HCA Healthone Rose

“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: 52761 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 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 interviews and documents reviewed, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients as needed, in accordance with the facility’s nurse staffing plan. A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document reviews, the facility failed to ensure patients in the intensive care unit (ICU) with Impella devices (a mechanical pump inserted into the heart that takes over the functions of the heart while the heart rests and recovers) were assessed according to physicians’ orders. This failure was identified in two of two ICU patients reviewed with Impella devices. (Patient #2 and #4)”

“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: 52761 Based on interviews and documents reviewed, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients as needed, in accordance with the facility’s nurse staffing plan. Findings include: Facility policies: The Adult Intensive Care Unit (ICU) Scope of Services policy read, nursing care shall be provided to patients with life-threatening conditions that require continuous assessment. The goals of patient-centered care include continuous assessment and prompt intervention by the registered nurse (RN); and to match the patient’s needs with the proper level of care of service while attending to the resources that are available and appropriate for the presenting and co-morbid conditions. The Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy read, reassessments shall be completed every four hours. If the ICU patient has skin issues, the RN shall assess skin condition every four hours. The RN shall conduct assessments of the skin condition and pain of the medical level of care patient (patient who does not require high-level observation, however, still requires hospital care) every shift. Reference: The staffing plans, which were identified by staff as the facility’s staffing matrices, were provided by the facility. The staffing plans listed the name of each unit at the facility, specified the variable patient census range for each unit, and the specified number of RNs expected to be staffed and present on each unit according to the current patient census. 1. The facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed RNs to provide nursing care to all patients as needed. A. Document Review i. Review of Patient #6’s medical record revealed Patient #6 presented to the facility on 1/7/26 at 10:33 p.m. with concerns for aspiration (when foreign materials are breathed into the airway and lungs) and a blood oxygen saturation (SpO2) (measures the percentage of oxygen in the blood) level of 64% (normal 95-100%) on room air. Despite being placed on heated high flow nasal cannula (a heated and humidified system that delivers heated oxygen at very high rates), Patient #6 remained hypoxic (a state when there is insufficient oxygen in the blood) with an SpO2 of 89-90%. A physician’s note from 1/8/26 at 1:18 a.m. revealed a diagnosis of aspiration pneumonia (a lung infection caused by inhaling foreign material). The note also revealed Patient #6 required transfer to the ICU for critical care interventions, due to the risk for further decompensation and clinical instability. Patient #6 was transferred to the ICU on 1/8/26 at 2:00 a.m. Patient #6’s medical record also revealed Patient #6 had wounds to their bilateral lower legs. However, Patient #6’s medical record review failed to reveal nursing assessments of these wounds on 1/17/26 at 12:00 a.m., 4:00 a.m., or 8:00 a.m. This was in contrast to the Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy, which revealed the RN was to assess skin condition every four hours if the ICU patient had skin issues. Patient #6 received medical level of care status orders on 1/17/26 at 8:36 a.m. Patient #6’s medical record further failed to reveal a wound or pain assessment conducted during the day shift on 1/17/26. This was in contrast to the Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy, which revealed the RN was to conduct assessments of the skin condition and pain of the medical level of care patient every shift. a. Review of the 1/16/26 ICU staffing assignment sheet revealed, on the shift of Patient #6’s three absent wound assessments, the night shift census was 15 patients. There were six RNs assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of 15 patients, there would be eight RNs. Furthermore, three of the RNs were assigned three ICU level patients each, and one RN was assigned one ICU level patient and two telemetry level of care patients (a patient who does not require high-level observation, however, still requires hospital care). Patient #6 was cared for by an RN who was assigned three ICU level patients. b. Review of the 1/17/26 ICU staffing assignment sheet revealed, on the shift of Patient #6’s absent wound and pain assessment, the day shift census was 15 patients. There were six RNs assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of 15 patients, there would be eight RNs. Furthermore, one of the RNs was assigned one telemetry level of care patient and two ICU level patients, one RN was assigned one medical level of care patient and two ICU level patients, one RN was assigned two ICU level patients and one medical level of care patient, and one RN was assigned three patients. Patient #6, a medical level of care patient, was cared for by an RN who was assigned two other ICU level patients. ii. ICU staffing assignments sheets were further reviewed and revealed minimum staffing requirements were not maintained. a. On 1/5/26, the night shift census was 12 patients. There were four RNs and one charge RN assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of 12 patients, there would be six RNs and one charge RN. Furthermore, one of the RNs was assigned three ICU level patients and one medical level of care patient, one RN was assigned three ICU level patients, and the charge RN was assigned one medical level of care patient. b. On 1/17/26, the night shift census was 14 patients. There were six RNs assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of 14 patients, there would be seven RNs. Furthermore, one RN was assigned three ICU level patients, and another RN was assigned two ICU level patients and one medical level of care patient. c. On 1/18/26, the day shift census was nine patients. There were four RNs assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of nine patients, there would be five RNs. Furthermore, two of the RNs were assigned three ICU level patients each. d. On 1/26/26, the night shift census was six patients. There were two RNs assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of six patients, there would be three RNs. Furthermore, both RNs were assigned three patients each. e. On 2/3/26, the day shift census was 14 patients. There were 5 RNs assigned to these patients. This was in contrast to the ICU staffing plan which read, for a census of 14 patients, there would be seven RNs. Furthermore, two of the RNs were assigned three ICU level patients each. B. Interviews i. Between 2/4/26 to 2/11/26, interviews were conducted with facility staff. a. In an interview conducted with RN #1, RN #1 stated the ICU was frequently short staffed according to the staffing matrix, which often led to RNs being assigned three critically ill patients. RN #1 explained risks associated with inadequate staffing included a lack of time to thoroughly assess patients, which could prevent the RN from identifying abnormalities or potential complications in a timely manner. Additionally, RN #1 stated it was challenging to ensure patients received all necessary nursing interventions and hygiene care when the unit was short staffed. Furthermore, RN #1 explained they were uncomfortable voicing concerns about unsafe patient assignments or staffing to leadership. RN #1 stated their concerns were negatively met or ignored by leadership. This was in contrast to the Adult ICU Scope of Services policy, which revealed it was a goal to match the patient’s needs with the proper level of care of service while attending to the resources that were available and appropriate for the presenting and co-morbid conditions. b. In an interview conducted with house supervisor (Supervisor) #5, Supervisor #5 stated the staffing matrix was used for normal day to day operations. Supervisor #5 explained the surge plan was a staffing system separate from the staffing matrix. The surge plan was used to determine safe patient assignments when the facility was at capacity. Upon request, the facility was unable to provide a separate surge plan. Rather, the facility stated the staffing matrix and the surge plan were the same. c. In an interview conducted with Director #6, Director #6 stated charge RNs were not assigned patients because they needed to be available as a resource to ICU RNs and to attend hospital emergencies such as code blues (critical situation when a person stops breathing or their heart stops beating). This was in contrast to a review of the ICU staffing assignments sheet for the night shift on 1/5/26, which revealed the charge RN was assigned to care for one patient. Additionally, Director #6 stated nurses’ assignments were switched to ensure the nurses who cared for three patients did not have an ICU level patient as a third patient. This was in contrast to a review of the ICU staffing assignments sheets from the night shifts on 1/5/26 and 1/16/26, day and night shifts on 1/17/26, and day shifts on 1/18/26 and 2/3/26, which revealed RNs were assigned to care for more than one ICU level patient. Director #6 stated if an RN had concerns about an unsafe assignment or staffing, they should have voiced their concerns to a leadership member. The leadership member should have then provided support or adjusted the assignment to ensure patient safety. This was in contrast to an interview conducted with RN #1, who stated their concerns were not met with support or change. d. In an interview conducted with charge RN (RN) #4, RN #4 stated the charge RN was occasionally assigned up to two patients due to short staffing. This was in contrast to the interview conducted with Director #6, which revealed the charge RN should not have been assigned patients.”

“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: 52761 Based on interviews and document reviews, the facility failed to ensure patients in the intensive care unit (ICU) with Impella devices (a mechanical pump inserted into the heart that takes over the functions of the heart while the heart rests and recovers) were assessed according to physicians’ orders. This failure was identified in two of two ICU patients reviewed with Impella devices. (Patient #2 and #4) Findings include: Facility policies: The Adult ICU Scope of Services policy read, nursing care shall be provided to patients with life-threatening conditions that require continuous assessment. The goals of patient-centered care include continuous assessment and prompt intervention by the registered nurse (RN). The Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy read, vital signs shall be assessed every one hour and as needed. The Swan-Ganz catheter (a device inserted into the heart that continuously monitors heart function, blood flow, and pressures in real-time) position shall be measured once a shift and as needed. The initial insertion position shall be documented in the medical record. 1. The facility failed to ensure ICU patients with Impella devices were assessed according to physicians’ orders. A. Document Review i. Review of Patient #2’s medical record revealed Patient #2 presented to the facility on 1/29/26 at 8:23 p.m. with chest pain and shortness of breath. At 10:49 p.m., Patient #2 was emergently taken to the catheterization laboratory (cath lab) (a specialized unit where cardiologists perform tests and procedures to diagnose and treat heart conditions). Invasive coronary angiography (a procedure used to visualize heart arteries for blockages) revealed Patient #2 had a thrombotic occlusion (when a blood clot blocks a blood vessel) and severe multivessel coronary artery disease (a critical condition with significant blockage in two or more major arteries that supply blood to the heart, limiting oxygen flow to the heart) with elevated filling pressures (high pressure within the heart chambers when the heart fills with blood). An Impella was inserted into Patient #2’s right femoral artery (the main artery in the groin that supplies oxygenated blood to the lower leg). A Swan-Ganz catheter was inserted into Patient #2’s left femoral artery. The procedure ended on 1/30/26 at 2:12 a.m., and Patient #2 was transferred to the ICU for continued monitoring and treatment. At 2:07 a.m., the cardiologist placed orders for the RN to perform hourly assessments of the Impella insertion site. This was in contrast to Patient #2’s medical record review, which failed to reveal evidence of insertion site assessments completed by the RN. The cardiologist also placed orders for the RN to perform vital sign assessments every 15 minutes for one hour, and then every 30 minutes for two hours, followed by hourly vital sign assessments for four hours. Neurovascular assessments (assesses sensory and motor function, as well as blood circulation) were ordered to be completed with vital sign assessments. Review of the Post Endovascular Assessment Form (used by RNs to record patients’ vital signs, neurovascular assessments, and interventions for patients following return from the cath lab) in Patient #2’s medical record revealed neurovascular assessments were to begin at 2:30 a.m., and were to include assessments of swelling, bleeding, pressure, pain, distal extremity (lower leg) warmth, color, pulses, and sensation. This was in contrast to Patient #2’s medical record review, which revealed one neurovascular assessment performed at 4:29 a.m., two hours and 19 minutes after Patient #2’s arrival to the ICU, and failed to reveal evidence of ongoing neurovascular assessments. This was in contrast to the Adult ICU Scope of Service policy, which revealed nursing care was to be provided to patients with life-threatening conditions that required continuous assessment. The goals of patient-centered care included continuous assessment by the RN. Additionally, At 2:07 a.m., the cardiologist placed orders for the RN to complete the Impella Hourly Monitoring Flowsheet (used by RNs to record Impella device function, factors related to blood clotting medication, assessment of the Impella catheter, and complications related to bleeding). This was in contrast to review of Patient #2’s medical record, which failed to reveal evidence of completion of the Impella Hourly Flowsheet. Further review of Patient #2’s medical record failed to reveal evidence of assessment of the Swan-Ganz catheter position. This was in contrast to the Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy, which revealed the Swan-Ganz catheter position was to be measured once a shift and as needed, and the initial insertion position was to be documented in the medical record. Patient #2 was transferred to an outside hospital for Extracorporeal Membrane Oxygenation (ECMO) (a mechanical pump that circulates blood through an artificial lung back into the bloodstream while the heart and lungs rest and recover) on 1/30/26 at 9:09 a.m. ii. Review of Patient #4’s medical record revealed Patient #4 presented to the facility on 10/24/25 at 10:14 a.m. following a cardiac arrest (when the heart suddenly stops pumping). At 11:06 a.m., Patient #4 was emergently taken to the cath lab where an Impella was inserted in their left femoral artery and a Swan-Ganz catheter was inserted in their right intrajugular vein (a major vein in the neck that drains blood from the brain, face, and neck). The procedure ended at 1:11 p.m., and Patient #4 was transferred to the ICU for continued monitoring and treatment. At 1:24 p.m., the cardiologist placed orders for the RN to perform assessments of the Impella insertion site every hour. This was in contrast to Patient #4’s medical record review, which failed to reveal evidence of insertion site assessments completed by the RN following the insertion of Patient #4’s Impella. The cardiologist also placed orders for the RN to perform neurovascular assessments with vital sign assessments. The Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy revealed vital signs were to be assessed every one hour and as needed. This was in contrast to review of Patient #4’s medical record, which failed to reveal neurovascular assessments completed by the RN until 4:00 p.m., two hours and 36 minutes following the order start time. Additionally, the facility was unable to provide a completed Post Endovascular Assessment Form for Patient #4. This was in contrast to the Adult ICU Scope of Service policy, which revealed nursing care was to be provided to patients with life-threatening conditions that required continuous assessment. The goals of patient-centered care included continuous assessment by the RN. Additionally, at 1:24 p.m., the cardiologist placed orders for the RN to complete the Impella Hourly Monitoring Flowsheet. This was in contrast to review of Patient #4’s Impella Hourly Flowsheet, which revealed Patient #4’s activated clotting time (ACT) (laboratory value that measures how long it takes blood to clot) and a partially-completed assessment of the Impella device function at 2:30 p.m, one hour and 19 minutes after Patient #4 was transferred to the ICU. The Impella Hourly Flowsheet failed to reveal assessments of four out of six variables related to Impella device function, assessment of the Impella catheter, or complications related to bleeding. Additionally, the Impella Hourly Flowsheet failed to reveal continued assessments completed on an hourly basis. Further review of Patient #4’s medical record failed to reveal evidence of assessment of the Swan-Ganz catheter position. This was in contrast to the Assessment and Reassessment: Practice Guidelines for Nursing Staff by Patient Type policy, which revealed the Swan-Ganz catheter position was to be measured once a shift and as needed, and the initial insertion position was to be documented in the medical record. At 3:40 p.m., Patient #4 was transferred back to the cath lab for removal of the Impella. iii. Email correspondence sent from the vice president of quality and safety (VP) #7 to the surveyor on 2/9/26 at 2:07 p.m. revealed the Impella site assessments and neurovascular assessments were to be documented on the Post Endovascular Assessment Form. This was in contrast to review of Patient #2 and Patient #4’s medical records, which failed to reveal evidence of completed Post Endovascular Assessment Forms. B. Interviews i. Between 2/4/26 to 2/11/26, interviews were conducted with facility staff. a. In an interview conducted with RN #2, RN #2 stated the Impella Hourly Flowsheet was to be initiated by the cath lab RN and transferred with the patient to the ICU. The ICU RN should have documented the next assessment on the Impella Hourly Flowsheet as soon as the patient arrived in the ICU. RN #2 explained the Impella Hourly Flowsheet was an important tool which helped the RN recognize trends in the patient’s vital signs and Impella device function, and monitored for potential complications. RN #2 stated it was essential for the RN to be able to recognize potential problems or abnormal trends in order to intervene quickly and prevent the patient from decompensating. This was in contrast to review of Patient #2 and Patient #4’s medical records, which failed to reveal evidence of completed Impella Hourly Flowsheets. Additionally, RN #2 stated placement of the Swan-Ganz catheter was to be assessed immediately upon arrival to the ICU, and the position of the catheter should have been documented in the patient’s medical record. RN #2 explained it was important to ensure the catheter had not moved from its original position because migration of the catheter could result in fatal complications. This was in contrast to review of Patient #2 and Patient #4’s medical records, which failed to reveal evidence of Swan-Ganz placement assessments following either patient’s arrival to the ICU. b. In an interview conducted with RN #3, RN #3 stated the RN should have conducted assessments of the Impella insertion site, and of the patient’s neurovascular status, every 15 minutes for the first hour following the patient’s arrival to the ICU, and then every 30 minutes for two hours, followed by hourly assessments for four hours, and then every two hours for eight hours. RN #3 explained ongoing and frequent assessments of the Impella insertion site were important to monitor for signs of external bleeding or hematoma (a collection of blood outside of the blood vessel) formation. Additionally, RN #3 stated it was important to conduct neurovascular assessments to monitor for complications such as thrombus (blood clot) or dissection (a tear in the blood vessel). This was in contrast to review of Patient #2 and Patient #4’s medical records, which failed to reveal assessments of the Impella insertion site, or the patients’ neurovascular status, every 15 minutes for the first hour following the patients’ arrival to the ICU, every 30 minutes for two hours, every hour for four hours, and then every two hours for eight hours. c. In an interview conducted with Director #6, Director #6 stated the facility did not follow national guidelines or have policies pertaining to the management of patients with Impellas. Additionally, Director #6 stated patients with Impellas were to be placed as one-to-one assignments (when one RN is assigned to care for one critically ill patient due to the severity of illness or complexity of care) in order to ensure the patient received ongoing and continuous assessments. This was in contrast to review of Patient #2 and Patient #4’s medical records, which failed to reveal evidence of ongoing and continuous assessments.”