Community Memorial Hospital - Ojai

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 49405 The hospital failed to meet the regulatory requirements for the Condition of Participation: CFR 485.635 Provision of Service as evidenced by the following: 1. The hospital failed to ensure implementation of policy and procedures (P&P) for safe and effective systems for: a. A crash cart (a portable wheeled cart that contains all the necessary equipment and medications used during critical care situations) check was completed daily. b. A computer screen with patient information was left open outside patient room, visible to non-medical staff. c. Pain assessment was not completed per P&P on one of seven sampled patients (Patient 303). d. A registered nurse (RN) failed to notify a physician of a critical lab value for one of seven sampled patients (Patient 303). e. Fall measures or precautions were not documented for one of seven sampled patients. (Patient 101) f. Patient 103’s operative report was incorrect because the report indicated a right total knee surgical procedure was performed however the procedure was performed on the left knee. These failures had the potential to result in patients not receiving quality care per assessment, the delay in care and potential for violation of patient privacy. (Reference C-1006). 2. The hospital failed to ensure unauthorized staff did not have access to medication room, drug and biological’s were stored and labeled per (P&P) when: a. Only authorized staff had access to the hospital’s Emergency Room Medication Room. b. Outdated, mislabeled, or otherwise unusable drugs and biological’s were not available for patient use. c. Patient medications were labeled and stored correctly per policy and procedure (P&P). d. Multiuse vial of medication was labeled per P&P. e. Glucometer (device to measure blood sugar) control solutions were not expired. f. Eye drops were not stored securely. These failures had the potential to compromise patient safety and hospital security. (Reference C-1016). 3. The hospital failed to ensure their policies and procedures (P&P) related to identifying patients at risk for malnutrition, measuring patients weight upon admission to acute care and completion of a nutrition assessment (NA) by a Registered Dietitian (RD) were followed for 4 of 6 sampled patients (Patient 102, Patient 306, Patient 600 and Patient 601) when: a. The Malnutrition Risk Screen (MRS) was not completed accurately during the nutrition screening portion of the nursing admission assessment for Patient’s 306, 600, and 601. b. Patient 102 and Patient 306 were not weighed upon admission to acute care, in accordance with hospital P&P and professional standards of practice designed to identify nutrition risk. c. Patient 600 did not have a nutrition assessment documented in the electronic health record (EHR) by a RD in accordance with hospital P&P. These failures had the potential to delay nutritional assessment, interventions and plan of care for the patients which had the potential for negative impacts on patient health and safety.(Reference C-1020). 4. The hospital failed to follow P&P and standards of practice for medication administration when: a. The drug manufacturer’s package-insert and the associated Black Box warning for the administration and monitoring a medication, for one of one sampled patient’s (Patient P-400). b. An electrocardiogram (ECG- a device that measures the electrical activity of the heart to evaluate its rhythm and rate) was not performed on Patient P-400 in accordance of manufacturer’s package insert. This failure had the potential of jeopardizing patient safety, which could result in patient harm or death. (Reference C-1049). The cumulative effects of these systemic problems resulted in the hospital’s inability to ensure an effective, system-wide provision of services and to ensure the safety and quality of care provided to patients.”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 51423 Based on observation, interviews and review of hospital documents, the hospital failed to maintain an acceptable level of safety and quality of the physical environment when: 1. The top of the convection oven was not properly maintained in a sanitary condition. There was dirt and grime buildup material on top. 2. The food bins were not properly maintained in a sanitary condition. There was a black particle in the sugar bin. 3. The intensive care unit (ICU) M-1 glucometer (a portable device that measures blood sugar levels by analyzing a small drop of blood on a test strip, providing results in about 5 seconds) was not functioning at all but yet was available in a patient care area ready to be used. 4. The post anesthesia care unit (PACU) room 6 Code blue alarm (a hospital emergency announcement indicating a patient is experiencing a critical, life-threatening situation, such as cardiac or respiratory arrest. It alerts a specialized team to immediately provide resuscitation, CPR, and advanced life support) was not working. 5. A BiPAP (Bilevel Positive Airway Pressure-noninvasive ventilator used to assist breathing by delivering pressurized air through a mask) machine stored in the respiratory department preventive maintenance PM was past due. 6. The Pre-Op area, bed B’s patient call light (a critical communication device used in healthcare settings to allow patients to alert staff when they need assistance) was not working or alarming These failures had the potential to pose the risk for exposure of unsanitary conditions to affect the quality of food which can lead to the patients not meeting their nutritional needs as well as the growth of microorganisms which can lead to food-borne illnesses in a medically vulnerable population of 5 patients. Furthermore, places patient safety at risk when equipment, alarms and devices were nonfunctioning and available in patient care areas. Findings: 1. During a concurrent observation and interview on 4/21/26 at 10:00 a.m. with Food Service Manager (FSM) in the kitchen, the top of the convection oven was unclean and sticky with black dirt and grime. There were two pans stacked on top of the convection oven. The FSM confirmed there was dirt and grime on top of the convection oven. The FSM confirmed that pans were stored on top of the convection oven which posed the risk for cross-contamination. During a review of the document titled, “Area Equipment Cleaning Schedule and Inspections In Food and Nutrition Services”, dated 4/26, indicated a cleaning frequency is determined for all areas and equipment in the Food and Nutrition Services Department/ Dining Services ...all staff is trained and assigned area and equipment cleaning tasks ... During a review of the hospital document titled, “Cleaning Log”, dated 4/20/26, the log did not include wiping down the top of the convection oven. 2. During a concurrent observation and interview on 4/21/26 at 10:00 a.m. with Food Service Manager (FSM) in the kitchen, a black particle was detected in the bin of sugar. The FSM confirmed that there was a black particle in the bin of sugar that should not have been and was unidentifiable. During a review of the hospital document titled, “Area Equipment Cleaning Schedule and Inspections In Food and Nutrition Services”, dated 4/26, the document indicated a cleaning frequency is determined for all areas and equipment in the Food and Nutrition Services Department/ Dining Services ...all staff is trained and assigned area and equipment cleaning tasks ...” During a review of the USDA Food Code 2022, Section 4-601.11 titled, “Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.” 35399 3. During a tour of the Intensive Care Unit (ICU) on 4/21/26 at 11:16 a.m., accompanied by the patient safety & risk management director (PSRM), a glucometer was observed inside the nurses’ station. Registered nurse (RN9) confirmed the glucometer was ready to be used for patient care. RN 9 was asked to demonstrate how to perform quality control (QC-glucometer test is a verification procedure ensuring a blood glucose meter and test strips are working accurately together) on the glucometer. RN 9 attempted to log into the glucometer to perform the QC. However, the glucometer was not working and did not allow RN 9 to log into the glucometer. RN 9 attempted to log into the glucometer two more times without being able to log into the glucometer. Then, RN 9 stated “This glucometer is not working.” During a concurrent observation of the glucometer and interview with the PSRM on 4/21/26 at 11:18 a.m., the PSRM was asked if a glucometer that is not functioning should be available at the patient care unit. The PSRM acknowledged and confirmed that a nonfunctioning glucometer should not be available in the patient care unit. 4. During a tour of the post anesthesia care unit (PACU) accompanied by the director of nursing (DON) and the PSRM on 4/21/26 at 11:41 a.m., the unit consists of bed 5 and 6. The code blue button alarm for bed 6 was tested to see if the alarm was working properly. The button was pressed, however, there was no alarm or sound at all. The button in bed 6 did not light up when pressed indicating the button was not functioning at all. The DON acknowledged and confirmed that the code blue alarm was not working for bed 6 in the PACU and it should be working. 5. During a tour of the respiratory services department accompanied by the PSRM on 4/21/26 at 3:53 p.m., a BiPAP machine was observed stored and ready to use on patients. On the machine a preventive maintenance PM sticker was noticed on the side of the machine. The sticker indicated “PM Status: PASS. PM DATE: 08/2025. DUE DATE: 02/2026, Tech initials”. The PSRM confirmed the BiPAP’s PM sticker information, acknowledged the PM date was passed due and indicated will request for the latest PM for this BiPAP machine. During an interview with the PSRM on 4/22/26 at 3:10 p.m., the PSRM confirmed that a PM was not performed on the BiPAP machine on 02/2026. The PSRM stated “We don’t have any documentation that a PM was done in February 2026 for this (BiPAP) machine.” 6. During a tour of the Pre-Op unit (specialized hospital unit or holding area where patients are prepared for surgery immediately before their procedure) and concurrent interview with the PSRM on 4/21/26 at 1245 p.m., the Pre-Op unit consists of two beds (A & B). The patient call light for bed B was tested to see if it was functioning properly. The call light button was pressed, however there was no alarm or sound heard to alert staff. The PSRM acknowledged and confirmed that the call light was not functioning, and it should be.”

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 35399 Based on observation, interview and record review, the facility failed to ensure their Annual ACH & Room Pressurization Report for 2025 contained the post anesthesia care unit (PACU) air changes per hour (ACH-measures how many times the total air volume in a room is replaced per hour) calculation information details. The facility’s failure resulted in not being able to validate if the PACU’s ACH measurements or calculations were conducted. Finding: During a tour of the PACU accompanied by the Registered Nurse (RN) Manager 2 on 4/21/26 at 12:20 p.m., the PACU was observed to be a non-enclosed unit. The PACU was part of the ICU area, located at the back of the ICU, which consists of two beds (bed 5 & 6). RN Manager 2 was asked what the air changes per hour (ACH) in the PACU were. RN manager 2 indicated not knowing this information however will get someone who does. During a concurrent review of the facility’s 2025 Annual ACH & Room Pressurization Report, and interview with facilities staff (FS 1) and facilities staff (FS 2) on 4/21/26 at 12:30 p.m., in the report the PACU’s ACH was not listed. The report was handed over to FS 1 to review the report and to point out where in the report the PACU ACH was listed. FS 1 & FS 2 review the report, however, could not locate PACU’s ACH. FS 1 acknowledged and confirmed that the PACUs ACH was not listed in the report and did not know the reason. Furthermore, FS 1 confirmed the facility follows the ASHRAE Standards- Standard 170 (Ventilation of Health Care Facilities) defines mandatory minimum requirements for HVAC design in hospitals, outpatient clinics ... to ensure infection control, odor removal, and thermal comfort ...defining air change rates, pressure relationships, and filtration ... to reduce airborne contaminants. During an interview with the Patient Safety Risk Manager (PSRM) on 4/23/26 at 3:13 p.m., the PSRM confirmed the facility follows ASHRAE standards and has adopted Association of periOperative Registered Nurses AORN guidelines for their surgical services. The facility provided a copy of the ASHRAE Standards- Standard 170 which indicates the PACU requires a minimum total of six ACH. During a review of the 2025 Association of periOperative Registered Nurses (AORN) guidelines, in the Design and Maintenance guideline, in part 3.8. indicated “Design the HVAC system and parameters to meet the requirements associated with the intended use of the space (Table 5). In Table 5 indicates Phase I Post anesthesia Care Unit (PACU) and Phase II Recovery Area the Minimum Total Air Changes/Hour (ACH) is 6.””

“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: 49405 During on observation, interview, and record review, the facility failed to ensure implementation of policy and procedure (P&P) when: 1. A crash cart (a portable wheeled cart that contains all the necessary equipment and medications used during critical care situations) check was completed daily. 2. A computer screen with patient information was left open outside patient room, visible to non-medical staff. 3. Pain assessment was not completed per P&P on one of seven sampled patients (Patient 303). 4. A registered nurse (RN) failed to notify a physician of a critical lab value for one of seven sampled patients (Patient 303). 5. Fall measures or precautions were not documented for one of seven sampled patients. (Patient 101) 6. Patient 103’s operative report was incorrect because the report indicated a right total knee surgical procedure was performed however the procedure was performed on the left knee. These failures had the potential to result in patients not receiving quality care per assessment, the delay in care and potential for violation of patient privacy. Findings: 1. During a review of facility’s P&P titled, “Emergency Cart, HS-NUR061”, dated 05/2025, the P&P indicated, “Purpose: the purpose is to ensure that appropriate persons are knowledgeable of the operations of the emergency carts. Policy: To Provide appropriate, strategically placed emergency resuscitation equipment and medications for those patients experiencing cardiopulmonary arrest or acute respiratory compromise eliciting a hospital wide response. Procedure: ... B. Daily Emergency Cart Check 1. During each day of department operation, licensed staff will check the Emergency Carts per 2. a-f below. Emergency Carts will be checked by licensed staff once every 24-hours Departments not open 24 hours will check the emergency cart at the start of daily operations ...”. During a concurrent observation and interview on 04/21/26 at 11:30 a.m. with Clinical Quality Coordinator (CQC), Crash cart #8 located in the hall near room 104, was missing the daily check on 04/18/26. CQC stated that crash cart checks are completed daily and agrees that the crash cart check was not completed on 04/18/26 per P&P. 2. During a review of facility’s P&P titled, “I/S Access Policy, HS-IS002”, dated 06/2024, the P&P indicated, “The purpose of this policy is to maintain an adequate level of security to protect Community Memorial Health System’s (CMHS) data and information systems from unauthorized access. Scope: A. this policy affects all employees of CMHS and its subsidiaries, and all contractors, consultants, temporary employees and business partners ... Procedure: B. Workstation Access Control System: 2. Active workstations are not to be left unattended for prolonged periods of time. When a user leaves a workstation, that user is expected to properly lock or log off of their workstation. Users will be held responsible for all actions taken under their sign-on.” During a concurrent observation and interview on 04/21/26 at 11:40 a.m. with CQC, a computer on wheels was left unattended in the doorway of room 104 with the computer screen open. The computer screen was visible to the public passing in the hall and patient information was on the screen. CQC acknowledges that the screen had patient information visible to the public and was left unattended. CQC states that the Respiratory Therapist did not follow P&P with locking the screen. 3. During a review of facility’s P&P titled, “Nursing Standard of Care for Medical-Surgical / Swing, OV-NUR-221”, dated 09/2025, the P&P indicated, “Purpose: To describe the nursing standards of care being rendered to patients in the medical-surgical unit Community Memorial Hospital - Ojai. Policy: It is the policy of the hospital to ensure that patients in the Med-Surg unit are cared for appropriately, safely, efficiently, and compassionately by competent staff, in compliance with accreditation standards and regulations ... Procedure: D. Standards and Guidelines for Care 4. Vital Signs: minimum of every 8-hours or per physician-ordered frequency.” During a concurrent interview and record review on 04/23/26 at 09:30 a.m. with CQC, Patient 304’s “Pain flowsheet”, dated 12/02/25 - 12/04/25’s was reviewed. The flowsheet indicated, on 12/03/25 Patient 304’s pain assessment was documented at 2:00 p.m. and not assessed again till 12/04/25 at 08:00 a.m. CQC acknowledges there was no pain assessment documentation for 18 hours and states the nurse did not follow P&P nursing standard of practice for pain assessments. During a concurrent interview and record review on 4/23/26 at 09:45 a.m. with CQC, the facility’s P&P titled “Nursing Standard of Care for Medical-Surgical / Swing, OV-NUR-221”, dated 09/2025 was reviewed. The P&P indicated, “Standards and Guidelines for Care 4. Vital Signs: minimum of every 8-hours or per physician-ordered frequency”. CQC stated that per nursing standards, nurses are expected to do vital signs every 8 hours including pain assessment, for med-surg and swing patients, unless a MD orders differently. CQC states that there is not a specific policy referring to pain assessments and that the nurses are to use “Nursing Standard of Care for Med-Surg” policy. CQC stated that nurses are expected as their standard of practice to assess pain as their “5th” vital sign and acknowledged that pain assessment was not completed per P&P. 4. During a review of facility’s P&P titled, “Critical Values & Tests, HS-NUR046”, dated 02/2024, the P&P indicated, “Purpose: A. When any Critical Value is obtained as a result of patient examination or testing of a patient specimen it is the policy of Community Memorial Health System to promptly notify the licensed individuals responsible for the immediate care of the patient. Policy: A. ... All critical values shall be immediately called to the ordering or on-call physician and documentation of the calls noted in the patient’s medical record. All critical tests shall be completed and called to the ordering or on-call physician according to the specified timeframe’s approved by Medical Staff and documentation of the calls noted in the patient’s medical record ... B. Licensed Nurse Responsibility: 1. Licensed nurse should verify the reported laboratory value by viewing the results in computer or printing from EHR/EMR [electronic health record] when receiving report of critical value. 2. Within 30 minutes Licensed nurse shall notify the physician of the critical value using the read back/verify process as defined in general guidelines or implement therapy based on protocol or previously written orders for the patient. 3. The nurses shall document physician notification whether via telephone or in person or when modifying/implementing therapy based on previous orders or protocol. During a concurrent interview and record review on 04/23/26 at 10:18 a.m. with CQC, Patient 303”s “Result Review”, dated 04/09/26, was reviewed. The record indicated that at 5:29 p.m. a lab technician reported to a registered nurse (RN) a critical Troponin (critically high troponin indicates significant heart muscle damage) lab test result of 217. CQC stated that there was no documentation from RN to physician of the critical Troponin result in Patient 303’s medical record. CQC acknowledges that per facility P&P the RN should have notified the physician on critical result and did not follow facility P&P. 35399 5. During a concurrent review of Patient 101 and interview with nursing informatics manager (NIM) on 4/23/26 at 11:40 a.m., record indicated this was a 71-year-old female who was hospitalized due to a fall which resulted in the right hip fracture and right wrist fracture. In the Safety Management Shift Group section of the record for 3/26/26 day shift from 8:00 a.m. to 8:00 p.m., indicated the safety management documentation was missing. The NIM acknowledged and confirmed there were no safety measures documented for the day shift on 3/26/26. During an interview with the patient safety & risk management director (PSRM) on 4/23/26 at 11:49 a.m., the PSRM confirmed the safety management documentation should be documented every shift. During a review of the facility’s policy and procedure (P&P) titled “Nursing Documentation-Including Admission, Shift, Plan of Care, and Discharge, HS-NUR011”, dated 10/23, in subpart C. 6. Shift Group, the P&P indicated “Shift documentation must be done under Shift Group and should include ...general assessments ... Safety.” 6.During a concurrent review of Patient 103’s medical record and interview with director of surgical services (DSS) on 4/23/26 at 12:30 p.m., the operative report dated 7/1/25 indicated pre-operative and post- operative diagnosis was left knee osteoarthritis (progressive “wear-and-tear” disease where protective cartilage wears away, causing chronic knee pain, stiffness, swelling, and reduced mobility). The surgical procedure consent and case information indicated the surgical procedure was performed on the left knee. The DSS acknowledged and confirmed the operative report had listed the incorrect knee side on the report. DSS stated “Yes, I agree the report says the knee surgery was performed on the right knee. But this is wrong. The knee surgery was done on the left knee ...” During an interview with the chief quality officer (CQO) on 4/24/26 at 9:05 a.m., the CQO was asked if someone in the facility reviews the surgical records for accuracy. The CQO indicated the facility’s policy is to review the surgical records for accuracy. If there is a surgical record that is not accurate. The record is brought to the provider to correct or amend. Furthermore, the CQO acknowledged and confirmed that this patient’s record had not gone through that process since the operative report still indicated the knee procedure was performed on the right knee.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 13095 Based on interview with hospital staff, review of the hospital’s policies and procedures, record review, and inspection of the hospital’s drugs and biological’s, the hospital failed to ensure: 1) Only authorized staff had access to the hospital’s Emergency Room Medication Room. 2) Outdated, mislabeled, or otherwise unusable drugs and biological’s were not available for patient use. 3) Patient medications were labeled and stored correctly per policy and procedure (P&P). 4) Multiuse vial of medication was labeled per P&P. 5) Glucometer (device to measure blood sugar) control solutions were not expired. 6) Eye drops were not stored securely. The hospital’s failure had the potential compromise patient safety and hospital security. Findings include: 1) During an inspection of the hospital’s Emergency Room (ER) Medication area on 4/21/2026 at 10:50 am, while touring the area with the hospital’s Director of Nursing (DON), the DON, turned to the ER’s “Patient Access” employee, a non-Nursing staff position. The “Patient Access” employee proceeded to share the door code with both the DON and the Surveyor. The DON then proceeded to open the Medication Room door and entered the Room. Review of the hospital’s policy and procedure entitled: “******* Not completed yet*** 2) Inspection of the ER Medication Room Supplies revealed one bottle of Hemoccult Developer Solution 15 milliliters (ml), which did not contain an expiration date on the bottle from the manufacturer. The original box which this Hemoccult Developer Solution came out of could not be found in the ER’s Medication Room. The Hemoccult Developer Solution represented a mislabeled biological from the manufacturer. 49405 3) During a review of facility’s P&P titled, “Medication Brought Into the Hospital by Patients for Use or Storage, HS-NUR084”, dated 11/2020, indicated, “Purpose: A. To identify and document all medication brought into the hospital by patients for use or storage during their hospital stay. Procedure: A. when a patient brings personal medications into the hospital, the physician will note and document on the chart what medications the patient has been taking. The patient’s family will then be encouraged to take the medications home. B.2. ...The medications are to be taken to the Pharmacy for identification and visual evaluation of the medication’s integrity. The pharmacist will process the order under “patients own medication” and affix the hospital barcode label to the container. D. Procedure for Storage of Medication and creation of electronic tracking. 1. Patient medications not ordered by the physician and not taken home by the family are to be placed in a valuable’s envelope by nursing personnel at the time of admission. 2. The envelope will be stamped with the patients name and hospital identifiers. 3. The number of home medication containers will be noted in the contents section. 4. The number of medications containers placed in the valuable’s envelope will be verified with the patient or family member and the envelope signed by both. In the event that the patient is incapable of verifying and not family is in attendance, the envelope may be verified by two licensed staff. 5. One copy of the receipt will be given to the patient or family member. 6. The envelope must travel with the patient to the floor if the patient enters through the emergency Room. If the physician needs to access the valuable’s bag to verify medications taken by the patient, a new valuables envelope must be generated. 7. Nursing will place a copy of the receipt into the chart stapling it to the discharge teaching form. the nurse will enter into Electronic Health Record under the intervention called ADMISSION, Hx/AD/Belongings that medication(s) were sent to pharmacy. The interventions last screen contains the query “Medications Placed in Valuables Envelope & Sent to Pharmacy”. The nurse will answer “Y” If the patient is a direct admit, the valuable envelope will be generated there and sent to pharmacy if no family is available to take the medications home. 8. The pharmacist will enter an order in Electronic Health Record under “BULK MEDS” called “CLINICAL STAFF REMINDER” (In the label comments a pharmacist can retrieve a comment by selecting F5 and typing “PTOWN”). This will indicate that the pharmacy is storing patients own medications. 9. At the time of discharge the patient’s medications from home may be requested from pharmacy. Once the envelope is received nursing will verify contents with the patient and document on the appropriate records. 10. As stored medications are requested, the pharmacy will process the request and document in the comments section under the “Clinical Staff Reminder” when and to whom the medications were delivered. F. 1. Unclaimed medications will be processed as pharmaceutical waste after 14 days post discharge. During a concurrent observation and interview on 04/21/26 at 10:50 a.m. with Clinical Quality Coordinator and Registered Nurse (RN)13, medications belonging to patients that had been discharged from the facility were found in a cabinet in the nurses station without a facility pharmacy label. RN 13 states that all of these patients (Patient 301, 302, 303, 304, and 305) had been discharged from the facility. RN 13 states that the medications for Patient 302, 303, 304, and 305 were patient mediations that were brought in by the patient from home on admission and acknowledged that they did not have a facility pharmacy label and that they should have been stored in the computer on wheels (COW) and sent home with the patient at discharge. RN 13 states Patient 301’s mediation had a pharmacy label but was not sent back to pharmacy upon patients discharge. CQC acknowledged that patient medications were not labeled and stored per P&P. 4) During a review of facility’s P&P titled, “Medication Storage and Medication Preparation Areas, HS-PHA101”, dated 02/2025, indicated, “Policy: Drug storage and preparation areas within the Pharmacy and throughout the hospital are under the supervision of the Director of Pharmacy. Department Managers are responsible for implementing and enforcing medication storage policies within their departments. Procedure: ... Multiple dose vials should be dated with the last date of use “expiration date” and may be used until gone, until suspected or visible contaminated occurs, or until the manufacturer’s expiration date is reached”. During a concurrent observation and interview on 04/22/26 at 09:50 a.m. with Registered Nurse (RN) 14, an open vial of Betamethasone Sodium Phosphate and Betamethasone Acetate injectable suspension (30 mg/5 ml) (quantity/unit of measure) 5 ml multidose (multiple doses can be given out of one vial) was found in the locked cabinet in the clean lab without an open date or expiration date written on the vial. RN 14 acknowledges that the vial was not labeled as per P&P and stats the vial should have been dated immediately when opened. 5) a. During a review of the facility’s policy and procedure (P&P) titled, “Blood Glucose Monitoring Nova Stat Strip Training and Quality Control, HS-LAB481”, dated 02/2026, indicated, “Purpose: A. to assure accurate use of the Nova Stat Strip blood glucose meter/system, including: quality control (QC) procedures, meter maintenance, and procedure for testing patient blood glucose levels. Equipment: C. Stat Strip Glucose Control Solution Levels Low and High 1. Unopened Stat Strip Glucose Control Solutions are stable until the expiration date on the container. Once opened control solutions are stable for 90 days. The bottles must be dated in the space provided with the “Expiration” date. Any open outdated or undated glucose control solutions will be discarded”. During a concurrent observation and interview on 04/21/26 at 10:45 a.m. with Clinical Quality Coordinator (CQC) and Registered Nurse (RN) 13, an open vial of Stat Strip high control solution and a Stat Strip low control solution with an expiration date of 04/02/26 were found in the nurses station in an unlocked cabinet. RN 13 acknowledged that the solutions were expired and should have been discarded. CQC stated that the solutions were expired and should have been discarded per P&P. 40678 5) b. During a concurrent observation and interview on 04/21/26 at 10:45 a.m. in the emergency room with Clinical Nurse Manager of Medical Surgical and Emergency (CMMSED), a vial of Stat Strip high control solution and a Stat Strip low control solution were both open; the low had an expiration date of 2/24/26 and the high expiration date was unreadable. CMMSED confirmed the solutions should have been discarded. 6) During a concurrent observation and interview on 04/21/26 at 10:30 a.m. in the emergency room with CMMSED, two bottles of eye drops were found in the nurses’ station drawer. CMMSED confirmed the eye drops should be stored securely in the medication room and not in the drawer. During a review of facility’s P&P titled, “Medication Storage and Access”, dated 7/2023, indicated, “Drugs should be stored in an orderly manner in locked medication cabinets or rooms ... Drugs shall be accessible only to authorized personnel ...”.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 27157 Based on observation, interview, and record review, the hospital failed to ensure their policies and procedures (P&P) related to identifying patients at risk for malnutrition, measuring patients weight upon admission to acute care and completion of a nutrition assessment (NA) by a Registered Dietitian (RD) were followed for 4 of 6 sampled patients (Patient 102, Patient 306, Patient 600 and Patient 601) when: 1. The Malnutrition Risk Screen (MRS) was not completed accurately during the nutrition screening portion of the nursing admission assessment for Patient 102, Patient 600, Patient 306, and Patient 601. This failure created a potential delay in nutrition interventions and negative impacts on patient safety. 2. Patient 102 and Patient 306 were not weighed upon admission to acute care, as required per hospital P&P and professional standards of practice designed to identify nutrition risk. Failing to obtain a measured baseline weight hinders accurate nutritional assessment by the Registered Dietitian (RD) and may lead to unmet individualized nutritional needs. 3. A nutrition assessment was not documented in Patient 600’s electronic health record (EHR) by a RD in accordance with hospital P&P. This failure created a potential delay in nutrition plan of care and effective discharge planning for the health and safety of the patient. Findings: 1a. During a concurrent interview and record review on 4/22/26 at 9:43 a.m. with Registered Dietitian (RD) 2, Nursing Informatics Manager (NIM) and Coordinator of Risk Management and Patient Safety (CRMPS), Patient 102’s nursing admission assessment under the heading “Malnutrition Risk Screen,” dated 4/21/26 was reviewed. The “Malnutrition Risk Screen” (MRS) heading lists criteria to be answered based on a validated NRS (Nutrition Risk Screen) tool. Patient 102’s MRS was left blank under the category titled, “Final Screening Total Score”. RD 2 stated an RD consult should have been generated from the MRS due to Patient 102’s BMI of 18.79 (Body Mass Index; a screening tool calculating a person’s body fat based on height and weight), pneumonia (infection in the lungs) and age of 72 years, but was not. CRMPS stated nursing did not complete the MRS correctly in accordance with hospital P&P, as there were multiple areas left blank, and therefore there was no score generated under “Final Screening Total Score”. During an interview on 4/22/26 at 10:50 a.m. with Director of Food and Nutrition (DFN), DFN stated a final screening score via the validated NRS tool of greater than or equal to (>) 3 would automatically generate an RD consult to trigger an RD to complete a comprehensive nutrition assessment (NA) for a patient within two days of admit to inpatient. During a review of the directions on the NRS located in Patient 102’s EHR, dated 4/21/26, the NRS indicated, “2-Moderate Score: BMI 18.5 -20.5 + impaired general condition. . .,One point is added for 70 years and older. . .Score > 3 (greater than/equal to 3) patient is at risk for malnutrition and a nutrition care plan should be initiated.” During a review of the hospital’s P&P titled, “Nursing Documentation - - Including Admission, Shift, Plan of Care, and Discharge, HS-NUR011.” dated 10/2023, the P&P indicated, “Purpose: To provide a process and framework for data collection in nursing documentation. Policy: Nursing documentation contains a complete, accurate medical record of each patient’s hospitalization, reflecting an interdisciplinary approach to the delivery of quality care based on the Nursing process (assessment, planning, intervention, and evaluation) and professional, legal and accreditation standards.” During a review of the hospital’s document titled, “Malnutrition Risk Assessments for RNs,” dated 2026, the document indicated, “The diagnosis and treatment of inpatient protein-calorie malnutrition is an important part of improving the clinical outcomes of patient care. Follow these steps to complete accurately the nursing admission malnutrition risk screen. . . open the Admit-Transfer navigator and select all answers that apply. Select Show Row Info to see information that helps you fill out the form. . .Document Impaired Nutritional Status. . ., Document Severity of Disease. . ., Review the Final Screening Total Score. . .If your patient is 70 or older, 1 point is added automatically. Scores of “3” to “7” points for adults indicate serious nutrition problems that need intervention. The Dietitian assigned to this unit will see the score in Patient Lists and perform an assessment for adult patients with scores of “3” or more.” During a review of the hospital’s P&P titled, “Initial Screening, Prioritization and Assessment,” dated 03/2026, the P&P indicated, “Purpose: To establish the screening and assessment process or nutritional care for each patient. . ., Procedure: A. Initial Screening: 1. Nursing: a. Gathers information from patients within 24 hours of admission based on pre-determined validated nutrition criteria and documents in the medical record. b. Based on results of initial screening, consults the dietitian. 2. Registered Dietitian Nutritionist: a. Acts on information/consult results from the Nursing Admission Assessment within the designated timeframes. . ., Nutrition Assessment Prioritization: Within 2 days: RN [Registered Nurse] referral. . .” 1b. During a concurrent interview and record review on 4/22/26 at 12:10 p.m. with RD 1, NIM and CRMPS, Patient 600’s nursing admission “Malnutrition Risk Screen [MRS],” dated 4/2/26 was reviewed. RD 1, NIM and CRMPS stated there was no level of nutrition risk assessed, no nutrition risk score generated, because the “MRS” was not completed by nursing for Patient 600, and should have been. During an interview on 4/24/26 at 10:03 a.m. with DFN, DFN stated she reviewed Patient 600’s EHR and verified the MRS that should have been completed during the nursing admission assessment for Patient 600 by nursing was missed. 1c. During a concurrent interview and record review on 4/23/26 at 11:51 a.m. with RD 1 and DFN, Patient 306’s nursing admission “Malnutrition Risk Screen,” dated 4/16/26 was reviewed. RD 1 and DFN stated the MRS that contained NRS questions was inaccurately marked “None of the above,” therefore, a final screening total score was not calculated. During a review of the MRS that contained NRS questions the following was required to be reviewed and checked if applicable: “Nutrition Initial Screening (Adult) select all that apply: Patient BMI is less than 20.5, The patient has lost weight within the last 3 months, The patient had a reduced dietary intake in the last week, The patient is severely ill (e.g. in intensive therapy), None of the above. . .Any choices other than “None” will cascade rows that MUST be filled out. Malnutrition risk level can ONLY be calculated if ALL of the cascasded rows are completed. . ., 4. Severity of illness (RN judges: Does your patient have an acute or chronic problem that includes such as wounds, drains, infections, sepsis, major surgeries, other serious medical or surgical conditions).” The hospital’s nutrition screening upon admission included, “Final Screening Total Score: One point is added for 70 years and older.” During a review of Patient 306’s “Hospitalist Progress Notes,” dated 4/16/26, the progress note indicated, “Chief Complaint/Reason for Admission: COPD [Chronic Obstructive Pulmonary Disease is a progressive, long-term lung disease that blocks airflow, making it difficult to breathe] exacerbation [an acute, sustained worsening of symptoms], pneumonia. . .This is a 80 y.o. with a history of. . .COPD admitted with CAP (community acquired pneumonia) and a COPD exacarbation. . .Continues to require supplemental O2 [oxygen]. Having frequent non-productive cough. . .she is obese. . .Was hypoxic [low levels of oxygen in your body tissues] in the 80’s [low oxygen saturation level] on the ER with imaging [tests] suggestive of developiong PNA [Pneumonia].” 1d. During a concurrent interview and record review on 4/23/26 at 12:20 p.m. with RD 1 and DFN, Patient 601’s nursing admission “Malnutrition Risk Screen,” dated 4/17/26 was reviewed. RD 1 and DFN stated there was no further MRS completed by nursing, other than the one dated 4/17/26. RD 1 and DFN stated the MRS that contained NRS questions was inaccurately marked as “None of the above”. RD 1 and DFN stated Patient 601 had diagnosis/conditions such as PAD (Peripheral Artery Disease), prostate cancer, renal cell cancer, Diabetes Type II and recent weight loss and was 90 years old with increased protein needs. RD 1 and DFN stated Patient 601 met MRS nutrition screening criteria that should have generated a “Final Screening Total Score” of > 3 had the MRS been completed accurately. DFN stated instead nursing marked “None of the above”, which resulted in no RD consult/referral to the RD from the nursing nutrition screen upon admission. During a review of Patient 601’s “Hospitalist History and Physical (H&P),” dated 4/17/26, the “H&P” indicated, “[Name of patient] is a 90 y.o. [years old] male with a past medical history of a-fib [Irregular Heartbeat], PAD and metastatic [spreading] renal cell carcinoma [cancer]. . .presenting with weakness. . .he has become progressively weak, with poor oral intake and 20 lb weight loss. . .” During a review of Patient 601’s “Admit to inpatient (Order 2177115494)”, dated 4/19/26, the order indicated it “counted as a hospital inpatient day.” During a concurrent interview and record review on 4/23/26 at 12:40 p.m. with DFN, DFN stated within the EHR, there was a sidebar screen a nurse could open up to review descriptions of how to determine to mark “0-Absent Score 1-Mild Score, 2-Moderate Score, or 3-Severe Score” under the category “Severity of Disease” located on the Malnutrition Risk Screen portion of the nursing admission assessment. The sidebar “Severity of Disease Reference (=increase in requirements),” indicated, “Absent Score 0: Normal nutritional requirements, Mild Score 1: Patient with chronic disease, admitted to hospital due to complications. The patient is weak but out of bed regularly. Protein requirement is increased, but can be covered by oral diet or supplements in most cases. Examples: Chronic patients in particular with acute complications such as hip fracture, cirrhosis, COPD, chronic hemodialysis, diabetes, oncology, other. Moderate Score 2: Patient confiened to bed due to illness, eg, following major abdominal surgey. Protein requirement is substantially increased, but can be covered by diet, although tube feeding or parenteral feeding is required in many cases. Examples: Major abodominal surgery, stroke, severe pneumonia, hematologic malignancy, other. Severe Score 3: Protein requirement is increased and cannot be covered even by tube feeding or parenteral feeding. Protein breakdown and nitrogen loss can be significantly attenuated. Patient may be in intensive care with assisted ventilation, etc. Examples: Head injury, bone marrow transplantation, intensive care patients (APACHE [acute physiology and chronic health evaluation] >10), other. . .Nutrition Risk Screening (NRS) 2002.” 2a. During an interview on 4/22/26 at 10:04 a.m. with RD 2, RD 2 stated she conducted an RD nutrition risk screen for Patient 102 on 4/22/26 and determined a NA was required due to Patient 102’s age of 72 years, 18.79 BMI, poor appetite and pneumonia with increased protein needs per hospital P&P titled, “Initial Screening, Prioritization and Assessment,” dated 03/2026. Patient 102’s NA dated 4/22/26, indicated, “Height: 170.2 cm [centimeters] (5’ [feet] 7” [inches]), Admit weight: 54.4 kg [kilograms] (120 lb [pounds]), Weight Method: Stated.” RD 2 stated the only weight available was a “stated [self reported by patient]” weight that she used to calculate Patient 102’s individualized, daily calorie and protein nutritional needs. During a concurrent interview and record review on 4/22/26 at 10:15 a.m. with RD 2, Patient 102’s EHR contained a note written to Patient 102’s nurse titled, “Conversation with [name of nurse],” dated 4/22/26 was reviewed. RD 2’s note indicated, “I noticed her weight is stated. Can you get a measured weight when you get a chance or when she gets up?”, in which the nurse immediately replied, “. . .yes will do! I’ll update you on weight.” RD 2 stated a measured weight versus a “stated” weight that relied on the patient’s memory and unspecified timeframe was important to accurately evaluate, assess and recommend a nutrition plan of care for Patient 102. During a concurrent interview and record review on 4/22/26 at 3:44 p.m. with Medical (Med)/Surgical (Surg) Educator (MSE) and Clinical Nurse Manager of Med/Surg and Emergency (CMMSED), Patient 102’s weight, dated 4/20/26, was reviewed. MSE stated Patient 102 had only one weight entered in her EHR which indicated, “Weight: 54.432 kg, Weight method: Stated”, dated 4/20/26. MSE stated Patient 102 was admitted as an in-patient on 4/21/26 from the ER (emergency room). MSE stated it was nursing standard of practice to weigh patients upon admission from the ER to acute care in-patient, which was not done as the only weight showing on Patient 102’s flowsheet was from the ER, dated 4/20/26, at 54.432 kg. CMMSED stated there should have been a weight obtained for Patient 102 after Patient 102 was admitted into the acute care hospital from the ER department, instead of relying on the reported “stated” weight during the ER encounter. 2b. During a concurrent interview and record review on 4/23/26 at 12:00 p.m. with RD 1 and DFN, Patient 306’s NA, dated 4/18/26 was reviewed. The NA indicated, “Admit Weight: Weight: 111.7 kg (246 lb), Weight Method: Stated. . ., Weight used for calorie calculations: 111.6 kg (246 lb 0.5 oz).” RD 1 stated the only weight available to her was a “stated” weight so she used that weight to calculate Patient 306’s daily caloric needs. RD 1 stated using a “stated” weight had the potential to affect accuracy of Patient 306’s NA. RD 1 stated she did not communicate to nursing to request Patient 306’s measured weight to be obtained in accordance with professional standards of practice. DFN stated RD 1 should have asked nursing to measure Patient 306’s weight in accordance with professional standards of practice to promote accuracy of Patient 306’s NA. During a review of the hospital’s job description (JD) titled, “Clinical Dietitian,” dated 8/12/22, the “JD” indicated, “Position Overview: Responsible for providing clinical nutrition services, including nutrition assessment, Essential Functions and Responsibilities: Completes all required documentation, reports and logs in a timely, professional and thorough manner. Communicates effectively with all care team members. . .” During a review of established standards of practice from the Acadmy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2026, the “NCM” indicated, “Malnutrition Criteria: Height and weight should be measured rather than estimated to determine body mass index.” During a review of the hospital’s P&P titled, “Nursing Standard of Care for Medical-Surgical/Swing, OV-NUR-221,” dated 9/2025, the P&P indicated, “Purpose: To describe the nursing standards of care being rendered to patients in the Medical-Surgical unit [name of hospital]. . .Policy: It is the policy of the hospital to ensure that patients in the Med-Surg unit are cared for appropriately, safely, efficiently, and compassionately by competent staff, in compliance with accreditation standards and regulations. . ., This policy applies to all nursing staff providing care to Med-Surg/Swing patients and Observation patients. . ., Patient Assessment and Care Planning: Criteria from the initial assessment or subsequent assessments may include identification of patients at risk for complications, patients at risk for nutritional problems...When identified, further assessment by other disciplines may be requested including but not limited to. . .dietary. . ., Standards and Guidelines for Care: Patients will be weighed on admission. . .” During a review of the hospital’s document titled, “Malnutrition Risk Assessments for RNs,” dated 2026, the document indicated, “The diagnosis and treatment of inpatient protein-calorie malnutrition is an important part of improving the clinical outcomes of patient care. Follow these steps to complete accurately the nursing admission malnutrition risk screen. . ., First, Record Weight: 1. Record Height, Weight, and Method in the vital signs flowsheet. Weight on admission should be an actual measured weight, not a “stated” or “estimated” weight, except in rare situations. . .Weigh patients for safe and accurate treatment and for medication dosing calculations.” 3. During a concurrent interview and record review on 4/22/26 at 12:15 p.m. with RD 1, NIM and CRMPS, RD 1 stated Patient 600 met the hospital’s criteria per policy for an RD NA due to 3 day length of stay (Patient was hospitalized for 3 consecutive days), as Patient 600 was admitted on 4/2/26. RD 1 stated Patient 600 was on a regular diet, but not eating well, so RD 1 added one can of ProSource gelatin (nutrition supplement to increase protein and caloric intake) on 4/5/26 at 1:40 p.m.. RD 1 stated there was not a completed nutrition assessment in Patient 600’s EHR. NIM stated Patient 600 did not discharge from the hospital until 5:41 p.m. on 4/5/26. During an interview on 4/23/26 at 12:55 p.m. with DFN, DFN stated there should have been a completed initial NA in Patient 600’s EHR before RD 1 initiated the nutrition supplement on 4/5/26. During a review of Patient 600’s “Hospitalist Discharge Summary,” dated 4/5/26, the “Hospitalist Discharge Summary” was completed at 2:47 p.m. During a review of the hospital’s P&P titled, “Initial Screening, Prioritization and Assessment,” dated 03/2026, the P&P indicated, “Purpose: To establish the screening and assessment process or nutritional care for each patient. . ., Procedure: Assessment by Registered Dietitian Nutritionist (RDN) 1. Further assessment will be conducted following the Nutrition Care Process Model, a. Based on the Nutrition Assessment findings, the dietitian identifies a Nutrition Diagnosis and gains patient agreement on the appropriate Nutrition Intervention. . .” During a review of the hospital’s job description (JD) titled, “Clinical Dietitian,” dated 8/12/22, the “JD” indicated, “Position Overview: Responsible for providing clinical nutrition services, including nutritin assessment, Essential Functions and Responsibilities: Completes all required documentation, reports and logs in a timely, professional and thorough manner.””

“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: 13095 Based on Pharmacy and Nursing staff interviews, record review, and review of the hospital’s policy and procedures, the hospital failed to follow: A) The drug manufacturer’s package-insert and the associated Black Box warning for the administration and monitoring of Droperidol, for one of one sampled patient’s (Patient P-400), contrary to the Drug Manufacturer’s indication and the FDA’s Black Box warning. This patient had an ECG completed just before his dose of Droperidol but the ECG came back “abnormal” ECG [QTC 477 msec for this male]. The manufacturer’s package insert, stays that for male patients with “QTc greater than 440 msec”, the patient should not have been administered to this patient, as the patient’s QTC exceeded the 440 msec manufacturer’s threshold. B) The hospital also failed to perform an ECG on this patient, 2-3 hours after the administration of this drug, as outlined in the manufacturer’s package insert. This failure had the potential of jeopardize this patient’s safety, which could have ultimately resulted in this patient’s harm or his potential death. Findings: A) During a review of the hospital’s package insert from American Regent INC., dated 1/ 2009, which contained the drug manufacturer’s and the Food and Drug Administration (FDA’s) Black Box Warning. This Black Box Warning is the FDA’s strongest warning that the FDA makes available, which reads: “Cases of QT prolongation and/or torsade de pointes have been reported in patients receiving Droperidol at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal. Due to its potential for serious proarrhythmic effects and death, Droperidol should be reserved for use in the treatment of patients who fail to show an acceptable response to other adequate treatments, either because of insufficient effectiveness or the inability to achieve an effective dose due to intolerable adverse effects from those drugs ... the Black Box Warning goes on to say: “Cases of QT prolongation and serious arrhythmias (e.g., torsade de pointes) have been reported in patients treated with Droperidol. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of Droperidol to determine if a prolonged QT interval (i.e., QTc greater than 440 msec for males or 450 msec for females) is present. If there is a prolonged QT interval (greater than 440 msec for males), Droperidol should NOT be administered. For patients in whom the potential benefit of Droperidol treatment is felt to outweigh the risks of potentialy serious arrhythmias, 12 lead ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment to monitor for arrhythmias ... Droperidol should be administered with extreme caution to patients who may be at risk for development of prolonged QT syndrome (e.g., congestive heart failure, bradycardia, use of a diuretic, cardiac hypertrophy, hypokalemia, hypomagnesemia, or administration of other drugs known to increase the QT interval). Other risk factors may include age over 65 years, alcohol abuse, and use of agents such as benzodiazepines, volatile anesthetics, and IV opiates. Droperidol should be initiated at a low dose and adjusted upward, with caution, as needed to achieve the desired effect”. The drug manufacturer also states: “QT interval prolongation, torsade de pointes, cardiac arrest, and ventricular tachycardia have been reported in patients treated with Droperidol. Some of these cases were associated with death. Some cases occurred in patients with no known risk factors, and some were associated with Droperidol doses at or below recommended doses.” This patient, who received Droperidol (for non-FDA approved indications), based on the drug manufacturer and the Food and Drug Administration (FDA)’s limited lists of approved indications. Both the drug manufacturer and the FDA have approved this medication for the following indication: “reducing the incidence of nausea and vomiting associated with surgical and diagnostic procedures”. The manufacturer of Droperidol also states: “Droperidol is not recommended for any use other than for the treatment of perioperative nausea and vomiting in patients for whom other treatments are ineffective or inappropriate.” The drug manufacturer also refers to the following warning in the drug’s package insert: “Droperidol should be administered with extreme caution in the presence of risk factors for development of prolonged QT syndrome, such as: 1) clinically significant bradycardia (less than 50 bpm), 2) any clinically significant cardiac disease, 3) treatment with Class I and Class III antiarrhythmics, 4) treatment with monoamine oxidase inhibitors (MAOI’s), 5) concomitant treatment with other drug products known to prolong the QT interval (see PRECAUTIONS, Drug Interactions), and 6) electrolyte imbalance, in particular hypokalemia and hypomagnesemia, or concomitant treatment with drugs (e.g., diuretics) that may cause electrolyte imbalance.” During a review of the following Patient (Patient) the clinical record, these clinical records did not reveal that this patient’s most recent ECG made this patient not eligible for the administration of Droperidol. During a review of the clinical record with the hospital’s MSP regarding Patient P400 on 4/23/2026 at 3:50 p.m., revealed that Patient P 400 had received a 1.25 mg of Droperidol on 4/15/2026 at 11:32 p.m., by I.M. (intramuscular injection). A baseline ECG had been completed (as outlined by the FDA and the drug’s manufacturer, however this baseline ECG came back as a corrected ECG of 477 msecs. Based upon this corrected ECG, the drug’s manufacturer states that ECGs above 440 (for this male patient), makes the administration of Droperidol for this patient, contraindicated and this medication should not have been administered to Patient P400. The manufacturer of the drug Droperidol published a package insert which has the FDA’s Black Box Warning in bold print and it reads: “WARNING Cases of QT prolongation and/or torsade de pointes have been reported in patients receiving Droperidol at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal. Due to its potential for serious proarrhythmic effects and death, Droperidol should be reserved for use in the treatment of patients who fail to show an acceptable response to other adequate treatments, either because of insufficient effectiveness or the inability to achieve an effective dose due to intolerable adverse effects from those drugs (see CONTRAINDICATIONS, WARNINGS, PRECAUTIONS, and ADVERSE REACTIONS). Cases of QT prolongation and serious arrhythmias (e.g., torsade de pointes) have been reported in patients treated with Droperidol. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of Droperidol to determine if a prolonged QT interval (i.e., QTc greater than 440 msec for males or 450 msec for females) is present. If there is a prolonged QT interval, Droperidol should NOT be administered. For patients in whom the potential benefit of Droperidol treatment is felt to outweigh the risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment to monitor for arrhythmias . . .” Interview with the Hospital’s Nursing Manager on 4/24/2026 at 10:55 am revealed that both the hospital’s Pharmacist and this patient’s Physician, had previously recieved education from the hospital regarding the use of Droperidol, but neither the patient’s Physician nor the order verifying Droperidol Pharmacist, followed that FDA’s or the drug manufacturer’s administration for Droperidol. “Droperidol should be administered with extreme caution to patients who may be at risk for development of prolonged QT syndrome (e.g., congestive heart failure, bradycardia, use of a diuretic, cardiac hypertrophy, hypokalemia, hypomagnesemia, or administration of other drugs known to increase the QT interval). Other risk factors may include age over 65 years, alcohol abuse, and use of agents such as benzodiazepines, volatile anesthetics, and IV opiates. Droperidol should be initiated at a low dose and adjusted upward, with caution, as needed to achieve the desired effect.” During a review of the hospital’s currently approved policy and procedure entitled: “Formulary Restriction, HS-PHA 150”, dated 1/2026, indicated “P. Droperidol (Inapsine), 1. May use if all of the following criteria met, a. Prescribed by Emergency Medicine [Emergency Room], Palliative Care, and Intensivists only .... b. indication includes agitation, refractory headache, cyclic or intractable vomiting, (yet P 400 received this Droperidol for “Acute abdominal pain”, based on this patient’s physician “Emergency Department Provider Note”, which was not included in the hospital’s P&P for the administration of Droperidol. On 4/15/2026 at 11:54 pm, the patient’s physician wrote: “The patient states that the droperidol did not help with his pain and made him feel a bit agitated. He will be treated with Benadryl and additional intramuscular Dilaudid.” Patient P 400’s physician wrote on 4/16/2026 at 12:34 the next morning: “The patient states he is feeling very action is hoping to get something for an anxiolytic. The droperidol effect does not get completely curbed with diphenhydramine (Benadryl). He will get a shot of Ativan (Lorazepam) an antianxiety medication.” Additional review of the hosptial’s policy and procedure entitled: “Formulary Restriction, HS-PHA, states under section c. Doses less than 2.5 mg and no other risk factors for QT prolongation present (QTC less than 500 msec, Heart rate (HR) less than 50 bpm (beats per minute), concurrent MAOI (Monoamine Oxidase inhibitors) or antiarrhythmic or drugs known to prolong, QT interval ...do not require an ECG prior to administration, contrary to the drug manufacturer’s specification. B) During a review of the clinical record and interview with the hospital’s MSP regarding Patient P400, on 4/23/2026 at 3:50 p.m., Patient P 400’s record revealed that this patient had received a 1.25 mg of Droperidol on 4/15/2026 at 11:32 p.m., by I.M. (intramuscular injection). Further review of this patient’s clinical record revealed that the hosptial had not completed an ECG, for the 2-3 hours after the Droperidol, had been administered, and as outlined in the drug manufacturer’s package insert, for patient safety. Further interview with the hospital’s MSP, revealed that the MSP, was aware of the need for the 2-3 hours of post administration monitoring, as outlined by the FDA and the drug’s manufacturer, yet after clinical record review and speaking directly with the hospital’s Pharmacist (who had approved and filled this order), and speaking directly with the patient’s physician who had ordered the Droperidol, the hospital’s MSP was unable to provide clinical justification for the other two healthcare provider’s rationale for not providing Patient P400 with the required 2-3 hours of post drug administration monitoring (which are outlined by the drug’s manufacturer and the FDA). Interview with the Hospital’s Nursing Manager on 4/24/2026 at 10:55 am revealed that both the hospital’s Pharmacist and this patient’s Physician, had previously recieved education from the hospital regarding the use of Droperidol, but neither the patient’s Physician nor the order verifying Droperidol Pharmacist, followed that FDA’s or the drug manufacturer’s administration for Droperidol. Further interview with the Nursing Manager revealed that, if any “telemetry monitoring” had been completed by the hospital, this would have been done by the hospital using a “5 Lead ECG”, not a 12 Lead ECG.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 49405 Based on observation, interview, and record review, the facility failed to maintain infection control practices and processes when: 1. A Glucometer (device used to measure blood sugar) was not cleaned and disinfected per policy and procedure (P&P). 2. Respiratory Therapist (RT) did not perform hand hygiene when providing patient care. 3. Registered Nurse (RN) did not change gloves between cleaning and disinfecting the glucometer. 4. A barrier between the dirty utility room and the Intensive Care Unit (ICU) / Post-Anesthesia Care Unit (PACU), that would prevent aerosolized particles from entering the ICU/PACU from the dirty utility room, was not available. 5. Nursing station with a reprocessed instrument was stored in the Emergency Department (ED). 6. A lead apron was not cleaned after using it with a patient. 7. Staff were unable to verbalize Glucometer disinfecting per P&P. 8. Cleaning of the mammogram machine went from clean to dirty to clean. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact patient’s health and safety and cause preventable healthcare associated infections (HAI) for patients in an already compromised condition. Findings: 1. During a concurrent observation and interview on 04/21/26 at 10:39 a.m. with RN 13 and Clinical Quality Coordinator (CQC), RN13 demonstrated cleaning of the Stat Strip Glucometer. RN 1 placed gloves on, used a Super Sani Wipe (specialized cleaning wipe) and wiped down the front, back and sides of the glucometer and waited for two minutes and then return the device to dock. When RN 13 was asked if there is another step to the cleaning of the Glucometer RN 13 sated “No”. CQC stated that she would need to refer to the policy regarding proper procedure technique. During a concurrent interview and record review on 04/22/26 at 11:10 a.m. with CQC, the facility P&P titled, “Blood Glucose Monitoring Nova Stat Strip Training and Quality Control, HS-LAB481”, dated 02/2026 was reviewed. The P&P indicated, “Purpose: A. to assure accurate use of the Nova Stat Strip blood glucose meter/system, including: quality control (QC) procedures, meter maintenance, and procedure for testing patient blood glucose levels. Procedure: B. Quality Control 1. Cleaning the Meter: b. Make sure the test strip is removed from the meter. Lay the meter on a flat surface prior to cleaning and disinfecting the meter. Clean the Meter. Remove a fresh germicidal wipe from the canister. Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting wipe. Discard the used wipe into an appropriate biohazard container. Disinfect the Meter. Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the rest strip port making sure that no fluid enters the port. C. Observe surface contact time. Ensure the meter surface stays wet for 1 minute (Clorox Wipes) or for 2 minutes (Super Sani Wipes) then allow to air dry for an additional 1 minute. Dispose of wipes and gloves. Dispose of used wipe and gloves in an approved waste container. Equipment: C. Stat Strip Glucose Control Solution Levels Low and High 1. Unopened Stat Strip Glucose Control Solutions are stable until the expiration date on the container. Once opened control solutions are stable for 90 days. The bottles must be dated in the space provided with the “Expiration” date. Any open outdated or undated glucose control solutions will be discarded”. CQC acknowledged that RN13 did not follow policy when demonstrating cleaning of the glucometer on 04/21/26. 2. During a review of the facility’s P&P titled, “Hand Hygiene, HS-QM211”, dated 01/2026 the P&P indicated, “Purpose: To provide information on required hand hygiene practices essential to reduce the transmission of infection via healthcare worker hands during the course of attending patients. Procedure: Disposable Glove Use: 1. Perform hand hygiene before donning gloves ... c. When in contact with a patient or patient equipment / environment during Contact Precautions. 2.Remove gloves for the following indications, and perform Hand Hygiene: a. If gloves are damaged and integrity is suspected to be compromised. b. When contact with blood, body fluid, non-intact skin, or mucous membranes has ended. c. When contact with a single patient and his or her surroundings or a contaminated body site on a patient has ended ... J. Additional Considerations: 1. Wearing gloves does not negate hand hygiene ... During a concurrent observation and interview on 04/21/26 at 11:40 a.m. with Clinical Quality Coordinator (CQC), outside of droplet isolation room #104, patient was receiving care from RT 1. RT 1 was observed coming out of room 104 in an isolation gown and gloves where RT1 took off their goggles without removing gloves and proceeded to pick up their personal eyeglasses, documented in the computer on wheels located in the hall with the same gloves, then removed the eyeglasses, replaced the goggles and went back into room 104 to complete patient care. CQC acknowledged that RT1 should have removed her dirty gloves and performed hand hygiene before touching the computer. During an interview on 04/21/26 at 11:45 a.m. with RT 1, RT 1 stated she did not removed dirty gloves and perform hand hygiene prior to touching her personal glasses and the computer. 35399 3. During a glucometer cleaning and disinfecting observation and interview with registered nurse (RN 9) on 4/21/26 at 11:18 a.m., RN 9 was observed applying a pair of gloves to perform the glucometer cleaning process then proceeded to perform the glucometer disinfecting process with the same pair of gloves. RN 9 acknowledged and confirmed that the pair of gloves used to perform the glucometer cleaning process should have been discarded and a new pair of gloves should have been applied to perform the glucometer disinfecting process. RN 9 stated “Yes, I agree I should have applied a new pair of gloves to disinfect the glucometer.” 4. During a tour of the intensive care unit ICU and post-anesthesia care unit PACU areas on 4/22/26 at 9:48 a.m., accompanied by patient safety & risk management director (PSRM) an open hallway was observed that led to a corner/area where a hopper (a specialized, flushing sanitary fixture located in soiled utility rooms. It is used to safely dispose of clinical waste, such as blood, urine, suction canister contents, and bedpan waste), a container with dirty leg sequential sleeves, a trash container with trash inside, one waste Biohazard (medical waste-that poses a threat to human health or the environment) container, two non-biohazard (green and black colored) containers were located. The area represented a “dirty utility” area however there was no door or barrier separating this area and the patient care areas (ICU & PACU). The hopper is used to discard patients’ body fluids (e.g. feces, urine, emesis ...). The PSRM was asked how the waste aerosol particles are prevented from blowing into the patient care areas (ICU and PACU) which are right next to this corner. The PSRM stated “I don’t know ...” During an interview with the chief quality officer (CQO) on 4/23/26 at 11:05 a.m., the CQO explained that a door to enclose the area cannot be installed due to the hallway being too narrow and building code issues. Communicated to CQO the infection control concern is that when body fluid waste is discarded into the hopper, waste aerosol particles are blowing into the patient care areas (ICU & PACU) since there is no barrier/door between that corner and patient care areas. CQO acknowledged the corner/area represented a “dirty utility” area. 40678 5. During a concurrent observation and interview on 4/21/26 at 10:34 a.m. with the Clinical Nurse Manager of Medical Surgery and Emergency (CMMSED), sterile reusable (non-disposable) long forceps (a surgical instrument used when increased length is needed for deeper tissue manipulation) were in the ED nurses station drawer, CMMSED confirmed and acknowledged they should not be there. During a review of the facility’s report, “TempTrak Daily Summary Sensor: EmergencyDept.RMTemp”, dated 2/25/26 - 3/30/26 indicated, the temperature was above 75 degrees multiple days and times. During a review of the facility’s policy and procedure (P&P) titled, “Decontamination and Reprocessing of Reusable Instrumentation and Equipment”, dated 3/2026 the P&P indicated, “Reusable medical equipment (RME) is equipment intended for repeated use on different patients with appropriate decontamination and other processing between uses ... Semi-Critical Items are those that come in contact with non-intact skin or mucous membranes ... Storage areas for critical and semi-critical RME require temperature is to a maximum of 75 degrees, humidity 20-60%... in order to protect RME ... [name of facility] must have monitored, climate-controlled areas for the reprocessing of critical and semi-critical RME including the storage of those reprocessed items. The minimum climate control parameters apply to all areas ... critical or semi-critical RME is stored ...” 6. During a concurrent observation and interview on 4/21/26 at 11:24 a.m. with the Diagnostic Imaging Clinical Services Supervisor (DICSS) and radiology technician (RadT1), RadT1 placed a lead apron on a patient (Patient 200) for a CT scan (shows 3D images of bones, organs, and soft tissue), after CT scan RadT1 removed lead apron from Patient 200 and placed it back on hook without cleaning it, where it touched other lead aprons. DICSS confirmed that the lead apron should be cleaned after patient use. During a review of the facility’s P&P titled, “Cleaning, Disinfection and Sterilization”, dated 8/2024 the P&P indicated, “Items that come in contact with intact skin whether or not visibly soiled ... minimum of low-level disinfection is acceptable. After each use vigorously clean with approved cleaning agent; with appropriate dwell time ...” 7. During an interview on 04/21/26 at 3:23 p.m. with RN 5 and Director Emergency Department (DED), RN 5 stated between patients RN 5 wipes the glucometer down with the grey wipes for 3 minutes or 2 minutes if I use the purple wipes and let it air dry and put it back in the dock. DED acknowledged that RN 5 could not verbalize procedure for cleaning and disinfecting the glucometer. During a review of the facility’s P&P titled, “Blood Glucose Monitoring Nova Stat Strip Training and Quality Control”, dated 2/2026 indicated, “Purpose: A. to assure accurate use of the Nova Stat Strip blood glucose meter/system, including: quality control (QC) procedures, meter maintenance, and procedure for testing patient blood glucose levels. Procedure: B. Quality Control 1. Cleaning the Meter: b. Make sure the test strip is removed from the meter. Lay the meter on a flat surface prior to cleaning and disinfecting the meter. Clean the Meter. Remove a fresh germicidal wipe from the canister. Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting wipe. Discard the used wipe into an appropriate biohazard container. Disinfect the Meter. Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the rest strip port making sure that no fluid enters the port. C. Observe surface contact time. Ensure the meter surface stays wet for 1 minute (Clorox Wipes) or for 2 minutes (Super Sani Wipes) then allow to air dry for an additional 1 minute. Dispose of wipes and gloves. Dispose of used wipe and gloves in an approved waste container. Equipment: C. Stat Strip Glucose Control Solution Levels Low and High 1. Unopened Stat Strip Glucose Control Solutions are stable until the expiration date on the container. Once opened control solutions are stable for 90 days. The bottles must be dated in the space provided with the “Expiration” date. Any open outdated or undated glucose control solutions will be discarded”. 8. During a concurrent observation and interview on 4/21/26 at 12:01 p.m. with RadT2 and DICSS, RadT2 removed purple top wipes and cleaned the top of the mammogram machine and then removed the used single use paper from the last patient, did not change gloves, got new wipes, and continued to clean the mammogram machine. DICSS confirmed RadT2 should not go from clean to dirty back to clean without changing gloves. During a review of the facility’s P&P titled, “Environmental Cleaning of the Surgical Practice Areas”, dated 4/2025 the P&P indicated, “Gloves must be exchanged between cleaning to prevent the spread of contamination. Hand hygiene must be performed before and after wearing gloves ...””

“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: 40678 Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment when the coating on the floor in x-ray room one was not intact. This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact patients’ health and safety and cause preventable healthcare associated infections (HAI) for patients in an already compromised condition. Findings: During a concurrent observation and interview on 4/21/26 at 11:40 a.m. in X-ray Room 1 with the Diagnostic Imaging Clinical Services Supervisor (DICSS), the floor surface was observed to have damaged coating and was not intact. The DICSS confirmed the condition and stated the floor was not fully cleanable. Review of the Center for Disease Control and Prevention (CDC) website, https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques accessed on 5/4/26, indicated in part “For all environmental cleaning procedures, always use the following general strategies: Conduct visual preliminary site assessment Proceed only after a visual preliminary site assessment to determine if: There is any damaged or broken furniture or surfaces to be reported to supervisor/management ...”.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (4) Use objective measures to evaluate its organizational processes, functions and services. This Standard is not met as evidenced by: 35399 Based on interview and record review the hospital failed to ensure the Emergency Department (ED) conducted a performance improvement project (PIP) which included measurable or quantitative goal to evaluate the ED services and as indicated by their performance improvement model. This failure has the potential to not measure the PIPs improvement correctly. Finding: During a concurrent review of the performance improvement project (PIP) titled “[facility’s name] ED PI project” and interview with the director emergency department (DED) with the quality director (QD) present on 4/22/26 at 12:45 p.m., the PIP indicated the goal was to “increase the number of positive Google reviews by activating our silent majority “the satisfied patients”. The DED was asked how this goal was going to be measured if the goal is not quantified. The DED did not answer. The QD was asked the same question. The QD stated “Yes, I know there has to be a measurable goal.” During a review of the document titled “Quality Management, Performance Improvement & Patient Safety Plan HS-QM001”, dated 01/2026, In the Part Key Performance Improvement and Patient Safety Activities indicated, the Performance Improvement Model was Plan, Do, Study, Act (PDSA). In the PDSA model, on the Plan step 1: Identify the Opportunity. Indicates to “Set a measurable goal.””

“QAPI CFR(s): (e) Standard: Program data collection and analysis. The program must incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program. This Standard is not met as evidenced by: 27157 Based on interview, and record review, the hospital failed to: 1. Collect and analyze data regarding the implementation of a nutrition risk screening tool process selected by the hospital about a year ago. (Cross Reference C-1020) 2. Ensure the Outpatient clinics performance improvement project (PIPs) data was evaluated and available for review. 3. Ensure the surgery department performance improvement project (PIP) data was evaluated and available for review. These failures prevented the identification and development of a QAPI project to improve staff accuracy in screening high-risk patients upon nursing admission assessment and collect and analyzed the PIPs data to monitor progress or improvement. Findings: 1. During a concurrent interview and record review on 4/22/26 at 9:43 a.m. with Registered Dietitian (RD) 2, Nursing Informatics Manager (NIM) and Coordinator of Risk Management and Patient Safety (CRMPS), Patient 102’s nursing admission assessment under the heading “Malnutrition Risk Screen,” dated 4/21/26 was reviewed. The “Malnutrition Risk Screen” (MRS) heading lists criteria to be answered based on a validated NRS (Nutrition Risk Screen) tool. Patient 102’s MRS was left blank under the category titled, “Final Screening Total Score”. CRMPS stated nursing did not complete the MRS correctly in accordance with hospital P&P, as there were multiple areas left blank, and therefore there was no score generated under “Final Screening Total Score”. During a concurrent interview and record review on 4/22/26 at 12:10 p.m. with RD 1, NIM and CRMPS, Patient 600’s nursing admission “Malnutrition Risk Screen [MRS],” dated 4/2/26 was reviewed. RD 1, NIM and CRMPS stated there was no level of nutrition risk assessed, no nutrition risk score generated, because the “MRS” was not completed by nursing for Patient 600, and should have been. During a concurrent interview and record review on 4/23/26 at 11:51 a.m. with RD 1 and DFN, Patient 306’s nursing admission “Malnutrition Risk Screen,” dated 4/16/26 was reviewed. RD 1 and DFN stated the MRS that contained NRS questions was inaccurately marked “None of the above,” therefore, a final screening total score was not calculated. During a concurrent interview and record review on 4/23/26 at 12:20 p.m. with RD 1 and DFN, Patient 601’s nursing admission “Malnutrition Risk Screen,” dated 4/17/26 was reviewed. RD 1 and DFN stated the MRS that contained NRS questions was inaccurately marked as “None of the above”. During an interview on 4/22/26 at 10:50 a.m. with Director of Food and Nutrition (DFN), DFN stated a final screening score via the validated NRS tool of greater than or equal to (>) 3 would automatically generate an RD consult to trigger an RD to complete a comprehensive nutrition assessment (NA) for a patient within two days of admit to inpatient. During an interview on 4/23/26 at 3:51 p.m. with DFN, DFN stated the hospital switched from utilizing a validated nutrition screening tool titled MST (Malnutrition Screening Tool) to utilizing NRS (Nutrition Risk Screening) about a year ago. DFN stated there had been zero data collection to monitor and identify whether implementation of the NRS tool criteria as listed on the Malnutrition Risk Screening located on the nursing admission assessment was being completed consistently, completely and accurately. DFN stated she had not communicated to QAPI committee the need for a formalized hospital- wide data driven QAPI project for PI (performance improvement) related to identifying high risk nutrition patients upon admission for prompt nutrition assessment and nutrition plan of care for patients via a Registered Dietitian. During a review of the hospital’s “Quality Management, Performance Improvement & Patient Safety Plan HS-QM001,” dated 1/2026, the plan indicated, “7. To ensure that new services and/or processes are safe, designed well and are in concert with the organization’s mission, patient/staff /community needs, current professional information, and information about performance of other organizations, including medical errors/adverse events. 8. To develop and maintain an effective, efficient quality assessment, performance measurement and data analysis system for performance improvement and patient safety activities. 9. To provide a process for organization wide communication regarding performance improvement and enhanced, continuous patient safety activities. . .High priority is given to high volume, high risk or problem-prone processes. Prioritization considers the incidence, prevalence and severity of problems. Priorities are based on: Strategic planning priorities;. . .Needs identified in operational processes. . .Leaders include: Department Directors Managers, Responsibility of Leaders: The leaders of [name of hospital] are responsible and accountable for ensuring that an effective quality management system is implemented and maintained. Performance improvement projects or similar activities are selected that address priorities for improved quality of care and patient safety and that focus attention on various processes, functions and areas of the organization. The number and scope of these projects to be conducted annually will be proportional to the scope and complexity of the organization. All departments will be responsible for identifying critical processes within their area that are consistent with the priorities identified to measure, assess and improve. Processes that impact patient safety, are high volume, high risk, or problem prone, which may include those provided through a contract, are studied to identify potential opportunities for improvement. Departmental Quality Controls are monitored in. . .Nutrition Services. . .” During a review of the hospital’s job description (JD) titled, “Clinical Dietitian,” dated 8/12/22, the “JD” indicated, “Essential Functions and Responsibilities: Participates in facility-wide and department Quality Assurance/Performance Improvement (QAPI) Program and on QAPI teams to improve processes and patient/resident care.” 35399 2.During a concurrent review of the outpatient performance improvement project (PIP) titled “Improving Accountability and Audit Readiness in the Ambulatory Clinic” and interview with the outpatient clinic supervisor (OCS) on 4/22/26 at 3:56 p.m., the PIP indicated a review of the compliance data will be performed monthly. Request to review the first quarter data collection results to evaluate the progress of the PIP. The OCS indicated not having the data and/or the quarterly data results. A review of the document titled “Quality Management, Performance Improvement & Patient Safety Plan HS-QM001”, dated 01/2026, indicated in part F. “The quality leadership council (QLC) is responsible for the following: Review of the progress of Quality and Performance Improvement projects ...In the Part Key Performance Improvement and Patient Safety Activities indicated the Performance Improvement Model was Plan, Do, Study, Act (PDSA). In the PDSA model, on the Plan step 2: Analyze the Process- indicates to collect and analyzed data related to the process ...” 3.During the review of the document titled “Instrument Staining-Corrective Work Documentation”, dated 1/22/26 and interview with the surgery clinical manager (SCM) on 4/22/26 at 1:01 p.m., the SCM claimed this was the PIP the surgery department was working on. The instrument trays were being audited for instrument staining. However, the document listed a historical series of events that occurred in the surgery department. The selected PDSA model was not utilized. The SCM was asked to provide the auditing tool and data audited for review. The SCM could not provide the collected data audited. During an interview with the quality director (QD) on 4/22/26/at 1:15 p.m., the QD was asked who in the facility ensures the PIPs are being conducted correctly and according to their QAPI plan. The QD acknowledges that the SCM needs assistance conducting a PIP and stated “Yes, I agree some departments need assistance with their performance improvement projects (PIPs)”. A review of the document titled “Quality Management, Performance Improvement & Patient Safety Plan HS-QM001”, dated 01/2026, indicated in part F. “The quality leadership council (QLC) is responsible for the following: Review of the progress of Quality and Performance Improvement projects ...In the Part Key Performance Improvement and Patient Safety Activities indicated the Performance Improvement Model was Plan, Do, Study, Act (PDSA). In the PDSA model, on the Plan step 2: Analyze the Process- indicates to collect and analyzed data related to the process ...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 35399 Based on record review and interview, the hospital staff failed to implement the Emergency Medical Treatment and Labor Act (EMTALA) and related policies and procedures (P&P) when the hospital failed to ensure: 1. Physician certification forms were complete for six (6) of 14 sampled patients (Patients 101, 102, 103, 104, 205, and 207). 2. Physician certification form time closely matched the transfer time for six (6) of 14 sampled patients (Patients 102, 206, 207, 208, 209 and 210). 3. Patients’ vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions) were documented at transfer for seven (7) of 14 sampled patients (Patients 101, 102, 205, 206, 207, 209, and 210). 4. The against medical advice (AMA) form was complete for one (1) of 14 sampled patients (Patient 204). The failures placed patients at risk of not being aware of their rights upon transfer, potentially not being declared stable at time of transfer, as evidence of not having any vital signs documented at time of transfer which could result in patient’s condition decompensating while in route to another facility. Findings: 1.During a review of the hospital’s policy and procedure (P&P) titled, “Emergency Medical Treatment and Labor Act (EMTALA),” dated 11/28/23, PROCEDURE part (5) (f) indicated, “A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual or ... from being transferred. The certification should meet the following requirements: i. The certification must state the reason for transfer ... But should be specific to the condition of the patient upon transfer. ii. The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risk associated with that transfer ...” a) During a review of Patient 101’s medical record, the medical record indicated, Patient 101 presented to the emergency department (ED) on 11/2/23 with complaint of facial pain after a fall. A trauma surgeon was contacted at another hospital who recommended to transfer patient to their hospital for surgical treatment for mandible open fracture (broken jaw). Patient 101’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, the form was not complete. Review of Patient 101’s “Patient Consent/Request for Transfer,” indicated, the date and time area was blank, there was no physician signature, and the date and time after the physician signature area was also blank. Patient 101 was transferred to another hospital on 11/2/23 at 12:38 p.m. b) During a review of Patient 102’s medical record, the record indicated, Patient 102 presented to the ED on 11/5/23 with complaint of altered mental status. Patient 102 was found to be hypothermic with a temperature of 86.1 Fahrenheit degrees (normal is 98.6) requiring intensive care unit setting for monitoring and further work-up. Patient 102’s “ EMTALA Certification and Transfer Form,” was reviewed and indicated, the form was not complete. The Mode/Support During Transfer as Determined by Physician area was left blank, there was no indication of the type of equipment or personnel required for transfer. The Consent to Transfer to another facility was left blank, there was no indication to which facility and for what purpose Patient 102 was being transferred. Review of Patient 102’s Unable to Obtain Written Consent box was checked, there was no reason for not consenting patient to transfer documented. The Reason area was left blank. Patient was transferred to another hospital on 11/5/23 at 4:05 p.m. c) During a review of Patient 103’s medical record, the record indicated, Patient 103 presented to the ED on 11/8/23 with complaint of abdominal pain. Review of physician note, dated 11/8/23, indicated, labs and imaging were notable for pancreatitis (pancreas infection), biliary dilation, possible occluded common bile duct (CBD) stent, requiring gastroenterologist consultation and treatment at another hospital. Patient 103’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, the form was not complete. The Physician’s signature date, and time were missing, area was left blank, no indication the date and time the form was signed. Patient was transferred to another hospital on 11/9/23 at 3:53 a.m. d) During a review of Patient 104’s medical record, the record indicated, Patient 104 presented to the ED on 11/18/23 with complaint of abdominal pain. Review of physician note indicated, abdominal pain has improved though not resolved after analgesics. Patient requires transferring to another hospital for surgical consult for chronic or recurrent early appendicitis (infection of the appendix). Patient 104’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, the form was not complete. The Consent to Transfer to another facility area was left blank, no indication for what purpose the patient was being transferred. The Physician’s signature, date, and time were missing, the area was left blank. Patient 104 was transferred to another hospital on 11/18/23 at 9:29 p.m., by private automobile. e) During a review of Patient 205’s medical record, the record indicated, Patient 205 presented to the ED on 11/22/23 with complaint of abdominal pain. According to physician’s note concern for possible preterm labor (when a patient goes into labor before 36 weeks). As no ultrasound available at our facility, labor and delivery patient requires transfer to labor and delivery facility. Patient 205’s “ EMTALA Certification and Transfer Form,” was reviewed and indicated, the Reason for Transfer box was not checked. The Mode/Support During Transfer as Determined by Physician area was blank; there was no indication of the type of equipment and personnel required for transfer. The Physician’s printed name, signature, date, and time were missing. Patient 205 was transferred to another hospital on 11/22/23 at 1:50 a.m. f) During a review of Patient 207’s medical record, the record indicated, Patient 207 presented to the ED on 12/2/23 with complaint of cough and difficulty breathing. According to physician’s note labs and imaging reviewed, impression epiglottitis (swelling of the small movable part in the throat). Transfer for ENT consult. Patient 207’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, the form was not complete, the Condition/diagnosis was missing. Patient 207 was transferred to another hospital on 12/2/23 at 9:15 a.m. During a concurrent review of the EMTALA Certification and Transfer form and interview with the ED medical director (EDMD) on 12/20/23 at 9:45 a.m. the EDMD confirmed that if any area on the form was left blank then the form was not complete. 2. During a review of the hospital policy and procedure (P&P) titled, “Emergency Medical Treatment and Labor Act (EMTALA),” dated 11/28/23, PROCEDURE part (5) (f) indicated “A physician must sign an express written certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk to the individual or ... from being transferred. The certification should meet the following requirements: iii. The date and time of the physician certification should closely match the date and time of the transfer.” a) During a review of Patient 102’s medical record, the record indicated, Patient 102 presented to the ED on 11/5/23 with complaint of altered mental status. Patient 102 was found to be hypothermic with temperature of 86.1 Fahrenheit degrees (normal is 98.6) requiring intensive care unit setting for monitoring and further work-up. Patient 102’s “EMTALA Certification and Transfer form,” was reviewed and indicated, the physician signed, dated, and timed the form on 11/5/23 at 12:47 p.m. The patient was transferred to another hospital on 11/5/23 at 4:05 p.m. The time between when the form was signed and the time the patient left the hospital ED was 3 hours and 18 minutes. b) During a review of Patient 206’s medical record, the record indicated Patient 206 presented to the emergency department (ED) on 11/20/23 with complaint of swelling. Impression: Hypoxemia (a low level of oxygen in the blood). Patient 206’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, the physician signed, dated, and timed the form on 11/20/23 at 3 p.m. The patient was transferred to another hospital on 11/20/23 at 4:25 p.m. The time between when the form was signed and the time the patient left the hospital ED was 1 hour and 25 minutes. c) A review of Patient 207’s medical record was conducted on 12/19/23. Patient presented to the emergency department (ED) on 12/2/23 with complaint of cough and difficulty breathing. According to physician’s note labs and imaging reviewed, impression epiglottitis (swelling of the small movable part in the throat). Transfer for ENT consult. Patient 207’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, physician signed, dated, and timed the form on 12/2/23 at 6:30 a.m. The patient was transferred to another hospital on 12/2/23 at 9:15 a.m. The time between when the form was signed and the time the patient left the hospital ED was 2 hours and 45 minutes. d) During a review of Patient 208’s medical record, the record indicated, Patient 208 presented to the emergency department (ED) on 11/29/23 with complaint of chest pain. According to physician’s note labs and imaging reviewed, impression chest pain and angina pectoris. Transfer for telemetry and cardiology. Patient 208’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, physician signed, dated, and timed the form on 11/29/23 at 11:35 a.m. The patient was transferred to another hospital on 11/29/23 at 1:45 p.m. The time between when the form was signed and the time the patient left the hospital ED was 2 hours and 10 minutes. e) During a review of Patient 209’s medical record, the record indicated Patient 209 presented to the emergency department (ED) on 11/23/23 with complaint of generalized weakness. According to physician’s note labs and imaging reviewed, impression diabetic ketoacidosis (DKU) (a serious condition caused by not enough insulin in the body). Transfer for DKU evaluation and ICU admission. Patient 209’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, physician signed, dated, and timed the form on 11/23/23 at 3:55 p.m. The patient was transferred to another hospital on 11/23/23 at 5:00 p.m. The time between when the form was signed and the time the patient left the hospital ED was 1 hour and 5 minutes. f) During a review of Patient 210’s medical record, the record indicated, Patient 210 presented to the emergency department (ED) on 11/27/23 with complaint of abdominal pain. According to physician’s note labs and imaging reviewed, impression aortic dissection, abdominal (tear or damage to the inner wall of the aorta). Transfer for telemetry and consult for aortic dissection. Patient 210’s “EMTALA Certification and Transfer Form,” was reviewed and indicated, physician signed, dated, and timed the form on 11/27/23 at 2:55 p.m. The patient was transferred to another hospital on 11/27/23 at 8:44 p.m. The time between when the form was signed and the time the patient left the hospital ED was 5 hours and 49 minutes. During a concurrent interview and record on 12/20/23 at 9:35 a.m. with the ED medical director (EDMD), the “EMTALA Certification and Transfer form,” was reviewed. The EDMD was asked how much time was consider “closely” to match the time of the transfer. Initially, the EDMD indicated the physician certification transfer form should be completed at the time of transfer. Then started explaining the form is completed when patient is accepted at another hospital. The timeframe varies from patient to patient. It was shared with EDMD the language “closely” in the policy is left open for interpretation therefore the hospital needs to define what timeframe is considered “closely.” 3. During a review of the hospital’s policy and procedure (P&P) titled, “Emergency Medical Treatment and Labor Act (EMTALA),” dated 11/28/23, PROCEDURE part (1) (c) indicated, “Continuous Monitoring: The medical secreening examination MSE is a continuous process reflecting ongoing monitoring in accordance with an individual’s needs. Monitoring will continue until the individual is stabilized or appropriately transferred. Reevaluation of the individual must occur prior to discharge or transfer.” a) During a review of Patient 101’s medical record, the record indicated, Patient 101 presented to the emergency department (ED) on 11/2/23 with complaint of facial pain after a fall. Patient 101’s vital signs were only performed on 11/2/23 at 11:42 a.m. Patient 101 was transferred to another hospital at 12:38 p.m., without any vital signs performed at the time of transfer. b) During a review of Patient 102’s medical record, the record indicated Patient 102 presented to the ED on 11/5/23 with complaint of altered mental status. Patient was found to be hypothermic with temperature of 86.1 Fahrenheit degrees (normal is 98.6) requiring intensive care unit setting for monitoring and further work-up. The last vital signs performed for Patient 102 was on 11/5/23 at 12:13 p.m., the patient’s temperature was still low at 88.6 Fahrenheit degrees. Patient was transferred to another hospital on 11/5/23 at 4:05 p.m., without any vital signs performed at the time of transfer. c) During a review of Patient 205’s medical record, the record indicated, Patient 205 presented to the ED on 11/22/23 with complaint of abdominal pain. Patient 205’s vital signs were only performed on 11/22/23 at 1:10 a.m. Patient was transferred to another hospital at 1:50 a.m., without any vital signs performed at the time of transfer. d) During a review of Patient 206’s medical record, the record indicated, Patient 206 presented to the emergency department (ED) on 11/20/23 with complaint of swelling (all over his body). Patient 206’s last vital signs were performed on 11/20/23 at 3:30 p.m. Patient was transferred to another hospital at 4:25 p.m., without any vital signs performed at the time of transfer. e) During a review of Patient 207’s medical record, the record indicated, Patient 207 presented to the emergency department (ED) on 12/2/23 with complaint of cough and difficulty breathing. Patient 207’s last vital signs were performed on 12/2/23 at 8:35 a.m. Patient was transferred to another hospital at 9:15 a.m., without any vital signs performed at the time of transfer. f) During a review of Patient 209’s medical record, the record indicated Patient 209 presented to the emergency department (ED) on 11/23/23 with complaint of generalized weakness. Patient 209’s last vital signs were performed on 11/23/23 at 4:37 p.m. Patient was transferred to another hospital at 5 p.m., without any vital signs performed at the time of transfer. g) During a review of Patient 210’s medical record, the record indicated, Patient 210 presented to the emergency department (ED) on 11/27/23 with complaint of abdominal pain. Patient 210’s last vital signs were performed on 11/27/23 at 7:26 p.m. Patient was transferred to another hospital at 8:44 p.m., without any vital signs performed at the time of transfer. During an interview on 12/20/23 at 9:53 a.m., with the ED Medical Director (EDMD), the EDMD indicated the ED staff performed vital signs on patients at time of transfer in accordance with standard practice. During an interview on 12/19/23 at 10:01 a.m. with the ED Director (EDD), the EDD indicated usually their practice was to perform vital signs on patients 15-30 minutes prior to discharge or transfer. 4. A review of the hospital policy and procedure (P&P) titled “Leaving Hospital Against Medical Advice (AMA)”, dated 9/27/22, the P&P indicated, PROCEDURE: “The physician must attempt to provide the patient ... information regarding why continued hospitalization is recommended ... the potential consequences of the action (the risks involved in leaving) ... DOCUMENTATION: Completion of the AMA form and ensure that it is on the medical record.”.” During a concurrent interview and record review on 12/20/23 at 9:05 a.m. with ED medical director (EDMD), Patient 204’s “Leaving Hospital Against Medical Advice (AMA),” dated 11/17/23 was reviewed. The AMA indicated, there were no date, time, physician’s printed name, or Physician’s signature documented for when and who explained the risks of leaving AMA. EDMD stated the AMA form should be complete and this one is not.”