Palo Verde Hospital

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 47071 Based on observation, interview, and record review, the facility failed to ensure supply of normal saline (NS, 0.9 % sodium chloride, a type of fluid administered intravenously [IV, through the vein]) flush (a type of NS in a syringe used to clear the IV line of medication and blood) is maintained and available for use in the Emergency Department (ED, specialty area in the facility providing care and treatment for emergencies and unscheduled care for severe injuries and life-threatening conditions). In addition, the facility failed to ensure NS flushes were not drawn and made by registered nurses (RNs) from NS IV fluid bags. This failure had the potential for an increased risk of delay in patient care and treatment during an emergency for patients seen at the ED. Findings: On February 2, 2026, at 9:30 a.m., a tour of the ED was conducted with the Executive Leadership Assistant (ELA). During the tour, at the nurses’ work area, Drawer 4 (four) of a cabinet in the nurses’ medication preparation area was observed to have three unlabeled 10 milliliters (ml, unit of measurement) syringes with pink caps and 18 g (gauge, unit of measurement) x (by) 1 ½ inch (unit of measurement) needles filled with clear liquid. On February 2, 2026, at 9:35 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the ED did not have any 10 ml of NS flushes available. RN 1 stated a pharmacist brought 50 ml NS fluid IV bags to the ED so the RNs could make the NS flushes from the 50 ml NS fluid IV bags. RN 1 stated she filled five 10 ml syringes from the NS fluid IV bags brought by the pharmacist, and the three of the five 10 ml syringes she filled were left in Drawer 4. RN 1 stated she prepared and drew up the NS in the syringes on the counter by the sink in the area where nurses prepare the medications in the ED. On February 2, 2026, at 11:51 a.m., an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the nursing staff knows they should not be making the NS flushes. On February 3, 2026, at 9:02 a.m., an interview was conducted with Pharmacist (Pharm) 1. Pharm 1 stated he provided the ED nursing staff with 50 ml IV bags of NS IV fluid just in case the NS flushes were needed and were only to be used until the NS flush supplies ordered by the facility came in. Pharm 1 stated no instructions were given to the nurses on how to make the 10 ml NS flush. Pharm 1 stated the 50 ml NS fluid IV bag is for one time use only and is not to be used for making 10 ml syringes NS flushes. A facility document titled, “PRESCRIBING INFORMATION, 0.9% Sodium Chloride Injection,” dated November 20, 2021, was reviewed. The document indicated, “...SPECIAL HANDLING INSTRUCTIONS...For single use only. Discard any unused portion...Aseptic technique [a set of strict, specific procedures and protocols used by healthcare professionals and scientists to prevent the contamination of patients, instruments, fluids, and medication] is required including when mixing with medication. This solution is intended for intravenous administration using sterile [rendered free of bacteria, viruses, and fungi] equipment...” A facility policy and procedure titled, “Medication Administration, Emergency Department,” dated May 2025, was reviewed. The document indicated, “...Pharmacy is responsible for compounding [the customized process where a licensed pharmacist or physician mixes, alters, or combines raw ingredients to create a medication or IV fluid]medications under the appropriate conditions...Do not administer medications from a single-dose vial or IV bag to multiple patients...””

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 47071 Based on observation, interview, and record review, the facility failed to ensure the defibrillator (a medical device that delivers a high-energy electric shock to the heart to correct life-threatening, irregular heart rhythms) on the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations [the action or process of reviving someone from unconsciousness or apparent death]) was checked (performance of a mandatory, routine daily or per-shift inspection of the emergency resuscitation cart to ensure all life-saving equipment, medications, and defibrillators are present, unexpired, functional, and properly stocked) and the logbook of the crash cart were completed daily. This failure had the potential for an increased risk of delay in patient care and treatment during an emergency. Findings: On February 2, 2026, at 10:00 a.m., a tour of the Emergency Department (ED, a specialty area in the facility providing care and treatment for emergencies and unscheduled care for severe injuries and life-threatening conditions) was conducted with the Executive Leadership Assistant (ELA). During the tour, three crash carts (Crash carts A, B, and C) at the ED were observed. 1. Crash cart A was observed. A facility document titled, “[Name of facility] Daily Emergency Cart Check List January 2026,” was observed on the top of crash cart A. During a concurrent review of the document, the document indicated the Crash cart A was not checked on January 17, 2026, at 7 a.m. (for the day shift [7a.m. to 7 p.m.]), and on January 31, 2026, at 7 p.m. (for the night shift [7 p.m. to 7 a.m.]). A checklist for the defibrillator was observed on the top of Crash cart A. The defibrillator checklist was reviewed and indicated the defibrillator was last checked on January 26, 2026 (the defibrillators were not checked for seven days). A copy of the facility document titled, “[Name of facility] Daily Emergency Cart Check List,” for February 2026, for Crash car A was requested from the ELA. The ELA was not able to provide a copy of the requested document. There was no documented evidence Crash cart A was checked on February 1, 2026. 2. Crash cart B was observed. A facility document titled, “[Name of facility] Daily Emergency Cart Check List, December 2025,” was observed on the top of Crash cart B. During a concurrent review of Crash cart B’s checklist, the document indicated Crash cart B was not checked on December 27, 2025, night shift, December 28, 2025, day shift, December 29, 2025, day shift, December 30, 2025, day and night shifts, and December 31, 2025, night shift. A checklist for the defibrillator was observed on the top of Crash cart B. The defibrillator checklist was reviewed and indicated the defibrillator was last checked on January 26, 2026 (the defibrillators were not checked for seven days). A copy of the facility document titled, “[Name of facility] Daily Emergency Cart Check List,” for February 2026, for Crash cart B was requested from the ELA. The ELA was not able to provide a copy of the requested document. There was no documented evidence Crash cart B was checked on February 1, 2026. 3. Crash cart C was observed. A facility document titled, “[Name of facility] Daily Emergency Cart Check List,” dated November 2025, was observed on the top of Crash cart C. During a concurrent review of Crash cart C’s checklist, the document indicated Crash cart C was not checked on the day shifts of November 16, 2025, day shift, on November 17, 2025, day shift, on November 30, 2025, day shift, and on January 31, 2026, day and night shifts. An undated (no month indicated) facility document titled, “[Name of facility] Daily Emergency Cart Check List,” was reviewed. The document indicated Carsh cart C was not checked on the following days of the month (the specific month was not indicated on the checkllist): 27, night shift; 28, day shift; 29, day shift; 30, day and night shifts; and 31, night shift. A checklist for the defibrillator was observed on the top of Crash cart C. The defibrillator checklist was reviewed and indicated the defibrillator was last checked on January 26, 2026 (the defibrillators were not checked for seven days). A copy of the facility document titled, “[Name of facility] Daily Emergency Cart Check List,” for February 2026, for Crash cart C was requested from the ELA. The ELA was not able to provide a copy of the requested document. There was no documented evidence Crash cart C was checked on February 1, 2026. On February 2, 2026, at 10:15 a.m., an interview was conducted with the Registered Nurse House Supervisor (RNHS). The RNHS stated the RNs are supposed to check the crash carts and the defibrillators each shift and the RN is to sign, and indicated the date and time on the checklists to indicate the crash carts and defibrillator checks have been completed. RNHS stated the last time the defibrillators on Crash carts A, B, and C were checked was on January 26, 2026. On February 2, 2026, at 11:51 a.m., an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the RNs should know the crash carts are to be checked each shift and the defibrillators are to be checked daily. The CEO was not able to provide a policy and procedure for the daily defibrillator checks and the crash cart checks each shift when requested.”

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure a portable space heater (a device used to heat a single, small-to-medium-sized room or confined area) brought in by staff from home was not used in in a patient care area, in accordance with the facility’s policy and procedure (P&P). This failure had the potential for increased risk of injury to patients and increased the risk of fire in the Emergency Department (ED, a specialty area in the facility providing care and treatment for emergencies and unscheduled care for severe injuries and life-threatening conditions). Findings: On February 2, 2026, at 8:59 a.m., a tour of the ED was conducted with the Executive Leadership Assistant (ELA). During the tour, a portable small black space was observed plugged in one of the electric sockets in the ED triage (an area where medical personnel quickly assess, and triage [a process used to assess the severity of the patients’ injuries or illnesses] patients) room. On February 2, 2026, at 9:04 a.m., during a tour of the ED triage area, the temperature on the thermostat mounted on the wall was observed to be at 74.8 degrees Fahrenheit (F, unit of measurement). On February 2, 2026, at 9 a.m., an interview was conducted with the Patient Access Clerk (PAC). The PAC stated the portable space heater was placed by staff in the triage room in case the room gets cold. The PAC stated the room gets very cold and they dress warmly with many layers of clothes to keep warm. On February 2, 2026, at 9:05 a.m., an interview was conducted with the ED Registered Nurse House Supervisor (RN/HS). The RN/HS stated she is aware staff should not be using the portable space heaters they brought in from home. On February 2, 2026, at 12:15 p.m., a tour of the ED triage area, was conducted with the ELA. During the tour, a portable small black space heater was observed plugged in one of the electrical sockets. The portable space heater was observed to be turned on and was being used by the staff in the room. On February 2, 2026, at 12:16 p.m., an interview was conducted with the PAC. The PAC stated the room was very cold so they turned on the portable space heater. On February 2, 2026, at 12:18 p.m., during a tour of the ED triage area, the temperature on the thermostat mounted on the wall was observed to be at 74.8 degrees F. On February 2, 2026, at 12:22 p.m., the Plant Engineer (PE) was observed to take the temperature of the air coming out of the air vent located above the triage room and the temperature reading taken by the PE was observed to be 72 degrees F. The PE was observed to take the temperature reading for the air coming out of the vent above the PAC desk and the temperature reading was observed to be 64 degrees F. On February 3, 2026, at 8:05 a.m., an interview was conducted with the PE. The PE stated the facility’s heating boiler (a closed vessel system which heats water or produces steam to provide warmth) was broken and has recently been fixed. The PE stated the facility’s heating component has an old technology and he needed to mix the hot and cold water to change the temperature in the facility. The PE stated he has not evaluated the portable space heaters which was observed in the ED. On February 3, 2026, at 9:30 a.m., an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the staff know they should not be using their personal portable space heaters brought from home in the facility. The CEO stated using portable space heaters brought from home in the facility is a safety concern. On February 3, 2026, at 3 p.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the ED is always cold and the staff has to wear multiple layers of clothes and thick jackets. RN 2 stated the staff uses the portable space heaters brought from home in the ED because it is very cold in the unit. A facility P&P titled, “Electrically Powered Equipment ‘A’,” dated June 2025, was reviewed. The P&P indicated, “...All Electrically Powered Equipment shall be considered either Patient Care Equipment or Non-Patient Care Equipment...All Electrically Powered Equipment shall be evaluated for inclusion in the Medical Equipment Program...” A facility P&P titled, “Electrically Powered Equipment ‘B’, dated June 2025, was reviewed. The document indicated, “...All electrically powered equipment being introduced into the hospital shall be evaluated for inclusion into the Equipment Management Program. Equipment included and/or not included in the Equipment Management Program shall be initially inspected for electrical safety and function...””

“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: 47071 Based on interview, record review, and observation, the facility failed to ensure the temperature in Emergency Department (ED, a specialty area in the facility providing care and treatment for emergencies and unscheduled care for severe injuries and life-threatening conditions) was monitored to ensure the temperature was maintained in the patient care areas. This failure had the potential for patients to feel uncomfortable in the ED. Finding: On February 2, 2026, at 12:15 p.m., a tour of the ED was conducted with the Executive Leadership Assistant (ELA) and the Plan Engineer (PE). During the tour, the temperatures of the patient waiting area, patient intake (area used when collecting patient information) and triage (place where medical personnel quickly assess, triage [an area where medical personnel quickly assess, and triage [a process used to assess the severity of the patients’ injuries or illnesses] patients) room, and a patient room where Beds 5 and 6 are located in the ED, were observed to be taken by PE. The following were the temperatures were observed to be obtained by PE during the tour: - In the patient waiting area, the temperature was 64 degrees F; - In the patient intake area the temperature was 64 degrees Fahrenheit (F, temperature scale system); - In the triage room, the temperature was 72 degrees F; and - In a patient room where Beds 5 and 6 are located, the temperature was 59 degrees F. On February 3, 2026, at 7:59 a.m., a tour of the ED was conducted with the ELA and the PE. During the tour, temperatures of all ED areas were observed to be taken by PE. - In the patient waiting area, the temperature was 70 degrees F; - In the patient intake area , the temperature was 70 degrees F; - In the triage room, the temperature was 66 degrees F; and - In a patient room where Beds 5 and 6 are located, the temperature was 56 degrees F. On Feb 3, 2026, at 9:25 a.m. an interview with the Plant Operations (the department and technical infrastructure responsible for the continuous operation, maintenance, and safety of the physical building and its utility systems) Manager (POM) was conducted. The POM stated they do not monitor the temperature in the ED on a daily basis. The POM stated the facility does not currently have a policy for monitoring the temperature in the ED. On February 3, 2026, at 3:33 p.m., a tour of the ED was conducted with the ELA and the Plant Operations Manager (POM). During the tour, temperatures of all ED areas were observed to be taken by POM. The following were the temperatures obtained by Plant Operations Manager (POM) during the tour: - In the patient waiting area, the temperature was 70 degrees F; - In the patient intake area, the temperature was 70 degrees F; - In the triage room, the temperature was 74 degrees F; and - In a patient room where Beds 5 and 6 are located, the temperature was 56 degrees F. On Feb 3, 2026, at 3:40 p.m. an interview with the Chief Executive Officer (CEO) was conducted. The CEO stated Plant Operations are not monitoring the temperatures in the ED on a daily basis only as needed. The CEO stated Plant Operations should be monitoring the temperature in the ED daily and should maintain a temperature log. The CEO was not able to provide a policy and procedure for monitoring the temperature in the ED when requested.”

“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: 47071 Based on observation, interview, and record review, the facility failed to ensure the of normal saline (NS, 0.9 % sodium chloride, a type of fluid administered intravenously [IV, through the vein]) flush (a type of NS in a syringe used to clear the IV line of medication and blood) were aseptically (a set of strict, specific procedures and protocols used by healthcare professionals and scientists to prevent the contamination of patients, instruments, fluids, and medication) compounded (the customized process where a licensed pharmacist or physician mixes, alters, or combines raw ingredients to create a medication or IV fluid), in accordance with the facility’s policy and procedure (P&P). This failure had the potential for an increased risk of infection and risk of delay in patient care during an emergency. Findings: On February 2, 2026, at 9:30 a.m., a tour of the Emergency Department (ED, a specialty area in the facility providing care and treatment for emergencies and unscheduled care for severe injuries and life-threatening conditions) was conducted with the Executive Leadership Assistant (ELA). During the tour, at the nurses’ work area, Drawer 4 (four) of a cabinet in the nurses’ medication preparation area was observed to have three unlabeled 10 milliliters (ml, unit of measurement) syringes with pink caps and 18 g (gauge, unit of measurement) x (by) 1 ½ inch (unit of measurement) needles filled with clear liquid. On February 2, 2026, at 9:35 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the ED did not have any 10 ml of NS flushes available. RN 1 stated a pharmacist brought 50 ml NS fluid IV bags to the ED so the RNs could make the NS flushes from the 50 ml NS fluid IV bags. RN 1 stated she filled five 10 ml syringes from the NS fluid IV bags brought by the pharmacist, and the three of the five 10 ml syringes she filled were left in Drawer 4. RN 1 stated she prepared and drew up the NS in the syringes on the counter by the sink in the area where nurses prepare the medications in the ED. On February 2, 2026, at 11:51 a.m., an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the nursing staff knows they should not be making the NS flushes. On February 3, 2026, at 9:02 a.m., an interview was conducted with Pharmacist (Pharm) 1. Pharm 1 stated he provided the ED nursing staff with 50 ml IV bags of NS IV fluid just in case the NS flushes were needed and were only to be used until the NS flush supplies ordered by the facility came in. Pharm 1 stated no instructions were given to the nurses on how to make the 10 ml NS flush. Pharm 1 stated the 50 ml NS fluid IV bag is for one time use only and is not to be used for making 10 ml syringes NS flushes. A facility document titled, “PRESCRIBING INFORMATION, 0.9% Sodium Chloride Injection,” dated November 20, 2021, was reviewed. The document indicated, “...SPECIAL HANDLING INSTRUCTIONS...For single use only. Discard any unused portion...Aseptic technique [a set of strict,, specific procedures and protocols used by healthcare professionals and scientists to prevent the contamination of patients, instruments, fluids, and medication] is required including when mixing with medication. This solution is intended for intravenous administration using sterile [rendered free of bacteria, viruses, and fungi] equipment...” A facility policy and procedure titled, “Medication Administration, Emergency Department,” dated May 2025, was reviewed. The document indicated, “...Pharmacy is responsible for compounding [the customized process where a licensed pharmacist or physician mixes, alters, or combines raw ingredients to create a medication or IV fluid]medications under the appropriate conditions...Do not administer medications from a single-dose vial or IV bag to multiple patients...””

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 45431 Based on interview and record review the facility failed to follow their policy and procedure when Pitocin (Oxytocin - a medication that can help induce labor) was administered to a laboring patient (Patient 1) in the Emergency Department (ED). This failure had the potential to put both mother and fetus at risk for harm. Findings: On August 5, 2024, an unannounced visit was conducted at the facility for an Emergency Medical Treatment and Labor Act (EMTALA) survey. A review of Patient 1’s electronic medical record (EMR), was conducted on August 5, 2024, at 11:50 a.m., with the Chief Nursing Officer (CNO). The facility document titled, “ED Provider Note,” dated July 25, 2024, was reviewed. The document indicated, “...Chief Complaint...Uterine contractions G4 P4 [Gravida Para a medical term that relate to pregnancy and birth] first twin, LMP [Last Menstrual Period] Oct 2 [October] she said Aug 1st [August] according to pregnancy calculator wheel July 28; she starts contraction at about 5 p.m. now every 3 minutes, no prenatal [before birth] care, did not break her water no vaginal bleeding...Physical Exam...Bladder: non tender cervix 5cm [centimeters- unit of measurement] dilated occiput anterior station+1 [Positive numbers are used when a baby has descended beyond the pelvis] no free amniotic fluid [the clear or slightly yellow fluid that surrounds and protects an unborn baby as it grows during pregnancy]...” A concurrent interview and record review was conducted on August 5, 2024, at 2: 27 p.m., with Physician 1, The facility document titled, “Progress Notes,” dated July 25, 2024 was reviewed. The document indicated, “...Pitocin was started which advanced contraction...at 11:11 a.m...” Physician 1 stated Pitocin was started because Patient 1’s delivery was not progressing. She also stated the ED is not equipped to continuously monitor the fetal heart tones during Pitocin infusion. A concurrent interview and record review was conducted on August 6, 2024, at 8:15 a.m., with Physician 1. The facility’s policy and procedure (P&P) titled, “ER Oxytocin (Pitocin) Administration” dated July 2022, was reviewed. The P & P indicated, “...Scope: Emergency Department...Use of Pitocin, oxytocin, Cervadil [medication that can help dilate the uterus], Cytotec [medication used to induce labor], or any other drug used to encourage labor in the emergency room for the purpose of delivering a live fetus is against the policy of [Name of Hospital]...” Physician 1 stated she was unaware of this policy. A concurrent interview and record review was conducted on August 6, 2024, at 8:28 a.m., with the ED Manager. The facility’s P&P titled, “ER Oxytocin (Pitocin) Administration” dated July 2022, was reviewed. ED manager stated she was unaware of the policy and further stated the policy was not followed when Pitocin was given to Patient 1 in the ED. An interview was conducted on August 6, 2024, at 2:40 p.m., with Registered Nurse 3 (RN 3). RN 3 stated she was unaware of the policy indicating Pitocin cannot be given in ED and continuous fetal monitoring was not done during Pitocin infusion.”