Intermountain Health St. Mary’s Regional Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 Patient’s Rights, was out of compliance. A-0144 The patient has the right to receive care in a safe setting. Based on interviews and documents reviewed, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure a suicidal patient was monitored in accordance with facility policy and providers’ orders in two of three records reviewed for patients who were suicidal. (Patient #16)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 50313 Based on interviews and documents reviewed, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure a suicidal patient was monitored in accordance with facility policy and providers’ orders in two of three records reviewed for patients who were suicidal. (Patient #16) Findings include: Facility policies: The Acute Care Suicide Risk policy read, all patients 12 and older presenting to the facility will be screened for risk of suicide using a validated screening tool. After assessment, patients identified with acute suicide risk will receive additional evidence-based interventions as indicated and appropriate suicide precautions. Suicide precautions/environmental safety procedures will be ordered for patients with acute risk for suicide. This includes continuous monitoring,documented in the electronic health record (EHR), by trained caregivers who can provide immediate intervention when needed. The Suicide Risk Procedure policy read, the Ask Suicide Screener Questions (ASQ) (a set of four screening questions to determine risk for suicide) will generate a patient’s suicide risk at one of three levels: imminent risk, potential risk, and no risk. Suicide precautions will be ordered for patients with imminent risk for suicide. Suicide precautions for patients at imminent risk include continuous monitoring at all times until the patient is assessed and the order is discontinued. Continuous monitoring should be performed by a trained caregiver who can provide immediate intervention when necessary. Documentation of continuous monitoring will be documented in the EHR. 1. The facility failed to ensure a suicidal patient was monitored to ensure safety in accordance with facility policy and providers’ orders. A. Document Review i. A review of Patient #16’s medical record revealed Patient #16 presented to the emergency department (ED) on 3/1/26 at 3:57 a.m. with a chief complaint of suicidal ideation (thoughts of suicide). The ED Care Timeline revealed staff assessed Patient #16 at 4:05 a.m. using the ASQ screening tool and calculated Patient #16 was at imminent risk for suicide. At 4:06 a.m., the provider ordered suicide precautions and safety checks every 15 minutes starting at 4:07 a.m. The ED Care Timeline revealed a 15 minute safety check was not completed until 7:00 a.m., two hours and 53 minutes later. This gap in monitoring was in contrast with the provider’s order for staff to complete safety checks every 15 minutes on Patient #16 starting at 4:07 a.m. This was also in contrast with the Suicide Risk Procedure policy which read, suicide precautions for patients at imminent risk should have included continuous monitoring at all times until the patient was assessed and the order was discontinued. Continuous monitoring should have been performed by a trained caregiver who could provide immediate intervention when necessary, and continuous monitoring should have been documented in the EHR. The provider’s order for safety checks was discontinued and Patient #16 was discharged from the ED at 2:18 p.m. ii. Medical record review revealed Patient #16 presented to the ED for a second time on 3/1/26 at 4:36 p.m., two hours and 18 minutes later, with a chief complaint of a suicide attempt. The ED Care Timeline revealed staff assessed Patient #16 at 5:00 p.m. using the ASQ screening tool and calculated Patient #16 was at imminent risk for suicide. At 5:06 p.m., the provider ordered suicide precautions for Patient #16. At 10:18 p.m., five hours and 12 minutes later, the provider ordered safety checks every 15 minutes starting at 10:19 p.m. This was in contrast to the Acute Care Suicide Risk policy which read, patients identified with acute suicide risk would receive appropriate suicide precautions. Suicide precautions/environmental safety procedures would be ordered for patients with acute risk for suicide, which included continuous monitoring by trained caregivers who could provide immediate intervention when needed. The ED Care Timeline revealed the order for safety checks every 15 minutes was discontinued on 3/2/26 at 5:54 a.m. There was no evidence staff conducted safety checks every 15 minutes for Patient #16 from 3/1/26 at 10:19 p.m. until 3/2/26 at 5:54 a.m., a period of seven hours and 35 minutes. This gap in monitoring was in contrast with the provider’s order for staff to complete safety checks every 15 minutes for Patient #16 starting at 10:19 p.m. This was also in contrast with the Suicide Risk Procedure policy which read, suicide precautions for patients at imminent risk should have included continuous monitoring at all times until the patient was assessed and the order was discontinued. Continuous monitoring should have been performed by a trained caregiver who could provide immediate intervention when necessary, and continuous monitoring should have been documented in the EHR. B. Interview i. An interview was conducted on 3/25/26 at 9:54 a.m. with registered nurse (RN) #1. RN #1 stated safety checks were used to monitor suicidal patients’ behavior and location at 15 minute intervals and assessed if the patient and the patient’s environment was safe. RN #1 stated only trained staff members were able to complete safety checks. RN #1 stated staff should have monitored suicidal patients continuously, with patients being in view of the staff member at all times. RN #1 stated it was important to monitor suicidal patients closely to ensure patient safety. RN #1 stated there was a risk the suicidal patient could have harmed themselves or others if they were not monitored, and if safety checks were not completed by staff every 15 minutes. This interview was in contrast with the medical record review, which revealed safety checks were not completed every 15 minutes for Patient #16 according to providers’ orders or facility policy.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42693 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance. A-0175 PATIENT RIGHTS: RESTRAINT OR SECLUSION. The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on interviews and record review, the facility failed to ensure patients who required physical restraint were monitored according to facility policy in three of three medical records reviewed for patients who required restraint and were on the medical-surgical units. (Patient #1, Patient #8, and Patient #9).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 42693 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI, was out of compliance. A-0286 PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events. (c) Program Activities. (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities. The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: (3) That clear expectations for safety are established. Based on interviews and record reviews, the facility failed to thoroughly analyze the cause of a patient event and implement preventative actions to prevent recurrence. Specifically, upon review of a patient event record, the facility failed to identify CIWA scores were not completed in accordance with the Alcohol Withdrawal Assessment Scoring Guidelines which continued to occur in additional later patient admissions.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42693 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance. A-0392 STAFFING AND DELIVERY OF CARE. The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on record review and interviews, the facility failed to ensure nursing personnel provided nursing care to all patients as needed. Specifically, the facility failed to ensure patients were bathed and received oral care in three of three patient records reviewed who needed hygiene assistance on the medical surgical units (Patient #1, #8, and #9). A-0395 RN SUPERVISION OF NURSING CARE. A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and record review, the facility failed to ensure staff followed protocols and assessed patients for a change in condition. Specifically, the facility failed to ensure the Clinical Institute Withdrawal Assessment (CIWA) protocol (clinical assessment used to diagnose the severity of alcohol withdrawal) was followed according to provider orders for alcohol withdrawal patients. This failure was identified in five of six patients reviewed with CIWA orders (Patients #2, #4, #5, #6, and #8).”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 42693 Based on interviews and record review, the facility failed to ensure patients who required physical restraint were monitored according to facility policy in three of three medical records reviewed for patients who required restraint and were on the medical-surgical units. (Patient #1, Patient #8, and Patient #9). Findings include: Facility policy: The Patient Restraints Seclusion policy read, Restraint and/or Seclusion may only be imposed to ensure the immediate physical safety of the patient, an associate, or others, may only be used for the time necessary to accomplish their purpose, and must be discontinued at the earliest possible time when criteria for release have been met. Restraint and/or Seclusion use within the hospital is limited to situations with adequate and appropriate clinical justification based on a current individual assessment and only after the least restrictive interventions and alternatives have been considered and are deemed ineffective. For patients to whom Mechanical Restraints have been applied, associates will loosen/remove the Restraints to provide relief, except when the patient is sleeping, for at least ten (10) minutes as often as every two (2) hours, as long as it is safe for the patient and others for the restraints to be loosened/removed. During such relief periods, associates will ensure proper positioning of the patient and provide movement of limbs, as necessary. The patient ’ s dignity and safety shall be maintained during relief periods. Associates will document the relief periods in the patient ’ s medical record. Frequency of monitoring and documentation of that monitoring is determined by the type of Mechanical Restraint and setting. Monitoring is accomplished by observation, interaction with the patient, or direct examination of the patient by Qualified Staff. Patients Restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed. Additionally, RNs, LPNs, or PCT/CNAs perform checks and addresses physical needs every 2 hours to include: safety and comfort; need for hygiene/elimination; need for ROM of restrained extremities; repositioning; and food/fluids offered. 1. The facility failed to ensure patients in non-violent behavior restraints were assessed every two hours according to facility policy. A. Medical Record Review i. On 7/27/24 Patient #1 was admitted for treatment after a motorcycle crash. While on the neuro-trauma unit, mechanical restraints were ordered. Upon review of Patient #1’s flowsheets, gaps in restraint monitoring were identified. Examples include: a. On 8/6/24 Patient #1’s restraints were assessed at 5:00 p.m. The next assessment was completed at 7:51 p.m., two hours and 51 minutes after the previous assessment. b. On 8/9/24 at 12:28 a.m. Patient #1’s restraint status was assessed. The next assessment was completed at 4:00 a.m., three hours and 32 minutes after the previous assessment. This was in contrast to the patient restraint and seclusion policy which read, patients restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation, and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed. ii. On 10/14/24 Patient #8 was admitted to the facility for a potential GI bleed. During the admission, mechanical restraints were ordered. Upon the review of Patient #8’s flowsheets, gaps in restraint monitoring were identified. Examples include: a. On 10/19/24 at 4:00 p.m., Patient #8’s restraint status was assessed. The next assessment was completed at 8:00 p.m., four hours after the previous assessment. b. On 10/21/24 at 12:00 a.m., Patient #8’s restraint status was assessed. The next assessment was completed at 4:00 a.m., four hours after the previous assessment. This was in contrast to the patient restraint and seclusion policy which read, patients restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation, and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed. iii. On 8/1/24 Patient #9 was admitted for a subdural hemorrhage (a collection of blood between the brain and skull) after a fall. A review of Patient #9’s flowsheets revealed gaps in restraint monitoring. Examples include: a. On 8/1/24 at 10:00 p.m., Patient #9’s restraint status was assessed. The next assessment was completed on 8/2/24 at 8:00 a.m., ten hours after the previous assessment. b. On 8/6/24 at 2:00 p.m., Patient #9’s restraint status was assessed. The next assessment was completed at 8:00 p.m., six hours after the previous assessment. This was in contrast to the patient restraint and seclusion policy which read, patients restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation, and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed. B. Interviews i. On 11/12/24 at 10:01 a.m., an interview was conducted with registered nurse (RN) #8. RN #8 stated they primarily worked on the neuro-trauma unit. RN #8 stated if a patient was in non-violent mechanical restraints, the patient should have been assessed every two hours. RN #8 stated it was important for the patient to be assessed every two hours to ensure the patient had not injured themselves and was provided nourishment and other care as needed. ii. On 11/12/24 at 12:00 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated patients in non-violent restraints should have been assessed every two hours to check for circulation and status of the patient.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 42693 Based on interviews and record reviews, the facility failed to thoroughly analyze the cause of a patient event and implement preventative actions to prevent recurrence. Specifically, upon review of a patient event record, the facility failed to identify CIWA scores were not completed in accordance with the Alcohol Withdrawal Assessment Scoring Guidelines which continued to occur in additional later patient admissions. (Cross Reference Tag 0395) Findings include: Facility policy: The patient safety event reporting/sentinel event management policy read, a Sentinel Event is a Patient Safety Event (not primarily related to the natural course of the [patient ’ s] illness or underlying condition) that reaches a patient and results in death, Severe Harm (regardless of duration of Harm), or Permanent Harm (regardless of severity of Harm). A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following: death; permanent harm; severe temporary harm and intervention required to sustain life. Care sites that have experienced a Sentinel Event should focus attention on understanding the factors that contributed to the event (such as culture, systems, and processes), and on changing these factors to reduce the probability of such an event occurring in the future. Quality and Risk Management will be consulted when determining whether the event meets a Reviewable or not Reviewable Sentinel Event. A thorough and credible Root Cause Analysis and action plan will be prepared within 45 business days of the event or of becoming aware of the event. Clinical Risk Management will facilitate assembling the team to conduct the Root Cause Analysis. Team participation will include Operations from the area impacted, Quality and Risk Management representative(s), physicians, and individuals most closely involved in the event and processes or systems under review. References: The Alcohol Withdrawal Treatment Order Set (CIWA order set) read, CIWA Assessment - initiate assessments every six hours x 48 hours then per routine or if patient displays signs of withdrawal: If CIWA is 8 or greater - assess every one hour, then if CIWA is less than 8 x 3 consecutive assessments; assess every three hours x 3, then every six hours x 3, then per routine. If CIWA is 15 or greater for 3 consecutive assessments, contact the provider. The Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-ar) read, Procedure: 1. Assess and rate each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for “Orientation and clouding of sensorium” which is rated on a scale of 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (i.e.. start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater. 2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment Sheet. Document administration of PRN medications on the assessment sheet as well. 3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal. The assessment protocol from the Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment includes an initial vitals and CIWA assessment. If the initial score is greater than or equal to 8, repeat every hour for 8 hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If the initial score is less than 8, assess every four hours for 72 hours. If the score is less than 8 for 72 hours, discontinue the assessment. If the score is greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If indicated, administer prn medications as ordered and record on the medication administration record (MAR). 1. The facility failed to identify gaps in CIWA assessments for a patient who experienced an adverse event. a. A review of medical records revealed gaps in Patient #2’s CIWA assessments as well as gaps in additional CIWA assessments completed on alcohol withdrawal patients. i. On 7/5/24 Patient #2 arrived at the emergency department (ED) for hematemesis (vomiting blood). On 7/6/24 Patient #2 was then admitted to the 8th Floor and CIWA protocol was ordered due to potential concerns of alcohol withdrawal. On 7/6/24 at 3:51 a.m., an admission assessment was documented by the registered nurse (RN). The RN documented under the neuro assessment they were unable to assess the patient’s orientation status. Additionally, at that time, the patient status under orientation in the CIWA assessment was documented as oriented and able to do serial additions. The total CIWA score was 7. At 7:25 a.m., a shift assessment and CIWA assessment were completed. The patient’s orientation was documented as unable to assess. However, the patient’s orientation under the CIWA assessment was documented as oriented and able to do serial additions. The total CIWA score was 8. The CIWA assessments were in contrast to the neuro assessments which could have caused an inaccurately low CIWA score. At 8:25 a.m. a CIWA assessment was completed with a score of 6. The next CIWA assessment was completed at 10:00 a.m., one hour and 35 minutes later. This was in contrast to the CIWA order set which read if the score was greater or equal to 8, reassessments should occur every hour for three hours. A review of Patient #2’s medical record was in contrast to the record review in Patient #2’s grievance report. ii. On 10/18/24 Patient #6 was admitted to the facility and CIWA protocol was ordered. At 12:48 p.m., a CIWA assessment was completed and the patient’s score was 18. The next CIWA assessment was done at 2:42 p.m., almost two hours later. At 9:27 p.m., a CIWA assessment was completed and the score was 11. The next documented CIWA assessment was on 10/19/24 at 12:00 a.m. which read a CIWA score of 0 and that the patient was sleeping. On 10/19/24 at 8:55 p.m., a CIWA assessment was completed and the score was 20. The next CIWA assessment was on 10/20/24 at 12:00 a.m., over three hours later. The assessment read the score was 0 and the patient was asleep. On 10/20/24 at 9:56 a.m., a CIWA assessment was completed with a score of 24. The next CIWA assessment was completed at 1:12 p.m., over three hours later. The score at that time was 29. The next CIWA assessment was completed at 3:44 p.m., over two hours later, and the score was 13. Another CIWA assessment was done at 7:50 p.m., almost four hours later, and the score was 18. This was in contrast to the CIWA order set which read if the score was greater or equal to 8, reassessments should occur every hour for three hours. On 10/21/24 at 8:30 a.m., a CIWA assessment was performed and the score was 15. The next CIWA assessment was completed at 12:12 p.m., over three hours later, with a result of 19. The next CIWA assessment was completed at 2:10 p.m., almost two hours later and the score was 16. There was no evidence the provider was notified of the CIWA scores during this time period. This was in contrast to the CIWA order set which read, if CIWA was 15 or greater for 3 consecutive assessments, contact provider. Additionally, the CIWA assessments were not completed every hour for three hours as ordered by the provider. Similar findings of the CIWA protocol not being followed were identified in Patient #4, Patient #5, and Patient #8’s records. b. An email correspondence conversation from 8/12/24 in the grievance report for Patient #2 was reviewed. The email read the CIWA was assessed and treated in accordance with the provider’s order. c. Interviews conducted with facility leadership revealed the CIWA assessments which were not completed according to the Alcohol Withdrawal Assessment Scoring Guidelines were not identified upon review of Patient #2’s event. i. On 11/6/24 at 1:25 p.m., an interview was conducted with RN #2. RN #2 stated a provider placed orders for CIWA protocols when they determined a patient needed these assessments. RN #2 stated they were unaware of a CIWA policy at the facility. Additionally, RN #2 stated they had not received any CIWA training at the facility. RN #2 explained it was important for patients with alcohol withdrawal to be assessed and treated since alcohol withdrawal can lead to additional concerns such as falls and seizures. ii. On 11/6/24 at 2:30 p.m., an interview was conducted with the 8th floor medical surgical unit nurse manager (Manager) #4. Manager #4 explained they reviewed Patient #2’s medical record since the patient had experienced a code blue event on 7/6/24. Manager #4 stated they had not identified inconsistencies in neuro assessments and CIWA assessments. Manager #4 further explained staff may have received CIWA education if it was presented during the facility’s skills week or if the staff member was a newer nurse and was enrolled in the Specialty Nurse Advancement Program (SNAP). Manager #4 stated there was not a CIWA protocol policy at the facility, however, staff had access to Lippincott which held resources for clinical guidance. iii. On 11/12/24 at 10:31 a.m., an interview was conducted with director of quality (Director) #5. Director #5 stated the event with Patient #2 was sent to physician peer review and nurse peer review and the record was reviewed by facility leadership. Director #5 stated they reviewed the patient’s medical record however did not review the patient’s CIWA scoring and neuro assessments for accuracy. iv. On 11/5/24 at 1:20 p.m., an interview was conducted with the regional clinical risk and safety manager (Regional Manager) #7. Regional Manager #7 stated Patient #2’s record went through peer review as well as an external review of the patient’s course and care. Regional Manager #7 explained the review had identified potential inconsistencies with Patient #2’s neuro exam in regards to the Glasgow Coma Scale (a scale used to measure a patient’s level of consciousness). Regional Manager #7 stated it was determined that all nurses at the facility had the education and competency to perform CIWA assessments. This interview was in contrast with previous interviews in which staff stated they had not received CIWA education at the facility.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 42693 Based on record review and interviews, the facility failed to ensure nursing personnel provided nursing care to all patients as needed. Specifically, the facility failed to ensure patients were bathed and received oral care in three of three patient records reviewed who needed hygiene assistance on the medical surgical units (Patient #1, #8, and #9). Findings include: References: The Lippincott Bathing Procedure read, Performing a bed bath not only cleans a patient’s skin but also stimulates circulation, provides mild exercise, and promotes comfort. It also enables assessment of the condition of the patient’s skin, as well as joint mobility and muscle strength. Documentation associated with bed bath includes: the date and time of the bed bath, self-care abilities, and any unusual findings. The Lippincott Oral Care Procedure read, Oral care promotes patient comfort, nutritional intake, and oral health, and reduces dental plaque, oral colonization, and mucosal inflammation. Research shows that changes in oral bacterial colonization can occur within 48 hours of hospital admission. Aspiration of small droplets of secretions while sleeping can occur even in healthy adults from such causes as supine positioning and medications that suppress the central nervous system. Aspiration of small droplets does not usually cause pneumonia; however, in combination with decreased mobility and changes in oral colonization, patients are at an increased risk for infection due to organism growth in the respiratory tract. Without effective oral care, a patient can develop hospital-acquired pneumonia and other infections as well as reduced nutritional intake, which can increase mortality and hospital length of stay. Documentation associated with oral care includes the date and time of oral care. 1. The facility failed to ensure bathing and oral care were provided to patients needing assistance. A. Medical Record Review i. On 7/27/24 Patient #1 was admitted to the facility after a motorcycle crash. A review of the speech therapy notes revealed on 8/2/24, the speech therapist recommended oral care to be completed twice a day. On 8/3/24, Patient #1 was transferred from the ICU to the Neuro-Trauma unit. A review of Patient #1’s flowsheets revealed the patient had not received a bed bath or shower until 8/14/24, 11 days after admission to the Neuro-trauma unit. Additionally, Oral care was not documented until 8/14/24. On 8/16/24, Patient #1 received a shower and oral care. The next shower/bath the patient received was on 8/27/24, 11 days after the previous shower. ii. On 8/1/24 Patient #9 was admitted for a subdural hemorrhage (a collection of blood between the brain and skull) after a fall. A review of Patient #9’s flowsheets revealed on 8/5/24 the patient received a bed bath and oral care. On 8/14/24, Patient #9 received a shower, ten days after the previous bath/shower. iii. On 10/14/24 Patient #8 was admitted to the facility for a potential GI bleed. A review of Patient #8’s flowsheets revealed on 10/23/24 Patient #8 received a bed bath and oral care. On 10/28/24, Patient #8 received oral care and a shower, five days after the previous bath/shower. B. Interviews i. On 11/6/24 at 2:02 p.m., an interview was conducted with patient care technician (PCT) #10. PCT #10 stated a few of their assigned job duties were to assist patients with oral care and bathing. PCT #10 explained they tried to ensure patients received a shower or bed bath every other day. PCT #10 stated at times, PCTs may have 16 patients to care for, and in those situations, it was difficult to provide showers and baths to patients. PCT #10 explained it was important for patients to receive bathing and oral care to prevent skin and mouth issues. ii. On 11/6/24 at 1:49 p.m., an interview was conducted with PCT #11. PCT #11 stated some of their job duties were to assist patients with activities of daily living (ADLs), bathing, and taking vital signs, and bathing patients. PCT #11 explained there were typically two PCTs on the day shift on the 8th floor medical surgical unit, which was where they typically worked. PCT #11 further stated it was difficult to complete some tasks such as bathing when only two PCTs were staffed. PCT #11 explained that the expectation was for patients to receive a bed bath or shower every couple of days. They further explained this was important in order to provide dignity to patients and prevent skin issues. iii. On 11/6/24 at 2:11 p.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated the expectation was for patients to receive a shower or bed bath every other day. RN #3 explained bathing and hygiene assisted in preventing skin breakdown. iv. On 11/6/24 at 1:25 p.m., an interview was conducted with RN #2. RN #2 stated patients were expected to receive a bed bath or shower once a day. RN #2 stated it was important for patients to receive bathing in order to ensure the patient did not have any skin breakdown. v. On 11/12/24 at 12:00 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated bathing was to be offered to patients daily. They further explained if a patient refused a bed bath or shower, staff were to document the refusal in the patient’s record.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 42693 Based on interviews and record review, the facility failed to ensure staff followed protocols and assessed patients for a change in condition. Specifically, the facility failed to ensure the Clinical Institute Withdrawal Assessment (CIWA) protocol (clinical assessment used to diagnose the severity of alcohol withdrawal) was followed according to provider orders for alcohol withdrawal patients. This failure was identified in five of six patients reviewed with CIWA orders (Patients #2, #4, #5, #6, and #8). Findings include: References: The Lippincott Alcohol Withdrawal Management resources read, signs and symptoms of alcohol withdrawal can begin within six hours after the patient stops drinking and usually resolve in 24 to 48 hours. The patient initially experiences minor withdrawal signs and symptoms, including anorexia, nausea, anxiety, headache, insomnia, diaphoresis, tremulousness, and palpitations. Major motor seizures (alcohol withdrawal seizures) can also occur in the first 12 to 48 hours but rarely occur after that. Alcoholic hallucinations can develop 12 to 24 hours after the patient stops drinking and usually resolve in 24 to 48 hours. Delirium tremens (also called alcohol withdrawal delirium) - including hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis - usually begins 48 to 96 hours after the patient stops drinking and lasts one to five days. Healthcare professionals should be skilled in assessing and monitoring patients at risk for withdrawal signs and symptoms. If you know that the patient has a history of chronic alcohol use, using the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) assessment tool may help predict the severity of withdrawal symptoms. In addition to indicating withdrawal, a high score can predict whether seizures and delirium are likely to develop. The CIWA-Ar measures 10 signs and symptoms. The maximum score is 67. A patient who scores less than 10 usually does not require additional medication for withdrawal. The CIWA-Ar requires only about 5 minutes to administer. Orientation and clouding of sensorium - Ask “What day is this? Where are you? Who am I?” Score based on the observation as follows: 0 Oriented and can do serial additions; 1 Can’t do serial additions or is uncertain about the date; 2 Disoriented for date by no more than 2 calendar days; 3 Disoriented for date by more than 2 calendar days; Disoriented for place or person. Reassess the patient’s vital signs and condition frequently, as indicated by the withdrawal process. Patients with severe symptoms may require reassessment every 10 to 15 minutes. Use a facility-approved assessment tool to guide and evaluate the effectiveness of treatment. The facility’s Alcohol Withdrawal Treatment Order set (CIWA order set) read, CIWA Assessment - initiate assessments every six hours x 48 hours then per routine or if patient displays signs of withdrawal: If CIWA is 8 or greater - assess every one hour, then if CIWA is less than 8 x 3 consecutive assessments; assess every three hours x 3, then every six hours x 3, then per routine. If CIWA is 15 or greater for 3 consecutive assessments, contact the provider. The Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-ar) read, Procedure: 1. Assess and rate each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for “Orientation and clouding of sensorium” which is rated on a scale of 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (i.e.. start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater. 2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment Sheet. Document administration of PRN medications on the assessment sheet as well. 3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal. The assessment protocol from the Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment includes an initial vitals and CIWA assessment. If the initial score is greater than or equal to 8, repeat every hour for 8 hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If the initial score is less than 8, assess every four hours for 72 hours. If the score is less than 8 for 72 hours, discontinue the assessment. If the score is greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If indicated, administer prn medications as ordered and record on the medication administration record (MAR). A PowerPoint presentation used at the facility to educate newer nurses read, alcohol withdrawal symptoms (AWS) can escalate during sleep, assessments should not be deferred or omitted. Vital signs should be taken in conjunction with CIWA assessments. 1. The facility failed to ensure CIWA protocols were followed according to provider orders and guidelines. A. A review of medical records revealed gaps in the CIWA protocol being followed as ordered by the provider. i. On 7/5/24 Patient #2 arrived at the emergency department (ED) for hematemesis (vomiting blood). On 7/6/24 Patient #2 was then admitted to the 8th Floor medical surgical unit and CIWA protocol was ordered due to potential concerns of alcohol withdrawal. On 7/6/24 at 3:51 a.m., an admission assessment was documented by the registered nurse (RN). The RN documented under the neuro assessment they were unable to assess the patient’s orientation status. However, at that same time, the patient status under orientation in the CIWA assessment was documented as oriented and able to do serial additions. The total CIWA score was 7. At 7:25 a.m., a shift assessment and CIWA assessment were completed. The patient’s orientation was documented as unable to be assessed. However, the patient’s orientation under the CIWA assessment was noted as oriented and able to do serial additions. The total CIWA score was 8. The CIWA assessments were in contrast to the neuro assessments which could have caused an inaccurately low CIWA score. At 8:25 a.m. a CIWA assessment was completed with a score of 6. The next CIWA assessment was completed at 10:00 a.m., 1 hour and 35 minutes later. This was in contrast to the CIWA order set which read if the score was greater or equal to 8, reassessments should occur every hour for three hours. Since Patient #2’s CIWA score was 8 at 7:25 a.m., this required a reassessment a CIWA assessment at 9:25 a.m. ii. On 10/18/24 Patient #6 was admitted to the facility and CIWA protocol was ordered. At 12:48 p.m., a CIWA assessment was completed and the patient’s score was 18. The next CIWA assessment was done at 2:42 p.m. (almost two hours later). At 9:27 p.m., a CIWA assessment was completed and the score was 11. The next documented CIWA assessment was on 10/19/24 at 12:00 a.m. which read a CIWA score of 0 and that the patient was sleeping. On 10/19/24 at 8:55 p.m., a CIWA assessment was completed and the score was 20. The next CIWA assessment was on 10/20/24 at 12:00 a.m., three hours later. The assessment read the score was 0 and the patient was asleep. This was in contrast to the facility’s staff education which read, alcohol withdrawal symptoms (AWS) can escalate during sleep, and assessment should not be deferred or omitted. On 10/20/24 at 9:56 a.m., a CIWA assessment was completed with a score of 24. The next CIWA assessment was completed at 1:12 p.m., over three hours later. The score at that time was 29. The next CIWA assessment was completed at 3:44 p.m., over two hours later, and the score was 13. Another CIWA assessment was done at 7:50 p.m., almost four hours later, and the score was 18. This was in contrast to the CIWA order set which read, if the score was greater or equal to 8, reassessments should occur every hour for three hours. On 10/21/24 at 8:30 a.m., a CIWA assessment was performed and the score was 15. The next CIWA assessment was completed at 12:12 p.m., over three hours later, with a result of 19. The next CIWA assessment was completed at 2:10 p.m., almost two hours later, and the score was 16. There was no evidence the provider was notified of the CIWA scores during this time period. This was in contrast to the CIWA order set which read if CIWA was 15 or greater for 3 consecutive assessments, contact provider. Additionally, the CIWA assessments were to be completed every hour for three hours as ordered by the provider. iii. On 10/29/24 Patient #5 was admitted to the facility and CIWA protocol was ordered by the provider. On 10/29/24 at 3:21 p.m., a CIWA assessment was completed and the score was 10. The next CIWA assessment was not completed until 6:58 p.m., over three hours later. On 10/30/24 at 9:57 a.m., a CIWA assessment was completed and the score was 20. The next CIWA assessment was not completed until 3:40 p.m., over five and a half hours later. This was in contrast to the CIWA order set which read, if the score was greater or equal to 8, reassessments should occur every hour for three hours. Similar findings of the CIWA protocol not being followed were identified in Patient #4 and Patient #8’s records. B. A review of the facility’s alcohol withdrawal order set and the alcohol withdrawal assessment scoring guidelines revealed contradictions. i. The Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment included an initial vitals and CIWA assessment. If the initial score was greater than or equal to 8, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours then if stable, every four hours. If the initial score was less than 8, assess every four hours for 72 hours. If the score was less than 8 for 72 hours, discontinue the assessment. If the score was greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. ii. The facility’s Alcohol Withdrawal Treatment Order set (CIWA order set) read, CIWA Assessment - initiate assessments every six hours x 48 hours then per routine or if patient displays signs of withdrawal: If CIWA was 8 or greater - assess every one hour, then If CIWA was less than 8 x 3 consecutive assessments; assess every three hours x 3, then every six hours x 3, then per routine. If CIWA was 15 or greater for 3 consecutive assessments, contact the provider. The facility’s order set was inconsistent and less stringent with the time frames and frequencies required from the CIWA Scoring Guidelines for when a patient should have been reassessed. C. Interviews i. On 11/4/24 at 2:30 p.m. an interview was conducted with registered nurse (RN) #1. RN #1 stated if a patient had orders for CIWA, a CIWA assessment was to be completed at the beginning of the shift and then every one to two hours. RN #1 further explained if the patient’s CIWA score was 0-2 for some assessments, the CIWA scoring only needed to be done once a shift. RN #1 explained when a patient was on CIWA assessments, the provider would place an order for this assessment. ii. On 11/6/24 at 1:25 p.m., an interview was conducted with RN #2. RN #2 stated a provider placed orders for CIWA protocols when they determined a patient needed these assessments. RN #2 stated they were unaware of a CIWA policy at the facility. Additionally, RN #2 stated they had not received any CIWA training at the facility. RN #2 explained it was important for patients with alcohol withdrawal to be assessed and treated since alcohol withdrawal could lead to additional concerns such as falls and seizures. iii. On 11/6/24 at 2:11 p.m., an interview was conducted with RN #3. RN #3 stated they had worked on the neuro-trauma unit at the facility for about one year. RN #3 stated they had received training on CIWA when they were orienting with a preceptor. RN #3 stated when a patient was on CIWA, the protocol was ordered by the provider. RN #3 stated it was important for the CIWA protocol to be followed in order to track if a patient was exhibiting worsening withdrawal and potentially administer medications as ordered.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.43, Discharge Planning, was out of compliance. The standard level deficiency determined out of compliance was §482.43(b) Discharge Planning Evaluation (A-0806): The discharge planning evaluation must include an evaluation of the likelihood of a patient’s capacity for self-care. Findings under the standard level deficiency are as follows: Based on interviews and document review, the facility failed to implement discharge planning recommendations to ensure post-hospital care needs were met. Specifically, the facility failed to ensure a patient was safe to be discharged home in accordance with facility policy. This failure was identified in one of six patients (Patient #3). Findings include: Facility policies: According to the Discharge Planning policy, healthcare professionals should collaborate to ensure that each patient has a plan for continuing care during the transition into the community and thereafter. The components of discharge planning ensure that the patient is appropriate for discharge/ transition to a lower level of care with the provision of appropriate and available resources and services upon discharge to meet the needs for continuity of care. The implementation of a safe discharge plan reduces the likelihood of a hospital readmission and provides for appropriate and available resources and services to meet the patients’ needs for continuity of care. According to the Fall Prevention and Post Fall Management policy, factors assessed in fall risk include medications, substance use, gait, transferring and ambulatory aids, secondary diagnoses, and factors that may predispose a patient to fall. High fall risk patients with a Morse (an assessment used to determine a patient’s likelihood of falling) greater than or equal to 50 require a continuous physical presence, within arms reach of the patient, during toileting. 1. The facility failed to ensure a patient was safe to be discharged home according to facility policy. A. Document review i. A review of Patient #3’s medical record revealed Patient #3 was a now deceased 71-year-old admitted on 3/14/24 for an ankle fracture (break in the bone) after a fall. Patient #3 had a medical history of heart failure, respiratory (breathing) failure, diabetes mellitus (blood sugar imbalance), obesity (excessive fat deposits), and chronic pain. The admitting physician’s note revealed the physician believed Patient #3’s use of opioids (narcotic pain medications) and poorly controlled blood sugar had contributed to the fall. The discharge planning notes by multiple case managers throughout Patient #3’s stay revealed the patient had been on hospice before arriving at the facility and was going to be discharged home on hospice, however, the patient refused and staff sought placement in a skilled nursing facility (SNF). Case management notes on 3/25/24 revealed Patient #3’s insurance had refused SNF placement and the facility was not able to resubmit the request for authorization until 4/1/24. The case management notes on 3/25/24 further revealed the patient had “agreed” to return home. A nursing note entered by registered nurse (RN) #3 on 3/26/24 at 9:28 a.m. (eight hours and eight minutes before discharge), revealed Patient #3 scored 85 on the Morse Fall Risk Assessment, placing them at a high risk for falls, and nursing interventions were implemented which included supervision with ambulation and assistance with toileting. Physical therapist (Therapist) #1 assessed Patient #3 on 3/26/24 at 4:15 p.m., the day of discharge, and documented Patient #3 required assistance with ambulation (walking), transferring, and toileting. Therapist #1 described Patient #3 to be at an elevated risk for falls with a risk of additional injuries. Therapist #1’s note revealed insurance would not cover SNF placement and recommended the patient be supervised if they returned home. Therapist #1 also included the patient was not to bear weight on their right leg and foot. Additionally, Therapist #1 added Patient #3’s safety awareness was decreased due to balance, medical status, strength, range of motion (ROM), and decreased insight. Physician #5’s note from 3/25/24 at 9:03 p.m. revealed Patient #3 was waiting on a “safe discharge” to a skilled nursing rehabilitation facility. However, on 3/26/24 at 5:59 p.m., the day of discharge, Physician #5 wrote Patient #3 was “agreeable” to discharging home since their insurance would not cover SNF placement, although this patient was at a high risk for readmission due to insurance delays. They also wrote the patient would have support at home three times a day from a private caregiving company. Physician #5 wrote Patient #3 was not able to receive home health services as they were not yet established with a primary care physician (PCP) and their PCP appointment was to be scheduled “as soon as possible” (scheduled nine days later on 4/4/24), to receive care at home. The discharge medication list revealed Physician #5 discharged Patient #3 home on multiple medications, including Fentanyl (a narcotic pain medication), Oxycodone (a narcotic pain medication), and Temazepam (a medication used for sleep) to assist in the transition of care. Patient #3’s discharge home on 3/26/24 was in contrast to the 3/25/24 physician notes, nursing notes, and physical therapy notes which revealed Patient #3 had an impaired ability to care for themselves, they were at higher risk of physical harm without adequate supervision, and they ultimately required SNF placement to ensure proper care and a safe discharge. This was also in contrast to the Discharge Planning policy which read, healthcare professionals should collaborate to ensure each patient had a plan for continuing care during the transition into the community and thereafter. The components of discharge planning ensured the patient was appropriate for discharge to a lower level of care with the provision of appropriate and available resources and services upon discharge to meet the needs for continuity of care. The implementation of a safe discharge plan provided for appropriate and available resources and services to meet the patients’ needs for continuity of care. B. Interviews i. An interview was conducted on 5/13/24 at 2:04 p.m. with Therapist #1. Therapist #1 stated when they assessed patients for discharge, they conducted different balance tests and identified fall risk through a score used to evaluate patients’ safety. Therapist #1 stated if the patient lived alone, they would determine the level of assistance a patient required. Therapist #1 also stated if a patient required two people to assist with mobility, it was not safe to discharge the patient home. Therapist #1 stated they informed Physician #5 that Patient #3 required someone present to physically assist them if they discharged home. Therapist #1 stated they did not recommend Patient #3 to be discharged home alone. Therapist #1 stated Patient #3 had difficulty transferring to the bedside commode and was unable to toilet independently. Therapist #3 stated they were unsure how Patient #3 would have managed care at home without assistance. Therapist #1 stated they were recently made aware Patient #3 had passed away shortly after being discharged home. ii. An interview was conducted on 5/15/24 at 9:01 a.m. with care coordinator RN #7. RN #7 stated they assisted Physician #5 with discharge planning. They stated Patient #3’s insurance would not cover SNF placement until 4/1/24. RN #7 stated some patients did remain at the hospital while they waited for placement and Patient #3’s insurance may have covered the physician-recommended placement to a SNF in April, but felt Patient #3 did not want to wait on insurance. RN #7 stated Patient #3 did not have a PCP, which was necessary to set up home health care, so RN #7 helped to set up a PCP appointment on 4/4/24, nine days after discharge. RN #7 stated it was Patient #3’s choice to leave the facility to return home, although now, RN #7 did not consider this an ideal discharge. RN #7 stated they were aware the care team believed Patient 3 should have been discharged to a SNF or had skilled nursing available. They stated Patient #3 had a family member who was going to help provide home care and supervision. They also stated they were not sure if this family member had been involved in the care decisions while at the facility, if they knew of the patient’s needs, or if they were involved in the discharge planning process. RN #7 stated at the time of discharge, the patient was on many sedating (sleep-inducing) medications. They stated the medications Fentanyl and Oxycodone were opioid pain medications and the medication Temazepam was used for sleep. RN #7 stated these medications, when taken together, created an increased risk for respiratory depression (inadequate breathing), confusion, and loss of balance. RN #7 stated Patient #3 did not have an ideal discharge when they were discharged home, without skilled nursing assistance or being discharged to a SNF. iii. An interview was conducted with RN #3 on 5/13/24 at 3:32 p.m. RN #3 stated they had cared for Patient #3 and Patient #3 had difficulty with ambulation and transfers. They stated Patient #3 scored high on the Morse Fall Risk Assessment which meant the patient would probably fall. They stated they were present while Physician #5 and Patient #3 had a conversation about disposition (placement) on the day of discharge, and while Patient #3 did not refuse to leave, Patient #3 did not want to go home. RN #3 stated Patient #3 was discharged home due to insurance’s refusal to cover Patient #3’s stay. RN #3 stated they were unsure if this was a safe discharge for Patient #3. They stated discharging home put Patient #3 at risk for falls with the inability to get themselves back up, failure to thrive (a state of decline with decreased ability and increased health concerns), and a risk of hospital readmission. iv. An interview was conducted on 5/13/24 at 2:21 p.m. with case manager (CM) #2. CM #2 stated they should follow the recommendations of physical and occupational therapies and the instruction of the patient’s physicians to ensure a safe discharge. CM #2 stated physicians had the final say on when and where a patient would be discharged. CM #2 stated it was important for patients to be discharged appropriately to ensure patient safety and for patients to succeed at home without the need to be readmitted. This was in contrast to the medical record which revealed CM #2 had met with Patient #3 on 3/26/24 to discuss Patient #3 discharging home with support after insurance did not authorize SNF placement until after 4/1/24. CM #2 stated Patient #3 agreed to be discharged home and had support from private caregivers, although they did not know what level or frequency of care that entailed. v. An interview was conducted on 5/15/24 at 10:02 a.m. with Physician #5. Physician #5 stated they evaluated Patient #3 while they waited to be discharged to a SNF. Physician #5 stated they decided to discharge Patient #3 home due to insurance issues. Physician #5 stated Patient #3 needed to see a PCP to receive assistance from home health nurses, and they had set up an appointment with a PCP for Patient #3 as soon as possible. Physician #5 stated Patient #3 was discharged home with a front-wheeled walker, and required one-person assistance to safely use the walker because they were a high fall risk. Physician #5 stated it was important for Patient #3 to be discharged home with someone to assist them because they were at high risk for falls. Physician #5 stated they called Patient #3’s family member as a courtesy to inform them of the upcoming discharge and requested the family member keep an eye on the patient. Physician #5 stated as Patient #3 was cognitively aware, this call was only to inform the family, not to ensure the family member would be able to supervise the patient upon discharge. Physician #5 stated Patient #3 was taking high doses of narcotics, Fentanyl and Oxycodone, and the medication Temazepam upon coming to the facility and Physician #5 was concerned that there was an elevated risk for unsafe medication interactions. Physician #5 stated there was a risk of mixing opioids (narcotic pain medications) with high doses of long-acting benzodiazepines (a medication used for anxiety that slows down activity in the brain and causes sedation). Physician #5 stated they discharged Patient #3 home with a 30-day supply of narcotic pain medications to assist in the transition of care. Physician #5 stated discharging Patient #3 home on sedating medications put Patient #3 at risk for decreased balance and respiratory depression. Provider #5 stated the medical record indicated Patient #3 was deceased, although they were unsure how they had died. Physician #5 stated Patient #3 should have been discharged to a SNF, which was the best placement option for them.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, Nursing Services, was out of compliance. A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policies. Specifically, the facility failed to ensure registered nurses (RNs) assessed cardiac patients according to facility policy in one of three medical records reviewed (Patients #1). Additionally, staff failed to assess patients according to both facility policy and physician orders after the administration of scheduled medications in two of three medical records reviewed (Patients #1 and #3).”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50313 Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policies. Specifically, the facility failed to ensure registered nurses (RNs) assessed cardiac patients according to facility policy in one of three medical records reviewed (Patient #1). Additionally, staff failed to assess patients according to both facility policy and physician orders after the administration of scheduled medications in two of three medical records reviewed (Patients #1, and #3). Findings include: Facility policy: According to the Assessment Timeframes by Department policy, patients in the intermediate care unit (MCU), will receive an assessment twice in a twelve-hour period, and PRN (as needed) if their condition changes. Patients on the telemetry unit and Med/Surg (medical surgical) unit will receive a full assessment once in a twelve-hour period and focused assessments as needed based on the patient’s condition. 1. The facility failed to ensure patients were assessed according to facility protocol and policies. A. Record review i. A review of Patient #1’s medical record revealed on 12/21/23 the patient was admitted from the emergency department to the MCU (intermediate care unit) for a diagnosis of AFib RVR (an irregular heartbeat where the electrical signaling in the heart is disorganized and causes parts of the heart to beat out of sync). According to the History and Physical, the provider examined Patient #1 during morning rounds on 12/22/23. The provider documented that Patient #1 would be taking oral diltiazem (a medication that relaxes the blood vessels in the body and lowers heart rate and blood pressure) four times daily starting on 12/22/23, with a plan to monitor Patient #1’ s heart rate to ensure the rate stayed controlled without hypotension (abnormally low blood pressure). A provider’s order was written for diltiazem 90 milligrams (mg) four times a day. The order also included instructions to monitor Patient #1’s heart rate and blood pressure and to hold the medication if the heart rate dropped below 60 beats per minute, or if the systolic (the top number in a blood pressure that measures the pressure in the arteries) blood pressure dropped below 100. The provider’s order instructed the RN to reassess Patient #1’s heart rate and blood pressure within two hours after a held dose of medication. If the heart rate and blood pressure were above 60 beats per minute or 100 systolic, the medication was to be administered. If the heart rate was below 60 beats per minute or 100 systolic, the RN was to contact the provider. Further review of Patient #1’s nursing flowsheet revealed a nurse administered an initial dose of oral diltiazem 90 mg at 10:27 a.m., with Patient #1’s heart at 91 beats per minute and blood pressure at 114/78. There was no evidence that nursing staff held or administered the remaining three doses of diltiazem ordered for Patient #1 on 12/22/23. From 10:27 a.m. to 7:00 p.m., there was no evidence that staff obtained Patient #1’s heart rate or blood pressure to determine if the medication was effective or if the provider should be contacted for vital signs out of the range specified in the provider order. This was in contrast to provider’s order which instructed to administer diltiazem four times daily and to assess the patient’s heart rate and blood pressure before and after the medication was administered. At 7:00 p.m. staff found Patient #1 unresponsive, in asystole (a type of cardiac arrest where the heart stops beating completely). Staff called a code blue (a code used to indicate a patient required resuscitation) and CPR (cardiopulmonary resuscitation) was initiated. After approximately twelve minutes of CPR, a return of spontaneous circulation was achieved. Patient #1 was transferred to the intensive care unit (ICU) and subsequently died on 12/23/23 at 2:59 a.m., after a second cardiac arrest. An additional review of Patient #1’s flowsheets revealed on 12/22/23, the day shift (7:00 a.m. to 7:00 p.m.) nurse completed a full assessment on Patient #1 at 9:08 a.m. From 9:08 a.m. until 7:00 p.m., when the code blue was called, there was no evidence a second full nursing assessment was performed on Patient #1. This review was in contrast to the Assessment Timeframes by Department policy which read patients in the intermediate care unit (MCU), were to receive an assessment twice in a twelve-hour period, and PRN (as needed) if their condition changed. ii. A review of Patient #3’s medical record revealed on 3/9/24 the patient was admitted from the emergency department to the cardiac unit with the following diagnoses: atrial flutter with rapid ventricular response (an irregular heart rhythm causing the upper chambers of the heart to beat rapidly), cardiomyopathy (a disease that makes it harder for the heart to pump blood), and AICD (a device that can detect a life-threatening, abnormal heartbeat and deliver a shock) discharge. A further review of Patient #3’s medical record revealed on 3/10/24 the provider ordered an intravenous (IV) infusion of amiodarone 360 mg in D5W 200 milliliters (mL) (a medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias). The provider’s order for amiodarone included an order to monitor Patient #3’s blood pressure at baseline, then every 15 minutes for one hour, then every hour for four hours, then per unit standard of care. A review of nursing flowsheets revealed a nurse started the amiodarone IV infusion 3/10/24 at 12:42 p.m. Staff documented that Patient #3’s blood pressure was 98/57 at 12:45 p.m., 85/50 at 1:00 p.m., 97/54 at 1:15 p.m., 102/60 at 1:00 p.m. At 2 p.m., Patient #3’s blood pressure was 102/69. At 4:46 p.m., Patient #3’s blood pressure was 99/61. There was no evidence that staff measured Patient #3’s blood pressure from 2:00 p.m. until 4:46 p.m. (a period of two hours and 46 minutes) while the Amiodarone was infusing. This was in contrast to the provider order which stated to obtain Patient #3’s blood pressure every hour for four hours (after the initial blood pressure was obtained at 15-minute increments for an hour). B. Interviews i. An interview was conducted on 3/11/24 at 1:01 p.m. with certified nursing assistant (CNA) #2. CNA #2 stated CNAs answered call lights, took the patient’s blood pressure and other vital signs (heart rate, respiratory rate, and temperature), and conducted patient checks. CNA #2 stated the RNs and CNAs would alternate checking on patients every hour. CNA #2 stated it was important to make sure patients were taken care of and to check on patients constantly. An additional interview was conducted on 3/12/24 at 3:45 p.m. with CNA #2. CNA #2 stated they would only check a temperature as part of vital signs on patients admitted in MCU rooms, because those patients would have been monitored automatically from monitoring equipment in the room for blood pressure, heart rate, and oxygen saturation. CNA #2 stated it was important to check vital signs, including blood pressure because a patient’s condition could change. CNA #2 stated a patient’s blood pressure could become too high or too low. CNA #2 stated all vital signs should have been documented in the patient’s chart. CNA #2 stated it was important to check telemetry leads because an issue with telemetry monitoring might mean the patient did not have a heart rate. CNA #2 further stated the risk of not monitoring a patient could be death. ii. An interview was conducted on 3/11/24 at 5:00 p.m. with RN #6. RN #6 stated nurses should have completed a full assessment once per shift for patients admitted to a regular telemetry bed, with reassessments throughout the shift. RN #6 stated patients admitted under MCU status should have received two or more full assessments. RN #6 stated patient assessments were important to relay information to the physician and to identify changes in patient condition. RN #6 stated physicians would order increased frequency of vital sign monitoring with certain cardiac medications including amiodarone and diltiazem. RN #6 stated it was important to monitor vital signs when giving cardiac medications because these medications could have impacted the patient’s heart rhythm and rate. RN #6 stated the risk of not monitoring a patient’s vital signs would be missing a cardiac event, or changes in a patient’s heart rhythm. iii. An interview was conducted on 3/14/24 at 8:42 a.m. with the cardiac unit clinical nurse manager (RN) #3. RN #3 stated nurses should have completed one head-to-toe assessment per twelve-hour shift if the patient was admitted to the telemetry unit. RN #3 stated nurses should have completed two head-to-toe assessments in a twelve-hour shift if the patient was admitted to the MCU. RN #3 stated the protocol on the cardiac unit was for nurses to obtain vital signs at the beginning of the 12-hour shift, and then the CNA would obtain vital signs at 12:00 p.m. and 4:00 p.m. RN #3 stated the protocol for patients admitted in the MCU was for nurses to obtain vital signs at least every two hours, if not more per physician orders. RN #3 stated it was important to assess patients, and obtain vital signs, to provide early intervention for any subtle changes in patient condition. RN #3 stated it was important to follow physician orders for vital signs because some cardiac medications could have caused immediate changes in blood pressure and heart rate. RN #3 stated not monitoring vital signs could have led to a significant drop, or elevation, in a patient’s heart rate or blood pressure. RN #3 stated it was important to monitor vital signs to know if a medication was effective. RN #3 stated not monitoring a patient according to department guidelines or physician orders was a risk to patient safety. iv. An interview was conducted on 3/14/24 at 10:22 a.m. with physician (Physician) #4. Physician #4 stated they would not have been aware of changes in a patient’s condition unless the nurses were assessing the patient frequently. Physician #4 stated nurses should have followed physician orders for monitoring a patient when administering cardiac medications. Physician #4 stated it was important to monitor and assess patients in the cardiac unit to identify clinical changes earlier and because patients’ clinical status could have changed rapidly. Physician #4 stated the risk of not monitoring patients would be a change in heart rhythm, weakness, or loss of consciousness. v. An interview was conducted on 3/12/2024 at 11:25 a.m. with director of quality (Director) #1. Director #1 stated nurses should have assessed patients in the cardiac units following the MCU assessment guidelines if the patient was admitted to the MCU. Director #1 stated nurses should have assessed under medical surgical assessment guidelines if the patient was admitted to a regular room in the cardiac unit.”