should not have ice buildup and needed to be defrosted. The NM stated the ice could affect the temperature of the food in the refrigerator, and if it mels, it could contaminate the food below. During an interview on 3/26/25 at 1:30 p.m. with the Food Services Manager (FSM), the FSM stated there should be no ice buildup in any freezer because ice could change the internal temperature of the refrigerator/freezer. The FSM stated since the food goes directly to the patients, there was a risk of foodborne illness (caused by eating or drinking something that is contaminated with germs [such as bacteria, viruses, or parasites] or chemicals [such as toxins or metals that can make people sick when not properly frozen, thawed, or cooked). The FSM stated the refrigerator was used for all med/surg and ED patients, so all patients could get sick, and their hospital stay extended. The FSM stated there was no policy in place to check the refrigerator for ice buildup. During an interview on 3/26/25 at 1:45 p.m. with the Director of Facility Operations (DFO), the DFO stated, there was system in place for all staff to enter a “ticket” into the hospital internal maintenance system for broken or defective equipment. The DFO stated there was not a “ticket” for the refrigerator/freezer not working properly. The DFO stated there was no maintenance on the refrigerator/freezer except if a “ticket” is entered into the system and no maintenance personal check the refrigerator/freezer for proper functioning. The DFO stated there was no policy for checking or cleaning the refrigerator/freezer. The DFO stated if the refrigerator/freezer was not working properly, it could affect all patients in the med/surg unit and ED. The DFO stated patients could get sick or sicker if food from the malfunctioning refrigerator/freezer was consumed. was consumed from a refrigerator/freezer not functionally optimally. During an interview on 3/26/25 at 2:30 p.m. with the IP, the IP stated the refrigerator/freezer should not have ice buildup. The IP stated ice buildup could change the temperature of the device and lead to foodborne illness if patient ate food that was not properly frozen or thawed. During an interview on 3/26/25 at 2:57 p.m. with the CNO, the CNO stated her expectation was for all equipment should be working properly. The CMNO stated if equipment was not working, it should be “ticketed” and taken out for service. The CNO stated the refrigerator/freezer should not have ice buildup. The CNO stated food not stored at proper temperatures could be harmful to patients. During a review of the professional reference retrieved from https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/freezing-and-food-safety titled, “Freezing and Food Safety (usda.gov)” undated, the professional reference indicated, “ ...Freezing to 0 °F inactivates any microbes-bacteria, yeasts and molds- present in food. Once thawed, however, these microbes can again become active, multiplying under the right conditions to levels that can lead to foodborne illness ...”. During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf titled, “Guidelines for Environmental Infection Control in Health-Care Facilities,” dated 7/2019, the professional reference indicated, “ ... Infection-control strategies and engineering controls [physical changes to a work area or process that reduce or eliminate the risk of workers coming into contact with hazards], when consistently implemented, are effective in preventing opportunistic [exploiting chances offered by immediate circumstances], environmentally related infections in immunocompromised populations...” During a review of the professional reference titled “Controlling Hospital-Acquired Infection: Focus on the Role of the Environment and New Technologies for Decontamination”, dated 10/27/14, the professional reference indicated, “ ... a large number of reports include cleaning as an important control component for outbreaks of norovirus, VRE, C. Difficile, MRSA, and Multidrug-resistant (MDR) Gram-negative bacilli ... Removing visual and invisible dirt from the hospitals of today and for the future requires sufficient trained staff, ongoing monitoring ...”. 4. During a concurrent observation and interview on 3/25/25 at 9:30 with NM on the med/surg unit in the clean supply room, 11 central line stabilization kits (device used to keep medical tubing in place so it doesn’t get pulled out) was stored, and had an expiration date of 9/28/24. The NM stated the 11 expired central line stabilization kit could pose an infection control risk for patients because they are no longer considered sterile. During an interview on 3/26/25 at 2:00 p.m. with the Purchasing Manager and the (PM) the Chief Financial Officer (CFO), in the presence of the NM, The PM stated the purchasing department staff do not check the supply rooms or carts for expired products. The PM stated this was the responsibility of the nursing department. The PM stated when he restocks supplies based on par levels (the number of items that should be stocked for each item on unit) they rotate stock by placing the newest items at the back. The PM stated he does not check every item in the supply room for expiration, only the items being restocked. The CFO stated there was no consistent system for managing outdated supplies, and that this process needs to be fixed. During an interview on 3/26/25 at 2:30 p.m. with the IP, the IP stated the expired stabilization kits could pose an infection risk. The IP stated these kits were used to hold central intravenous lines in place and are placed near the insertion site, where the tubing enters the patient’s body. The IP stated she does monthly rounds in the department to check for outdated supplies, but it was the department managers’ responsibility to check for expired items regularly. The IP stated, “If we find something that is outdated during our rounds, we will pull it out of stock, but it is not our responsibility to monitor that.” The IP stated, “We shouldn’t have expired items. They might not be sterile after the expiration date.” The IP stated the supplies might degrade, which could harm to the patient. During an interview on 3/26/25 at 2:57 p.m. with the CNO, the CNO stated her expectation was all items in supply rooms be fully functional and not expired. The CNO state expired items should be pulled from stock immediately, and the right people should be notified. The CNO stated expired items could harm patient and cause cross contamination. The CNO stated there was no system for checking expired items. During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf titled, “Guidelines for Environmental Infection Control in Health-Care Facilities,” dated 7/2019, the professional reference indicated, “ ... Infection-control strategies and engineering controls [physical changes to a work area or process that reduce or eliminate the risk of workers coming into contact with hazards], when consistently implemented, are effective in preventing opportunistic [exploiting chances offered by immediate circumstances], environmentally related infections in immunocompromised populations...” During a review of the professional reference titled, “Good Storage and Distribution Practices for Medical Products”, (retrieved from https://www.who.int/publications/m/item/trs-1025-annex-7) dated 6/17/20, the professional reference indicated, “ ...Storage and distribution are important activities in the supply chain management of medical products ... Storage areas should be of sufficient capacity to allow orderly storage of the various categories of medical products ... Storage areas should be appropriately designed, constructed, maintained or adapted. They should be kept clean and there should be sufficient space and lighting ... Materials and medical products should be stored off the floor, away from walls and ceilings, protected from direct sunlight and suitably spaced, to permit ventilation, cleaning and inspection ... Materials and medical products should be handled and stored in such a manner as to prevent contamination, mix-ups and cross-contamination ...”. 5. During a concurrent observation and interview on 3/25/25 at 11 a.m. with the NM in the ED, the supply cabinet stored two 5.5 mm (millimeters, a unit of measure) endotracheal tubes (ET tube - a plastic tube inserted into the trachea (windpipe) through the mouth or nose to maintain an open airway and facilitate breathing when a patient cannot breathe on their own) with an expiration date of 2/19/25. The NM stated the ET tubes needed to be removed from stock because they pose an infection risk. During an interview on 3/26/25 at 2:30 p.m. with the IP, the IP stated the expired ET tubes could pose infection risk to patients because they are used inside the mouth, which was a route for infections to enter. The IP stated the ET tubes should have been removed from the ED supply cabinet. During a review of a professional reference titled, “Using Expired Supplies for Patient Care Due to Supply Chain Shortages?” dated April 2023, (found at https://www.hceglobal.org/using-expired-supplies-is-this-the-new-normal) the article indicated, “ ...Compromising patient care by using products that may be of inferior quality and integrity should not become the new standard of care ...”. During a review of the professional reference titled, “Keeping it Sterile: Fundamentals of Sterile Storage,” (retrieved from https://www.ormanager.com/keeping-it-sterile-fundamentals-of-sterile-storage/) dated 7/20/23, the professional reference indicated, “ ... Using sterile items ...is a fundamental practice, not a rudimentary one that can or should be taken for granted. Put simply, using unsterile items can result in a patient infection. If sterile storage conditions are not appropriate, the items can become contaminated. Such contamination may go undetected, rendering items unsafe and unusable. Therefore, healthcare facilities must take action to create an environment that properly protects sterile packages. This includes securing a proper sterile storage environment and developing policies and procedures to help ensure sterile packages are safely stored and handled ... Sterile packages should be handled with care and positioned so they are not crushed, bent, compressed, or punctured. Sterile items should never be stored on floors ...”. 6. During a concurrent observation and interview on 3/25/25 at 11:10 a.m. with NM in the ED, the ED supply cabinet stored one wound closure strips packets ready for patients use with an expiration date of 2/29/24. The NM stated the expired wound closure strips could pose a risk of infection to patients. The NM stated the wound closure strips should have been removed from the supply cabinet. During an interview on 3/26/25 at 2:30 p.m. with the IP, the IP stated the expired wound closure strips could pose a risk of infection to patients. The IP stated the wound closure strips risk are used for holding open wounds or lacerations in place which was a route for infection. The IP stated the expired wound closure strips should have been removed from the supply cabinet. During a review of hospital policy titled Infection Prevention and Control Plan Dated 05/21/2020 indicated, “POLICY: A. (Hospital name) Infection Prevention and Control Plan ensures that this organization develops, implements and maintains an active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources ...GOALS: ... 1. Preventing healthcare associated infections. 2. Limiting unprotected exposure to pathogens ...4. Preventing the transmission of infections associated with the use of medical equipment, devices, and supplies. Examples include cleaning, disinfection and sterilization of equipment and utilization of sterile supplies. 5. Ensuring policies and procedures follow current infection prevention guidelines and recommendations ... 7. Ensuring that a sanitary environment for patients, visitors and employees is maintained ...IV. INFECTION PREVENTION AND CONTROL ACTIVITIES/ACTION PLANS: A. Implementation of the DISTRICT’s Infection Prevention and Control Plan requires: 1. The development, review and revision of infection prevention and control policies and procedures 2. Ensuring that the infection prevention and control policies and procedures are followed by all staff, patients and visitors 3. Annual competencies with patient care staff in each department. B. Prevention: 1. Educating patients and staff about infection prevention and control guidelines 2. Policy and procedure review and evaluation ... C. Clinical Controls: ...2.Implementation of appropriate infection control measures ...4. Communicating responsibilities about preventing and controlling infection including hand hygiene and respiratory hygiene practices to all staff, medical staff, patients, families, and visitors ...3. Department managers shall enforce infection prevention policies and ensure that all personnel in their department are competent to participate in infection prevention and control activities. V. EVALUATION: A. Performance Improvement: B. The Infection Preventionist, in coordination with department managers and supervisors, shall continuously review and evaluate infection control practices. C. An evaluation of the organization’s Infection Prevention and Control Plan shall be conducted at least on an annual basis and whenever risks significantly change. D. The evaluation shall review: a. Infection prevention and control goals b. Implementation of infection control and prevention activities 4. Performance improvement findings and recommendations shall be provided to staff. 5. Information from the Infection Prevention and Control Program will be reported every quarter to the Medical Staff by the Chair of the Infection Prevention Committee.” During a review of a professional reference titled, “Quick Safety: Managing packaged sterile supplies and devices (QS),” dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, “ ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices...” During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf titled, “Guidelines for Environmental Infection Control in Health-Care Facilities,” dated 7/2019, the professional reference indicated, “ ... Infection-control strategies and engineering controls [physical changes to a work area or process that reduce or eliminate the risk of workers coming into contact with hazards], when consistently implemented, are effective in preventing opportunistic [exploiting chances offered by immediate circumstances], environmentally related infections in immunocompromised populations...””

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 40644 Based on interview and record review, the hospital failed to have an organized nursing service when: 1. License Nurses did not perform pain assessment and reassessment for Patient 9 and Patient 10 and did not notify the Physician when Patient 10’s temperature was 100.6 Fahrenheit (a scale of measuring temperature). (Refer to C-1006) 2. Patient 13 had a physician’s order Diltiazem (drug used to treat high blood pressure [a condition where the force of blood pushing against the walls of your blood vessels are consistently high] and to control chest pain) 5 milligrams (mg-a unit of mass)/milliliter (mL-a metric unit of measurement for volume or capacity) per 25 mL vial 20 mg IVP times 1 dose stat (immediately) and License Nurse administered diltiazem to Patient 13 without monitoring Patient 13’s blood pressure (the force of blood pushing against the walls of your blood vessels) every 15 minutes for the first two (2) hours and then every two (2) hours for the next six (6) hours and there was no initial Telemetry Monitoring Strips (TMS-a visual representation of a patient’s heart’s electrical activity) documented. Patient 13 was not monitored according to the hospital’s protocol titled, “Diltiazem Infusion,” the hospital’s policy and procedure (P&P) titled, “Telemetry Box Placement,” and P&P titled, “Telemetry Protocol.” (Refer to C-1049) 3. License Nurses did not develop and updated individualized care plan for Patient (Pt) (Pt 2, Pt 3, Pt 4, Pt 5, Pt 7, and Pt 8 when: 3a. Nurses did not develop an individualized care plan for Pt 2’s infection when his admitting diagnosis (the reason he was admitted to the hospital) was for an infected aortic endograph (a device used to treat an abdominal aortic aneurysm (AAA) (a bulge in the wall of the aorta, the body’s main artery, that occurs in the abdominal region without open surgery. (Refer to C-1050) 3b. Nurses did not develop an individualized care plan for Pt 3’s difficulty breathing when his admitting diagnosis was asthma and shortness of breath. (Refer to C-1050) 3c. Nurses did not develop an individualized care plan for Pt 4’s heart failure when his admitting diagnosis was congestive heart failure (a condition that occurs when the heart can’t pump enough blood to meet the body’s needs. (Refer to C-1050) 3d. Nurses did not develop an individualized care plan for Pt 5’s infection when his admitting diagnosis was cellulitis (a bacterial infection that affects the skin and the tissue just beneath it) in his lower left leg. (Refer to C-1050) 3e. Nurses did not develop an individualized care plan for Pt 7’s infection when her admitting diagnosis was colitis (an inflammation of the intestinal tract) and she was diagnosed with Clostridioides difficile (C. diff) (an infectious bacteria). C. diff can cause mild to severe diarrhea and can be life-threatening. (Refer to C-1050) 3f. Nurses did not develop an individualized care plan for Pt 8’s infection when his admitting diagnosis was a septic (sepsis - severely infected) hip. (Refer to C-1050) The cumulative effect of these deficient practices resulted in the facility’s inability to provide quality health care by the nursing staff.”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 45580 Based on interview and record review the hospital failed to ensure: 1.Two of 13 sampled patients (Patient 9 and Patient 10) pain assessments and reassessments was not conducted and documented according to the hospital’s policy and procedure (P&P) titled, “Pain Assessment, Reassessment and Management.” These failures had the potential for Patient 9 and Patient 10 to have continued and unrelieved pain which could affect their healing and psychosocial well-being. 2. One of two sampled patient’s (Patient 10) primary concern was not addressed while she was in the hospital’s emergency department. Patient 10 had a fever (a fever is considered to be a body temperature of 100.4 degrees Fahrenheit or higher) at triage and she continued to have a fever throughout her Emergency Department (ED) visit with no physician notification to address Patient 10’s fever according to the hospital’s P&P titled, “EMTALA Guidelines for ED Services,” This failure had the potential for Patient 10’s fever to continue to rise and cause clinical decline. Findings: 1. During a concurrent interview and record review on 12/12/24 at 10:20 a.m. with RN 3, Patient 9’s “History and Physical (H&P-the physician obtains a thorough medical history, performs a physical examination, and documents their findings)”, dated 11/16/24 was reviewed. RN 3 stated the H&P indicated, “Patient is an 81 year old [male] with [past medical history (PMH)] of hypertension [high blood pressure-a condition where the force of blood pushing against the walls of your blood vessels are consistently too high] ...Parkinson’s disease [a movement disorder that worsens over time] ...who presented to the ED earlier today for hallucinations [something that is believed to be true or real but that is actually false], decrease [by mouth] intake, generalized weakness, dizziness, with multiple falls over the last week ...He denies any focal weakness [a noticeable weakness in a specific part of the body]/numbness [partial or complete loss of feeling], headache, visual changes, head trauma [injury], and loss of consciousness [a state where a person is unaware of their surroundings and themselves] ...” During concurrent interview and record review on 12/12/24 at 11:15 a.m. with RN 3, Patient 9’s “Medication Record (MR),” dated 11/16/24 to 11/23/24 and Patient 9’s “Pain Assessment Flowsheet (PAF),” dated 11/17/24 to 11/23/24 were reviewed. RN 3 stated the MR indicated, acetaminophen 325 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) tablets, 650 mg as needed every six hours for mild to moderate pain and/or fever (a body temperature that’s higher than normal, which is typically 98.6 Fahrenheit (F-scale used for measuring temperature which water freezes at 32 degrees and boils at 212 degrees) was ordered at 12:03 p.m. RN 3 stated the MR indicated Patient 9 was administered acetaminophen (a drug that reduces pain and fever) on 11/17/24 at 12:16 p.m. with a reassessment at 3:13 p.m. of “Tolerated well, no adverse reaction.” RN 3 stated the PAF indicated Patient 9’s pain was not assessed when the acetaminophen was administered at 12:16 p.m. and there was no documented pain reassessment score documented at 3:13 p.m. RN 3 stated the MR indicated on 11/22/24 at 9:02 a.m. Patient 9 was administered acetaminophen with no documented pain score and there was no reassessment of Patient 9’s pain after the acetaminophen was administered. RN 3 stated Patient 9’s pain should have been reassessed within an hour of the pain medication administration. RN 3 stated the importance of pain assessments and reassessments was to ensure the medication was effective to treat the patient’s pain. RN 3 stated if the pain medication was not effective to treat the patient’s pain, the nurse should have notified the physician. During a concurrent interview and record review on 12/12/24 at 3:54 p.m. with RN 3, Patient 10’s “ED Nursing Triage (ENT),” dated 9/23/24 was reviewed. RN 3 stated the ENT indicated, “Triage Date/Time: 09/23/2024 [1:45 p.m.] Triage Location: Bedside- treatment area ...Chief Complaint Pt has [history] of pancreatic cancer [times] 5 years with a new mass [a lump in the body] diagnosed [patient] has had chills and fatigue [extreme feeling of tiredness] [times] 2 days [patient] has [nausea/vomiting] [times] 3 today [patient] with [temperature] 100.6 ...” During a concurrent interview and record review on 12/12/24 at 4:05 p.m. with RN 3, Patient 10’s “Vital Signs (VS),” Patient 10’s “Medication Administration (MA),” and Patient 10’s “ED Nursing Documentation (END),” dated 9/23/24 were reviewed. RN 3 stated the VS indicated at 2:30 p.m. temperature 100.6 oral, respiration 17, Pulse 93, pulse oximetry 98% on room air, blood pressure 113/62 and at 3:57 p.m. temperature 100.6 oral, respiration 17, pulse 88, pulse oximetry 95% on room air, and blood pressure 133/69. RN 3 stated there were no pain assessments documented with the two vital signs while Patient 10 was in the emergency department. RN 3 stated there should be a pain assessment with each vital sign. RN 3 stated the END indicated Patient 10 was discharged at 5:42 p.m. RN 3 stated the second set of vital signs documented were the last set of vital signs documented and when Patient 10 was discharged at 5:42 p.m. there should have been another set of vital signs assessed and documented 15 to 30 minutes prior to Patient 10’s discharge. During a review of the hospital’s P&P titled, “Documentation Requirements-Minimum,” dated 11/15/12, the P&P indicated, “ ...Vital signs include pain scale ...” During a review of the hospital’s P&P titled, “EMTALA Guidelines for ED Services,” dated 1/26/24, the P&P indicated, “ ...Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can determined whether the individual has an emergency medical condition or not ...Medical Screening Exams (MSEs) shall include at a minimum the following ...Vital signs ...Vital signs upon discharge ...” During a record review of Patient 10’s “Medication Administration (MA),” dated 9/23/24 and the hospital’s P&P titled, “Pain Assessment, Reassessment and Management,” dated 2/23/24, the MA indicated cyclobenzaprine (drug used to relax muscles) 10 mg by mouth times one stat (immediately) was administered at 4:36 p.m. and ketorolac (medication used to treat moderate to severe pain) 30 mg intravenous (in the vein) push times one stat was administered at 4:36 p.m. The MA indicated there was no pain assessment documented at 4:36 p.m. The MA indicated at 5:43 p.m. a pain reassessment for cyclobenzaprine was documented with “pain reduced” and at 5:42 p.m. a pain reassessment for ketorolac was documented with “pain reduced.” The MA indicated the pain reassessment for cyclobenzaprine was assessed one hour and seven minutes after the medication was administered. The MA indicated the pain reassessment for ketorolac was assessed one hour and six minutes after the medication was administered. The P&P indicated, “ ...The patient shall undergo reassessment of pain 30 minutes after every pain control mechanism employed by patient care providers to ensure effectiveness of intervention ...” The P&P was not followed when Patient 10’s pain was not reassessed 30 minutes after a pain control intervention was implemented. During an interview on 12/13/24 at 2:18 p.m. with the Chief Nursing Officer/Chief Administrative Officer (CNO/CAO), the CNO/CAO stated, “The purpose of pain assessments and reassessments were to ensure the interventions implemented worked or didn’t work.” The CNO/CAO stated the reassessments determined if the interventions were effective and if the interventions were not effective to meet the patient’s tolerable pain level, the nurses should have tried other interventions or notified the physician about their patient’s pain. The CNO/CAO stated if there were any questionable orders, it was the responsibility of the nurses to notify the physician. During a review of the hospital’s P&P titled, “Pain Assessment, Reassessment and Management,” dated 2/23/24, the P&P indicated, “Purpose: Effective pain assessment and management can remove the adverse psychological [relating to the mind, mental, and emotional] and physiological [relating to the body and its systems] effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness ...Policy ...shall respect and support the patient’s right to optimal pain assessment and management. Pain shall be assessed in all patients in the organization ...Procedure: It shall be the responsibility of all clinical staff to screen all patients expeditiously for the presence or absence of pain, and avoid delays related to testing, diagnostics or consultations. If the screening assessment reveals pain is present in the patient, it shall be the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain, and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality ...and responses to treatment. At time of admission to the facility, the patient shall be questioned regarding pain during the initial nursing assessment (pain screening) ...if the screening assessment identifies pain is present, the admitting nurse performs the initial patient assessment shall document the assessment in the [electronic health record (EHR-a digital version of a patient’s medical history)] ... The reassessed pain level will be documented in the EHR...Patients shall be taught that pain management is part of their treatment ...Ongoing Reassessment: As part of the reassessment, the [Emergency Department] team shall assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics. Include other pain interventions, vital signs, the effectiveness of all interventions and any side effects or adverse reactions. Documentation: Pain assessments and reassessments shall be documented in patient’s medical record. Response to pain medications and non-pharmacological interventions, noting any adverse reactions shall be documented in patient’s medical record ...” During a review of the hospital’s P&P titled, “Documentation Requirements-Minimum,” dated 11/15/12, the P&P indicated, “Purpose: To assure all required documentation is completed on admission to the inpatient unit ...This policy is a guide for staff to use detailing the minimum required documentation needed for inpatients ...While the patient is in the hospital: (Observation, Acute, Swing) ...RN Duties include but not limited to ...Round on your patients at the beginning of the shift ...Verify medication orders are correct and medicate as ordered ...Re assess after [as needed medications] given ...CNA duties ...Vital signs are done per orders or at the least every 4 hours ...Vital signs include pain scale ...Swing patient vital signs are done at minimum every shift ...Documentation minimum requirements: More frequent vital signs and assessments can be done as deemed necessary by the [registered nurse] ...” 2. During a concurrent interview and record review on 12/12/24 at 3:54 p.m. with RN 3, Patient 10’s “ED Nursing Triage (ENT),” dated 9/23/24 was reviewed. RN 3 stated the ENT indicated, “Triage Date/Time: 09/23/2024 [1:45 p.m.] Triage Location: Bedside- treatment area ...Chief Complaint Pt has [history] of pancreatic cancer [times] 5 years with a new mass [a lump in the body] diagnosed [patient] has had chills and fatigue [extreme feeling of tiredness] [times] 2 days [patient] has [nausea/vomiting] [times] 3 today [patient] with [temperature] 100.6 ...” During a concurrent interview and record review on 12/12/24 at 4:05 p.m. with RN 3, Patient 10’s “Vital Signs (VS),” and Patient 10’s “Medication Order (MO),” dated 9/23/24 were reviewed. RN 3 stated the VS indicated at 2:30 p.m. Patient 10’s temperature was 100.6 F. RN 3 stated the VS indicated at 3:57 p.m., Patient 10’s temperature was still 100.6 F. RN 3 stated the MO indicated Patient 10 was not ordered any fever reducing medications. During a concurrent interview and record review on 12/12/24 at 4:26 p.m. with RN 3, Patient 10’s “Electronic Health Record (EHR-a digital version of a patient’s medical records),” dated 9/23/24 was reviewed. RN 3 stated the EHR indicated there was no documentation a physician was notified of Patient 10’s fever. RN 3 stated the physician should have been notified about the fever. RN 3 stated the importance of notifying the physician was to ensure patient safety and care by reporting any abnormal signs and symptoms and labs. During a concurrent interview and record review on 12/13/24 at 2:18 p.m. with the Chief Nursing Officer/Chief Administrative Officer (CNO/CAO), the CNO/CAO stated, “If a patient had a fever, the nurse should report it to the physician and document the physician was notified of the fever.” The CNO/CAO stated when the nurse notified the physician about their patient’s fever, this gave the physician an opportunity to address the fever. During a review of the hospital’s P&P titled, “EMTALA Guidelines for ED Services,” dated 1/26/24, the P&P indicated, “Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not ...Stabilize: No material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition ...All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment shall be given to the patient and only maintenance care can be referred to a physician office or clinic ...The physician shall order appropriate medical staff to attend the patient, maintain and/or initiate treatment or medications and manage known potential adverse effects ...All patients shall receive a Medical Screening Exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic ...Medical Screening Exams (MSEs) shall include at a minimum the following ...Patient’s triage record ...Vital signs ...Necessary testing to rule out emergency medical conditions ...Vital signs upon discharge or transfer ...Complete documentation of the medical screening exam ...Upon completion of the MSE: Provide any necessary stabilizing treatment for EMCs and labor within the hospital’s capability and capacity ...””

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 45580 Based on interview and record review the hospital failed to ensure a medication was administered in accordance with physician orders, facility policy, and accepted standards of practice for one of four sampled patients (Patient 13) when a licensed nurse administered diltiazem (drug used to treat high blood pressure [a condition where the force of blood pushing against the walls of your blood vessels are consistently high] and to control chest pain) and Patient 13 was not monitored according to the hospital’s protocol titled, “Diltiazem Infusion,” the hospital’s policy and procedure (P&P) titled, “Telemetry Box Placement,” and P&P titled, “Telemetry Protocol.” This failure had the potential for Patient 13 to have undetected adverse reactions and/or negative outcomes which could contribute to clinical decline of the patient. Findings: During a concurrent interview and record review on 12/13/24 at 10:45 a.m. with Registered Nurse (RN) 3, Patient 13’s “History and Physical (H&P),” dated 12/8/24 was reviewed. RN 3 stated the H&P indicated, “Patient is a pleasant 69-year-old male with a past medical history of [chronic obstructive pulmonary disease (COPD-a lung disease that damages the airway or other parts of the lungs, making it hard to breathe)] on baseline 4 [liter-a metric unit of measurement for the volume of a liquid or gas] nasal cannula [a small, flexible tube with two prongs that are inserted into the nostrils to deliver supplemental oxygen] oxygen [a colorless, odorless gas that is essential for life] ...atrial fibrillation [a type of irregular heartbeat] reportedly on anticoagulation [prevents or treats blood clots] with [apixaban-drug used to prevent and treat blood clots] ...current smoker presented to the ER with complaints of worsening shortness of breath [the feeling of being unable to breathe deeply or normally] that started 2 to 3 days ago progressively worsening also patient is on oxygen but his oxygen concentrator [a medical device that provides a continuous supply of oxygen-enriched air] was not functioning very well so he has been without oxygen for the last few days denies any current chest pain, obvious fever, productive cough. Patient is a current smoker. Denies any obvious significant weight loss, denies any blood in sputum [mucus and other matter that comes up from the lungs when you cough] ...Plan ...[atrial fibrillation] ...current medications: [diltiazem] bolus [a single large dose of a drug given over a short period of time] continue with [diltiazem] drip [a method of delivering fluids and medications directly into a patient’s blood stream] ...” During a concurrent interview and record review on 12/13/24 at 11:30 a.m. with RN 3, Patient 13’s “Physician Orders (PO),” Patient 13’s “Vital Signs (VS),” dated 12/8/24 and the hospital’s protocol titled, “Diltiazem Infusion,” dated 8/2/23 were reviewed. RN 3 stated the PO indicated, Diltiazem 5 milligrams (mg-a unit of mass)/milliliter (mL-a metric unit of measurement for volume or capacity) per 25 mL vial 20 mg IVP times 1 dose stat (immediately) was ordered at 11:25 a.m. RN 3 stated the PO indicated, Patient 13 was administered diltiazem at 2:04 p.m. RN 3 stated the VS indicated Patient 13’s vital signs were documented at 2:43 p.m., 3:41 p.m., and 7:33 p.m. RN 3 stated the Protocol indicated, “[Blood pressure (BP)] should be monitored every 15 minutes for the first two (2) hours and then every two (2) hours for the next six (6) hours.” RN 3 stated Patient 13’s vital signs were not monitored according to the Protocol. RN 3 stated the importance of following the hospital’s protocol was to ensure patient safety. RN 3 stated not following the protocol could cause harm to the patient. During a concurrent interview and record review on 12/13/24 at 11:45 a.m. with RN 3, Patient 13’s “Electronic Health Record (EHR-an electronic version of a patient’s medical history),” dated 12/8/24 and the hospital’s protocol titled, “Diltiazem Infusion,” dated 8/2/23 were reviewed. RN 3 stated when a patient was placed on telemetry monitoring, the nurse documented if the patient was telemetry monitored in the Nurses Notes or Cardiac Section of the EHR. RN 3 stated at 2:04 p.m. there was no documentation Patient 13 was on cardiac monitoring. RN 3 stated the Protocol indicated, “Patients should be on telemetry for heart rate and rhythm for the duration of infusion and conversion therapy.” RN 3 stated the protocol was not followed when there was no documentation Patient 13 was telemetry monitored. During a record review of Patient 13’s “Telemetry Monitoring Strips (TMS-a visual representation of a patient’s heart’s electrical activity),” dated 12/10/24 and the hospital’s P&P titled, “Telemetry Box Placement,” dated 1/1/20, the TMS indicated there were no initial TMS documented on 12/8/24. The P&P indicated, “An initial strip is to be printed from the monitor to initiate telemetry monitoring and must have dual signature of CNA and Ward Clerk verifying that name, room number and box number are accurate. RN signing first reading is to confirm both signatures are present ...” During a record review of Patient 13’s “TMS,” dated 12/10/24 and the hospital’s P&P titled, “Telemetry Protocol,” dated 3/13/13, the P&P indicated, “A rhythm strip will be documented every four hours and for any complaint of chest pain or any change in rhythm ...A rhythm strip will also be documented when giving IV push cardiac medications ...” The TMS indicated there were no documented TMS on 12/8/24. During an interview on 12/13/24 at 2:18 p.m. with the Chief Nursing Officer (CNO), the CNO stated the risks of not following the hospital’s Diltiazem Protocol could cause harm to patients. The CNO stated protocols were evidence based and nurses should follow the hospital’s protocols. The CNO stated if a nurse had an issue with the protocol, the nurse should talk to the physician. During a review of the hospital’s protocol titled, “Diltiazem Infusion,” dated 8/2/23, the Protocol indicated, “Diltiazem ...infusions are indicated for control of rapid ventricular response to atrial fibrillation ...Initial Bolus ...Administer 0.25 mg/kg, average of 20 mg, via intravenous push (IVP) over 2 minutes ...Fifteen (15) minutes after the initial bolus, if the heart rate (HR) is still greater than 120 [beats per minute (bpm)] and systolic blood pressure (SBP) is greater than 100, repeat the bolus 0.35mg/kg, (average dose of 20 mg), IVP over 2 minutes ...If HR remains greater than 120 bpm after second bolus, notify the physician ...Continuous Infusion Rate ...Begin the drip rate at 5-10 mg/hour immediately after the initial bolus. The infusion rate may be adjusted in increments of 5 mg per hour up to 15 mg/hr MAX to maintain HR 70-110 bpm. If the patient converts to sinus rhythm, notify the physician to potentially discontinue the infusion or to titrate the infusion to maintain a HR of 70-110 ...Maximum duration of infusion is 24 hours. The physician should reevaluate and reassess the risks and benefits of continued infusion ...Monitoring Parameters ...Patients should be on telemetry for heart rate and rhythm for the duration of infusion and conversion therapy ...BP should be monitored every 15 minutes for the first two (2) hours and then every two (2) hours for the next six (6) hours ...” During a review of the hospital’s P&P titled, “Telemetry Box Placement,” dated 1/1/20, the P&P indicated, “Procedure: CNA and Ward Clerk are to place telemetry box on patient together and confirm number and patient name and room number. Ward Clerk is to enter patient into monitoring system and Ward Clerk and CNA staff are to double confirm box number and patient name and room number ...” During a review of the hospital’s P&P titled, “Telemetry Protocol,” dated 3/13/13, the P&P indicated, “Patients on telemetry will be covered by the accepted telemetry protocol ...This is to ensure rapid treatment of any potential harmful arrhythmias ...””

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 40644 Based on interview and record review, the hospital failed to ensure nursing staff updated and developed individualized care plans (required documents to help guide care for patients) for 6 of 13 patients (Pt) related to infection (Pt 2, Pt 5, Pt 7, and Pt 8), heart failure (Pt 4) or shortness of breath (Pt 3). 1. Nurses did not develop an individualized care plan for Pt 2’s infection when his admitting diagnosis (the reason he was admitted to the hospital) was for an infected aortic endograph (a device used to treat an abdominal aortic aneurysm (AAA) (a bulge in the wall of the aorta, the body’s main artery, that occurs in the abdominal region without open surgery. 2. Nurses did not develop an individualized care plan for Pt 5’s infection when his admitting diagnosis was cellulitis (a bacterial infection that affects the skin and the tissue just beneath it) in his lower left leg. 3. Nurses did not develop an individualized care plan for Pt 7’s infection when her admitting diagnosis was colitis (an inflammation of the intestinal tract) and she was diagnosed with Clostridioides difficile (C. diff) (an infectious bacteria). C. diff can cause mild to severe diarrhea and can be life-threatening. 4. Nurses did not develop an individualized care plan for Pt 8’s infection when his admitting diagnosis was a septic (sepsis - severely infected) hip. 5. Nurses did not develop an individualized care plan for Pt 4’s heart failure when his admitting diagnosis was congestive heart failure (a condition that occurs when the heart can’t pump enough blood to meet the body’s needs. 6. Nurses did not develop an individualized care plan for Pt 3’s difficulty breathing when his admitting diagnosis was asthma and shortness of breath. These failures had the potential to cause inconsistent delivery of care, which can result in the decline or lack of improvement for Pt’s 2,3,4,5,7, and 8. Findings: 1. During a concurrent interview and record review on 12/11/24 at 3:12 with Registered Nurse (RN) 1, RN 1 opened the Electronic Medical Record (EMR) for Pt 2. The document titled, “H&P (History and Physical) dated 08/31/2024 indicated, “ ... 86-year-old M [male] with past medical history of ... AAA, (status post EVAR (endovascular aneurysm repair - repair of the bulging vein) ... Patient was transferred to [outside hospital] for evaluation of findings related to infected endovascular graft. ID (Infectious Disease specialist - physician who specializes in infections that cause illnesses) at [outside hospital] recommended 6 weeks of IV (intravenous - liquid medication given directly into a vein) ceftriaxone (an antibiotic- a mediation that fights bacterial infections) ...and was transferred back for continuation of IV antibiotic. During a review of the hospital document titled, “Discharge Summary” dated, 9/4/24, the document indicated, “ ...Discharge Diagnosis: Endovascular graft infection ...” During a review of the hospital document titled, “Problem Activity,” RN 1 stated this is the document usually called a Care Plan in other facilities. RN 1 searched the document for a care plan related to infection and was unable to find one. RN 1 stated Pt 2 was admitted with an infection, and he still has infections, and a Care Plan should have been created for infections. During an interview and record review on 12/13/24 at 9:08 a.m. with RN 7, RN 7 stated she was the nurse assigned to Pt 2 but she does not remember him. RN 7 stated Care Plans should always include the patient’s primary diagnosis, and nurses can customize care plans to include any other items they need to be following, including safety concerns, such as fall risks and skin care. RN 7 stated care plans need to be patient specific. 2. During a concurrent interview and record review on 12/11/24 at 4:04 p.m. with Registered Nurse (RN) 1, RN 1 opened the Electronic Medical Record (EMR) for Pt 5. The document titled, “H&P (History and Physical) dated 08/31/2024 indicated, “ ...Chief Complaint: LT (left) Leg Infection ... 73 year old female with past medical history of Prediabetes (a serious health condition that occurs when your blood sugar levels are higher than normal, but not high enough to be diagnosed as type 2 diabetes) prior Pseudomonas (a type of bacteria) infection with history of sepsis 2 times in the past ...” During a review of hospital document titled “Problem Activity,” the document indicated, “ ...Nursing Physical Assessment ...Wound noted to LLL (left lower leg) ... wound cleaned and dressed ...” RN 1 stated this is the document that serves as a care plan in this hospital, and there is no other document called a “care plan.” RN 1 stated, “our care plan module isn’t good. There should definitely be a care plan for infection, that’s the main reason she was here. We need to do a lot of education with nurses.” 3. During a concurrent interview and record review on 12/12/24 at 10:33 a.m. with Registered Nurse (RN) 1, RN 1 opened the Electronic Medical Record (EMR) for Pt 7. The document titled, “H&P (History and Physical) dated 11/25/24 indicated, “79 year old female with past medical history of chronic A-fib (an irregular heart rhythm), who presented with severe recurrent diarrhea... Patient so far has had 4 watery BMs (bowel movements) while in the ED (Emergency Department) ...CT (computerized tomography) [of her] abdomen [and] pelvis positive for pancolitis (inflammation of the entire colon.) During a concurrent interview and record review of hospital document titled, “Discharge Summary” dated 11/30/24, the document indicated, “ Hospital course: ... During this admission patient was treated for acute (sudden onset) pancolitis and diagnosed with C. difficile colitis Clostridioides difficile (C. diff) (an infectious bacteria). C. diff can cause mild to severe diarrhea and can be life-threatening.) Patient was started on IV Flagyl (an antibiotic) and p.o. vancomycin (an antibiotic), but still patient continued with diarrhea with traces of blood. During a concurrent interview and record review of hospital document titled, “Problem Activity,” the document indicated, “ ...Nursing Physical Assessment ...Wound noted to LLL (left lower leg) ... wound cleaned and dressed ...” RN 1 stated this is the document that serves as a care plan in this hospital, and there is no other document called a “care plan.” RN 1 stated C. diff is the main reason this patient came to the hospital, it is a serious infection that is very contagious. 4. During an observation and interview on 12/11/24 at 12:30 p.m. with Pt 8, Pt 8 was observed sitting in a wheelchair next to his hospital bed. Pt 8 stated he had an infection in his hip, and they have been giving him medicine for his hip and knee. Pt 8 stated his hip and leg do not hurt much anymore, and he wants to go home. During a concurrent interview and record review on 12/12/24 at 11:00 a.m. with Registered Nurse (RN) 1, RN 1 opened the EMR for Pt 8. The document titled, “HOSPITAL H&P” dated 11/20/2024 indicated, “ ... patient is an 80-year-old and with PMH (past medical history) of ... bacteremia (an infection in the blood) ... and recurrent (happening over and over) right knee prosthetic (artificial) joint infection who was found to have right hip prosthetic joint staph aureus (a bacteria) infection. He underwent his right hip prosthesis revision (repair of previous hip surgery) ... on 11/12/2024, who has been transferred to [name of hospital] for ... completion of IV antibiotic (2 g (grams - a unit of measure) rocephin (an antibiotic) for total of 6 weeks (11/12 to 12/20/2024). Patient currently complains of right hip pain and denies any other symptoms ...”. During a concurrent interview and record review of hospital document titled, “Problem Activity,” RN 1 was unable to find a care plan for infection. RN 1 stated, “he had a septic him and knee, and came in for antibiotics. The whole reason he was here was for his infection, so she should have had a care plan for infection if nothing else.” 5. During a concurrent interview and record review on 12/12/24 at 11:30 a.m. with Registered Nurse (RN) 1, RN 1 opened the EMR for Pt 4. The document titled, “HOSPITAL H&P” dated 12/07/2024 indicated Pt 5 was an 81-year-old man admitted to the hospital on 12/7/24 for shortness of breath and atrial fibrillation (an irregular heart rhythm.) Note indicated ER physician’s examination he was found to have wheezing as well as possible evidence of CHF (congestive Heart Failure)and was given IV Lasix (a medication to reduce extra water in the body) ... During a concurrent interview and record review of hospital document titled, “Problem Activity,” RN 1 was unable to find a care plan for cardiac (heart) output. RN 1 stated she did not see any care plan that addressed heart failure or atrial fibrillation at all. RM 1 stated, “there should be a care plan for fluid volume and cardiac output at least.” 6. During a concurrent interview and record review on 12/11/24 at 11:30 a.m. with Registered Nurse (RN) 1, RN 1 opened the EMR for Pt 3. The document titled, “HOSPITAL H&P” dated 12/10/2024 indicated Pt 3 was a “ ... 50-year-old male with a past medical history of hypertension, asthma ... RESPIRATORY: positive for dyspnea (difficulty breathing). During a concurrent interview and record review of hospital document titled, “Problem Activity,” RN 1 was unable to find a care plan for shortness of breath or any reference to asthma, which was one of the reasons he came to the hospital.. RM 1 stated, “there should be a care plan for shortness of breath, since he has a history of asthma and was having difficulty breathing when he came in.” During an interview on 12/13/24 at 9:08 a.m. with RN 7, RN 7 stated Care Plans should always include the patient’s primary diagnosis, and nurses can customize care plans to include any other items they need to be following, including safety concerns, such as fall risks and skin care. RN 7 stated care plans need to be patient specific. During an interview on 12/13/24 at 10:19 a.m. with RN 4, RN 8 stated the purpose of a Care Plan is to make sure the problem is resolving (the patient is improving). RN 8 stated Care Plans are supposed to be updated every shift, and they should include safety issues such as skin breakdown, and any acute problems the patient is having. RN 8 stated the primary reasons for admission should always be included in the Care Plan. During a record review of hospital policy titled, “Policy and Procedure,” dated 11/24/2012, the document indicated, “ ... Subject: Care Plans ... POLICY: Patient care is to be delivered in accordance with a patient-specific care plan that addresses the patient’s physical and psychosocial needs. PURPOSE: To ensure appropriate nursing evaluation of and response to each hospitalized patient’s physical and psychosocial needs. PROCEDURE: 1. A plan of care, unique to each patient, will be initiated by nursing staff within 24 hours of admission. 2. The initial care plan includes identification and prioritization of patient problems, planned nursing interventions, and patient specific, measurable goals. 3. Care plans for both Inpatient and Swing patients will be re-evaluated every shift and updated as patient condition and/or needs require. 4. Unmet goals and/or new or ongoing problems may indicate a need for post-hospitalization services such as Home Health Care, outpatient services, or referral to community resources. 5. Documentation will reflect communication on plans to meet ongoing needs. 6. The patient care plan is a part of the permanent clinical record.”