Sky Ridge Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48269 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. A0144- The patient has the right to receive care in a safe setting. Based on document reviews and interviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure telemetry and continuous pulse oximetry monitoring were provided in accordance with physician’s orders and facility policies in one of three medical records reviewed. (Patient #2)”

“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: 48269 Based on document reviews and interviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to ensure telemetry and continuous pulse oximetry monitoring were provided in accordance with the physician’s orders and facility policies in one of three medical records reviewed. (Patient #2) Findings include: Facility policies: The Telemetry Monitoring policy read, its purpose was to provide guidelines for telemetry monitoring (electrode pads attached to the patient’s chest and connected to leads attached to a portable monitor transmitter providing wireless electrocardiogram (ECG) transmission to a remote or centralized monitoring station), to outline the process for notification and documentation of cardiac rhythm changes, to identify cardiac rhythm changes requiring provider notification, and to assess patients for appropriate discontinuation of cardiac telemetry monitoring. The registered nurse (RN) assumes responsibility for the initiation and management of cardiac monitoring including verification of an order. A provider order is required for telemetry monitoring. A telemetry discontinue order should be entered when telemetry monitoring is no longer indicated for patient care. The Telemetry Monitoring policy also read, the telemetry escalation process, in the event that a non-lethal arrhythmia is detected, the telemetry technician (tech) will initiate a multi-level escalation process, requiring loop closure/alarm resolution within five minutes. If resolution is not reached within five minutes, the telemetry technician will initiate a call to the house supervisor and initiate a telemetry alert on the unit. When a telemetry alert is initiated, all available personnel on the unit are expected to respond to the patient’s bedside to ensure the patient is assessed. The house supervisor will ensure the nurse responding to the patient notifies the telemetry tech once the patient has been assessed and provides an update on patient status and/or ensures the patient’s rhythm is being transmitted. The nurse will notify the provider in the event the changes are an abnormal rhythm. In the event the telemetry tech is unable to contact anyone within the multilevel escalation within five minutes a rapid response will be initiated. The telemetry technician will record the notifications via the approved notification log. The Pulse Oximetry policy read, its purpose was to define guidelines and limitations of pulse oximetry and how it should be utilized in making clinical decisions. Continuous pulse oximetry (SpO2, a non-invasive method used to measure the percentage of hemoglobin in the blood that is saturated with oxygen) is initiated by provider order. The criteria for discontinuation is per provider order. References: The facility’s Olanzapine (Zyprexa) intravenous (IV) Formulary document, dated September 2023, Pharmacy and Therapeutics committee read, olanzapine was Food and Drug Administration (FDA) approved for the treatment of agitation (bipolar one disorder or schizophrenia). Off-label FDA uses included acute agitation. The medication is only FDA-approved for oral or intramuscular (IM) use. Some of the adverse effects include: orthostatic hypotension (low blood pressure with position change), QT prolongation (longer than usual time it takes for the heart to recharge between beats), sedation, and neuroleptic malignant syndrome (NMS) (NMS can be fatal; symptoms include fevers, excessive sweating, rigid muscles, confusion, changes in breathing, heartbeat, and blood pressure). Available as 10 milligram (mg) powder for IM injection, oral tablets, and oral disintegrating tablets. Approved for use in head trauma or traumatic brain injury (TBI) patients only. Will use the IM formulary IV. The Chain of Command Algorithm read, the RN will assess the patient, recognize an issue, and then contact the appropriate provider regarding the concern. If the issue persists, the RN will notify the charge nurse or nurse manager of the concern, and the charge nurse will perform an independent assessment. If the issue persists, the charge nurse or nurse manager will notify the unit director or house supervisor regarding the concern. If the issue persists, the House Supervisor or Chief Nursing Officer (CNO) will notify the chief medical officer (CMO) of the issue. The CMO contacts the appropriate medical staff leadership until the issue is resolved, including, but not limited to, the medical staff president, department chairman, attending, risk director, and/or vice president of quality, legal counsel, until the concern is addressed and the patient is stable. During all steps, the nurse/healthcare provider must maintain the duty of care, retain accountability for the patient, and continue to monitor and call a rapid response when indicated. Documentation of each step is essential; the nurse should keep good documentation records and enter all necessary information in a nursing note and occurrence report. 1. The facility failed to ensure telemetry and continuous pulse oximetry monitoring were provided in accordance with the physician’s orders and facility policies to detect changes in a patient’s condition. A. Document Review i. Patient #2’s medical record was reviewed and revealed Patient #2 was a 37-year-old admitted to the facility on 10/6/24 after weeks of mental status deterioration and increased agitation. During hospitalization, Patient #2 had episodes of violent agitation, which presented a safety risk to the patient and the staff. A patient safety attendant (PSA) had been stationed at the bedside for 1:1 observation to keep Patient #2 safe. The medical record also revealed Patient #2 was diagnosed and treated for autoimmune encephalitis (the body’s immune system attacked healthy tissue, which inflamed brain tissue and caused swelling and abnormal brain function). In addition to the PSA, Patient #2 required frequent chemical and mechanical restraints for safety. On 10/8/24, Patient #2 was evaluated by a psychiatrist who recommended Zyprexa (medication used to regulate mood, thoughts, and behavior) for acute safety concerns. The psychiatrist had also recommended close cardiac monitoring of the QT interval (portion of the heartbeat, if prolonged could cause dangerous heart rhythms) and of potassium and magnesium levels (could cause dangerous heart rhythms if too low or too high). Patient #2 had been ordered Zyprexa 5 mg IV as needed every 24 hours. Additionally, medical record review revealed on 10/17/24 at 12:53 p.m., Patient #2’s physician ordered continuous pulse oximetry and telemetry monitoring for arrhythmia and electrolyte imbalance. Patient #2 received a one-time dose of Zyprexa 10 mg IV at 1:11 p.m. for sedation. At 7:00 p.m., the virtual telemetry tech posted a shift assessment ECG strip, which showed Patient #2 had a heart rate of 102 (normal 60 - 100 beats per minute), heart rhythm sinus tachycardia (heart beats greater than 100 beats per minute), QTc (QT interval) 0.43 (normal less than 0.45), and SpO2 92% (level of oxygen in the blood, normal 95 - 100%). At 8:00 p.m., Patient #2 was placed on two liters of oxygen by nasal cannula. Review of the Telemetry Notification Log revealed, on 10/18/24 at 6:18 a.m., the telemetry tech called the RN to notify them the telemetry leads were off. The RN directed the telemetry tech to keep the telemetry monitoring paused due to Patient #2’s agitation. This was in contrast to the Telemetry Monitoring policy, which read, a provider order was required to discontinue telemetry monitoring. This was also in contrast to the physician’s orders, which read Patient #2 should have been on continuous telemetry monitoring. Also, there was no evidence in the medical record or in the Tele Notification Log that telemetry monitoring had been resumed. The Protective Observation Tool documentation by the PSA read, at 7:30 a.m. Patient #2 kept jumping out of bed. At 7:45 a.m., the RN documented they had notified the physician of Patient #2’s increased agitation and requested an order for restraints; however, no order to restrain was received. At 7:49 a.m., the physician was at the bedside to assess Patient #2. The record revealed Patient #2’s vital signs at 7:52 a.m. had been a temperature of 98.1 Fahrenheit (F), a heart rate of 99, a respiratory rate of 15, a blood pressure of 129/86, and a SpO2 of 89% on room air. There was no evidence in the medical record that oxygen had been provided for Patient #2 until nursing documentation over an hour later at 9:00 a.m. revealed Patient #2 had been placed on heated humidified high flow oxygen by nasal cannula at 40 liters per minute. At 8:18 a.m., the Protective Observation Tool documentation read, the patient was hallucinating, and the RN and patient care technician (PCT) were at the bedside. At 8:45 a.m., the record revealed Patient #2 was administered Zyprexa 5 mg IV. The PSA documentation read, at 9:05 a.m. Patient #2 was yelling and hallucinating. At 9:15 a.m., the PSA documented Patient #2 was agitated and anxious. At 9:30 a.m., the PSA documented Patient #2 was awake, quiet, sleeping, or resting. At 9:45 a.m., the PSA documentation read, Patient #2 was sleeping or resting. The medical record revealed at 9:52 a.m., a code blue (medical emergency where the patient has stopped breathing or their heart has stopped) was called. The medical record revealed Patient #2 was resuscitated by the code blue team and transferred to the intensive care unit (ICU). ICU physician documentation revealed Patient #2 was not on telemetry or pulse oximetry at the time of the code blue. This was in contrast to the physician’s orders, which stated Patient #2 should have been on continuous pulse oximetry and telemetry monitoring for arrhythmia and electrolyte imbalance to detect any change in condition. This was also in contrast to the Pulse Oximetry and Telemetry Monitoring policies, which read an order was required to discontinue monitoring. The physician’s documentation also revealed Patient #2’s PSA reported Patient #2 had curled up in a ball on their side, and after several minutes, was found to be unresponsive by the nurse who had been called to the bedside. Finally, the medical record revealed on 10/21/24 at 3:58 p.m., Patient #2 died of anoxic brain injury (lack of oxygen to brain cells) after cardiac arrest. ii. An event report for Patient #2’s code blue and unanticipated transfer to the ICU was reviewed. Follow-up actions from the event analysis included a peer review of Patient #2’s medical record, a care concern escalation pathway had been developed for clinical staff, and education had been provided to all staff. The Chain of Command Policy and Algorithm were provided to the surveyor as evidence of the facility’s actions taken in response to the event. iii. On 5/28/25 at 10:37 a.m., upon request, the facility was unable to provide evidence of education provided to staff in response to Patient #2’s event. This was in contrast to the event analysis follow-up actions which read, education had been provided to all staff. B. Interviews i. On 5/29/25 at 1:20 p.m., an interview was conducted with telemetry technician (Tech) #1. Tech #1 stated telemetry would have been paused or discontinued only at the direction of the RN. ii. On 5/29/25 at 1:59 p.m., an interview was conducted with clinical nurse coordinator (CNC) #2. CNC #2 stated Patient #2 had been sweaty and agitated, and the staff were not able to keep the telemetry monitor on the patient. CNC #2 stated they had been in Patient #2’s room with the PCT before Patient #2’s code blue. CNC #2 stated they had been trying to fix Patient #2’s telemetry, and the nurse had received a medication order to help calm the patient down. CNC #2 stated they had asked the PSA at the bedside to notify them when Patient #2 had calmed down. CNC #2 stated the nurses and physicians had discussed the situation and had been in and out of Patient #2’s room several times. CNC #2 stated the physicians wanted Patient #2 to be monitored, and Patient #2 needed to be monitored, and there had been no physician order to discontinue the monitoring. Additionally, CNC #2 stated physician orders were important to follow for patient safety. CNC #2 stated telemetry monitoring could have detected a cardiac arrhythmia, and pulse oximetry could have detected a drop in Patient #2’s oxygen level. CNC #2 stated if Patient #2 had been on telemetry or pulse oximetry monitors, staff would have been able to detect a change in Patient #2’s condition. CNC #2 stated it was important to follow the physician’s orders to ensure a change in patient condition was not missed. iii. On 5/29/25 at 2:41 p.m., an interview was conducted with clinical pharmacist (Pharmacist) #3. Pharmacist #3 stated the total maximum dose of Zyprexa administered in 24 hours should have been 10 mg IV. This was in contrast to Patient #2’s medical record, which revealed Patient #2 had received a total of 15 mg of Zyprexa IV in 18 hours. Also, Pharmacist #3 stated Zyprexa could have caused positional low blood pressure, increased sleepiness, or dangerous heart rhythms. Pharmacist #3 stated Patient #2 should have been monitored closely. This was in contrast to Patient #2’s medical record, which revealed Patient #2 was not on continuous telemetry and pulse oximetry monitors as ordered on the morning of 10/18/24 when Patient #2 became unresponsive. iv. On 6/2/25 at 1:59 p.m., an interview was conducted with critical care intensivist (Physician) #4. Physician #4 stated they had been the physician who responded to Patient #2’s code blue event on 10/18/24 and cared for Patient #2 in the ICU. Physician #4 stated Patient #2 had not been on telemetry or continuous pulse oximetry at the time of the code blue. Physician #4 stated they did not know why Patient #2 was unmonitored at the time of the event. Physician #4 stated patients who received Zyprexa should have been monitored for QT prolongation and seizures. Physician #4 stated Patient #2 died of anoxic brain injury caused by the cardiorespiratory arrest. v. On 5/28/25 at 11:51 a.m., an interview was conducted with director of patient safety (Director) #5. Director #5 stated they participated in the review of Patient #2’s event. Director #5 stated the event follow-up included reeducation of staff on the chain of command policy and improved documentation. Director #5 stated this reeducation had occurred in discussions at team huddles. Upon request, the facility was unable to provide evidence of education provided to staff in response to Patient #2’s event.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 43825 Based on the life safety code complaint survey conducted 2/4/2025 through 2/5/2025, the facility failed to comply with regulations set forth in the Life Safety Code. The Condition of Participation §482.41 Physical Environment was out of compliance. A-0700 - The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The facility failed to comply with the regulations set forth for Life Safety. Deficiencies were cited under the Life Safety Code deficiencies K-0161, K-0211, K-0293, K-0321, K-0324, K-0341, K-0353, K-0363, K-0372, K-0521, K-0712, K-0919. See survey event ID KTJ021 for full details of the cited deficiencies.”

“An abbreviated survey, prompted by CO#38854, was completed on 2/5/2025. Twelve deficiencies were cited. Condition of Participation, §482.41 Physical Environment cited on the 8OB111 companion health survey. Building A-1-Main Hospital The Colorado Department of PublicSafety Division of Fire Prevention & Control conducted this survey in accordance with the Federal Register at Section 42 CFR Part 416.44(b). The initial comments, (ID Prefix Tag #K0000), are informational only and are a representation of the facility ’ s general characteristics. The facility is a seven-story, type I (332) structure with a garden level. The seventh floor contains mechanical equipment only including elevator mechanical rooms. Patient rooms are located on the second through sixth floors. The structure shares two-hour fire-rated walls and horizontal exits, on the first level, with two adjacent office buildings. The structure contained a full automatic fire suppression system which includes a pump from city water. This complaint survey, conducted February 4th through February 5th, 2025, included an inspection for compliance with the fire safety requirements of Chapter 19 of the 2012 edition of NFPA-101, Life Safety Code, published by the National Fire Protection Association (NFPA). The survey concluded with a discussion of the survey with the Director of Plant Operations, the Safety Officer, and other corporate “C” suite executives.”

“Building Construction Type and Height CFR(s): NFPA 101 Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. This Standard is not met as evidenced by: 43825 Based on observation and staff interviews during the course of the survey it was determined the facility failed to maintain the building construction in accordance with NFPA 101. The following evidenced this: Fire barriers and smoke partitions are cracking and separating throughout the facility. This involves the drywall cracking. NFPA 101 (2012) 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 43825 Based on observation and staff interview during the survey, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This was evidenced by the following: Egress path next to the ED area was blocked from free egress. There was a desk (no wheels) that was being used, that blocked free egress. Fixed during survey. Life Safety Code Section 19.2.1 requires that means of egress components be in accordance with Chapter 7. Life Safety Code Section 7.1.10.1 requires that every means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The means of egress deficiency has the potential to affect occupants, who might include staff and visitors within the affected smoke compartment; items were discussed during the survey and again during the exit conference.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 43825 Based on observation, staff interview and record review during the course of the survey it was determined the facility failed to maintain emergency exit signs in accordance with NFPA 101, section 19.2.10, 7.10. The following evidenced this: Exit signage needed facing a chevron from ED to stairwell 3. Zone 2 red exit sign needs both sided directional arrows The exit sign in the cath lab light is out Elevator lobby near chaplains office- missing exit signage needed facing No exit sign above the exit toward main entrance. Lobby- exit signage from main lobby to conifer lobby needs corrected temporary exit signage Life Safety Code Section 19.2.10.1 requires Means of Egress signs in accordance with 7.10. Section 7.10.1.5.1, in part, access to exits shall be marked by approved readily visible signs. The deficiency has the potential to affect occupants, who might include staff, residents and visitors within the smoke compartments; items were discussed during the survey and again during the exit conference.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 43825 Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 221. This was evidenced by: Fire rated walls throughout need inspected and all penetrations need repaired. 4.9.2 Firestop Systems and Devices Required. Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, assembly constructed as a fire barrier shall be protected by a firestop system or device. The deficiency has the potential to affect occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 43825 Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standard 96. This was evidenced by the following: 1) Kitchen cooking appliances were not provided with an approved method to ensure the appliances were returned to the correct design location below the fixed extinguishing system nozzles, as required. NFPA 96 (2011) Section 12.1.2.3.1: An approved method shall be provided that will ensure that the appliance is returned to an approved design location. The commercial cooking equipment deficiency has the potential to affect all staff in the kitchen smoke compartments; items were discussed during the survey and again during the exit conference.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 43825 Based on observation during the survey it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 19.3.4, 19.3.4.5, and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this: Storage room C smoke detector closer then 3 feet to the diffuser Across from Colleen ’ s office-detector too close to the diffuser. EEG- staff office smoke detector to close to diffuser. Fire alarm panel was upgraded without coming in for plan review. 17.7.4.1 * In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. A.17.7.4.1 Detectors should not be located in a direct airflow or closer than 36 in. (910 mm) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 43825 Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 13 and NFPA 25. This was evidenced by: 1. Cafe/kitchen, vending machines (ICU), RM 4404 loaded/corroded heads. 2. Escutcheons throughout the facility need repaired. 3. Loading mech outside entry-suppression pipe knuckle needs to be replaced. Life Safety Code Section 9.7.5 maintenance and testing of automatic sprinkler systems to comply with NFPA 25. NFPA 25 section 5.2.1.1.2, Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5) Loading (6) Painting unless painted by the sprinkler manufacturer 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler. 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the facility administrator and maintenance director during the exit conference.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 43825 Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by: Fire/Smoke doors throughout the facility do not close or are damaged. Missing smoke seal on pt room door 5201 Doors don ’ t latch when tested: 5302, 5206, 5208, 5300 wing staff elevator lobby doors, 5403, 5410. Main door into robotics waiting room: did not latch when tested. SC 1-A Room 4108: door seals poorly but latches 7.2.1.15.8 Door openings not in proper operating condition shall be repaired or replaced without delay. 5.2.15.2 Any breaks in the face covering of doors shall be repaired immediately. 5.2.15.3 Where a fire door, frame, or any part of its appurtenances is damaged to the extent that it could impair the door ’ s proper emergency function, the following actions shall be performed: (1) The fire door, frame, door assembly, or any part of its appurtenances shall be repaired with labeled parts or parts obtained from the original manufacturer. (2) The door shall be tested to ensure emergency operation and closing upon completion of the repairs. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the affected smoke compartments. Deficient items were discussed with the facility administrator during the exit conference.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 43825 Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: Throughout the building, all smoke barriers need insepcted and all penetrations through the barriers need fixed. Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, “Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.” This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 43825 Through observation during documentation review, it was determined that the facility failed to meet the building services requirements in accordance with NFPA 101 and NFPA 90A. This was evidenced by: Fire damper testing report shows there were failures in numerous dampers. Life Safety Code section 19.5.2.1 to comply with section 9.2. Section 9.2 to comply with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A section 5.4.8.1 to comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80 section This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 43825 Through observation during documentation review, it was determined that the facility failed to meet the operating features requirements in accordance with NFPA 101. This was evidenced by: 1. Fire drills were not conducted under varied conditions and or not completed: Two missing fire drills in the first quarter on 2nd and 3rd shift. Varied conditions were not met on the 2nd shift between 2nd and 3rd quarter. Life Safety Code, section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within all smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99) This Standard is not met as evidenced by: 43825 Based on observation and staff interview during the course of the survey, it was determined the facility failed to maintain electrical wiring and equipment in accordance with NFPA 101 and NFPA 70, National Electric Code. The following evidenced this: Ground floor intake west- open j box with exposed wires Ground mech- open j box Main electric- open j boxes Healing Garden Mech room-open junction box. Main OR electrical room: Green j-box in SE corner behind the transformer needs to be reattached. Spine/Joint OR: Leica microscope damaged electrical power cord Leica microscope Incorrect electrical power cord MRI computer room-Extension cord with box fan plugged into it. 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface. The electrical deficiency has the potential to affect all room occupants, who might include staff and visitors; items were discussed during the survey and again during the exit conference.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46674 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. A0144- §482.13 (c)(2) PATIENT RIGHTS: CARE IN SAFE SETTING. The patient has the right to receive care in a safe setting. Based on document reviews and interviews, the facility failed to conduct suicide screening risk assessments in accordance with national guidelines and facility policy to ensure patients received care in a safe setting. This failure was identified in three of three patients with behavioral health concerns who received care in the emergency department (ED). (Patients #1, #2, and #3)”

“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: 46674 Based on document reviews and interviews, the facility failed to conduct suicide screening risk assessments in accordance with national guidelines and facility policy to ensure patients received care in a safe setting. This failure was identified in three of three patients with behavioral health concerns who received care in the emergency department (ED). (Patients #1, #2, and #3) Findings include: Facility policy: The Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy read, the purpose is to assist with the identification of patients in non-BH settings who are at risk for suicide, ensuring a safe environment for the provision of care. The Columbia Suicide Severity Rating Scale (C-SSRS) is the initial screening tool utilized by the nurse. It will provide an auto-calculated level of no risk, low, moderate or high risk. It is the policy of the facility to create an environment of care that will foster the assessment, identification, and management of patients who are at increased risk for suicide or self-harming behaviors. Patients who are at an increased risk for suicide or self-harming behaviors require intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan begins at triage, prior to admission to the hospital, and continues until the patient is discharged. Minimum requirement: Patients in non-psychiatric areas (e.g., Emergency Room (ER) and non-BH inpatient units), ages 12 years and older, who are being evaluated or treated for BH conditions as their primary reason for care should be screened using the C-SSRS. The Provider/Practitioner will be notified of positive screens (i.e., at-risk patients). The at-risk patient’s (low, moderate, or high) environment will be made safe by implementing the checklist and observation precautions. Reference: According to the Columbia Lighthouse Project, About the Protocol, retrieved from https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/, the first step in effective suicide prevention is to identify everyone who needs help. The Columbia Protocol was the first scale to address the full range of suicidal thoughts and behaviors that point to heightened risk. That means it identifies risk not only if someone has previously attempted suicide, but also if he or she has considered suicide, prepared for an attempt (for example, buying a gun, collecting pills, or writing a suicide note), or aborted plans for suicide because of a last-minute change of mind or someone ’ s intervention. The Columbia Protocol screens for this wide range of risk factors without becoming unwieldy or overwhelming, because it includes the most essential, evidence-supported questions required for a thorough screening. Use of the protocol redirects resources to where they are needed most. It reduces unnecessary referrals and interventions by more accurately identifying who needs help and it makes it easier to correctly determine the level of support a person needs, such as patient safety monitoring procedures, counseling, or emergency room care. 1. The facility failed to conduct suicide screening risk assessments in accordance with national guidelines and facility policy to ensure patients received care in a safe setting. A. Document Review i. Medical record review revealed Patient #1 was a 17 year old who was transferred to the ED from a psychiatric facility on 5/21/24 at 9:25 p.m. with a chief complaint of hand injury. Patient #1’s record revealed they were admitted to the psychiatric facility for suicidal ideations with intent. Patient #1 eloped from the ED on 5/21/24 at 9:41 p.m. There was no evidence a suicide screening risk assessment (C-SSRS) had been completed for Patient #1. ii. Review of the Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy revealed suicide risk assessments were only completed for patients who were being evaluated or treated for BH conditions as their primary reason for care. This was in contrast to the Columbia Lighthouse Project guidelines which read, the first step in effective suicide prevention was to identify everyone who needed help. iii. Medical record review revealed Patient #2 was a 39 year old who presented to the ED on 12/14/24 at 2:40 p.m. with a chief complaint of hearing voices. Patient #2 eloped from the ED at 3:43 p.m. There was no evidence a C-SSRS had been completed for Patient #2. iv. Medical record review revealed Patient #2 returned to the ED on 12/14/24 at 3:58 p.m. with a chief complaint of hearing voices. Patient #2 again eloped from the ED at 5:10 p.m. There was no evidence a C-SSRS had been completed for Patient #2. v. Medical record review revealed Patient #3 was a 15 year old who presented to the ED on 10/23/24 at 4:53 p.m. with a chief complaint of intentional overdose and suicidal ideation. Nursing documentation at 5:12 p.m. revealed Patient #3 would not respond verbally, and at 5:17 p.m., nursing staff were unable to assess Patient #3’s suicide risk. Between 5:36 p.m. and 8:17 p.m., provider documentation revealed Patient #3 was able to answer questions. There was no evidence a C-SSRS had been completed for Patient #3 while they were in the ED. Medical record reviews for Patients #2 and #3 were in contrast to the Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy which read, the C-SSRS was the initial screening tool that should have been utilized by the nurse. At a minimum, patients who were being evaluated or treated for BH conditions as their primary reason for care should have been screened using the C-SSRS. B. Interviews i. On 12/18/24 at 1:52 p.m., an interview was conducted with registered nurse (RN) #1, who provided care to Patient #2 during their second ED visit on 12/14/24. RN #1 stated the C-SSRS was supposed to be completed any time a patient came to the ED with psychiatric related issues, such as depression, anxiety, if they wanted to harm themselves or had a recent attempt, or if they heard voices. RN #1 stated they never reported the C-SSRS scores to providers and nurses were not required to notify the patient’s provider of what the suicide risk assessment scores were because providers completed their own assessments to determine if patients needed to be placed on M1 holds (a 72 hour psychiatric hold). Additionally, RN #1 stated they used their best judgement and did not complete the C-SSRS on patients if they did not feel like the patients were at risk of suicide. RN #1 stated it was up to nurses to make a judgement call of whether the patient could benefit from further psychiatric interventions. RN #1 stated Patient #2 muttered under their breath but did not seem like they were talking to someone who was not there. RN #1 stated they did not feel Patient #2 was a candidate for a C-SSRS because they were alert and oriented, talking, did not want to be in the hospital, and asked to let them leave the facility. Furthermore, RN #1 stated it was important to know if a patient was at risk for suicide because it was the facility’s responsibility to ensure patients were mentally and physically safe. This was in contrast to the Suicide Risk Assessment for Non-Behavioral Health (BH) Settings policy which read, the purpose was to assist with the identification of patients in non-BH settings who were at risk for suicide and ensured a safe environment for the provision of care. The C-SSRS was the initial screening tool utilized by the nurse. It was the policy of the facility to create an environment of care that fostered the assessment, identification, and management of patients who were at increased risk for suicide or self-harming behaviors. Patients who were at an increased risk for suicide or self-harming behaviors required intensive support, close observation, and frequent reassessment for their emotional and physical well-being. The scope of this plan began at triage, prior to admission to the hospital, and continued until the patient was discharged. At a minimum, patients in the ED, ages 12 years and older, who were being evaluated or treated for BH conditions as their primary reason for care should have been screened using the C-SSRS. The Provider/Practitioner would be notified of positive screens (i.e., at risk patients). This was also in contrast to the Columbia Lighthouse Project guidelines which read, the first step in effective suicide prevention was to identify everyone who needed help. ii. On 12/19/24 at 2:43 p.m., an interview was conducted with ED manager (Manager) #2. Manager #2 stated the C-SSRS was used to identify individuals at a high risk for suicide and should have been completed for Patients #1, #2, and #3. Manager #2 stated Patient #3’s C-SSRS should have been completed as early as possible, once the patient was able to complete the assessment. Manager #2 stated staff were trained during the orientation process that suicide screenings were a safety measure which needed to be completed. Manager #2 stated staff could miss an opportunity to intervene if suicidal patients were not screened when they were being seen for a different complaint. Manager #2 stated every ED patient should have been screened for suicide risk, regardless of their chief complaint. Additionally, Manager #2 stated patients could be at risk of harming themselves if suicide screening risk assessments were not completed. Manager #2 stated staff needed to assess suicide risk to ensure the correct safety measures were implemented if patients were suicidal. This was in contrast to the medical record reviews for Patients #1, #2, and #3 which revealed the C-SSRS was not completed during their ED visits. This was also in contrast to the interview with RN #1 who stated they used their best judgement and did not complete the C-SSRS on patients if they did not feel like the patients were at risk of suicide, and it was up to nurses to make a judgement call of whether patients could benefit from further psychiatric interventions. iii. On 12/19/24 at 3:42 p.m., an interview was conducted with the director of patient safety (Director) #3. Director #3 stated it was a corporate decision to only screen patients for suicide if they presented with a BH diagnosis or gave a reason to be screened. Director #3 stated unnecessary interventions were put into place when all patients were screened for suicide risk. This was in contrast to the Columbia Lighthouse Project guidelines which read, the first step in effective suicide prevention was to identify everyone who needed help. The Columbia Protocol screened for a wide range of risk factors without becoming unwieldy or overwhelming because it included the most essential, evidence-supported questions required for a thorough screening. Use of the protocol redirected resources to where they were needed most. It reduced unnecessary referrals and interventions by more accurately identifying who needed help, and made it easier to correctly determine the level of support a person needed, such as patient safety monitoring procedures, counseling, or emergency room care.”

“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: 49541 Based on the manner and degree of the standard-level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Condition of Participation: NURSING SERVICES was out of compliance. A-0405 Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care, and accepted standards of practice: Based on observations, interviews, and document review, the facility failed to ensure patients with respiratory concerns received oxygen and monitoring in accordance with recognized standards and provider orders to ensure the safety of patients in one out of one patients who received continuous oxygen titration. (Patient #1)”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 49541 Based on observations, interviews, and document review, the facility failed to ensure patients with respiratory concerns received oxygen and monitoring in accordance with recognized standards and provider orders to ensure the safety of patients in one out of one patients who received continuous oxygen titration. (Patient #1) Findings include: Facility policies:. The Oxygen/Therapeutic Gas Administration and Humidification policy read, a respiratory therapist or registered nurse will review daily the need and appropriateness of oxygen therapy and follow all provider orders for titration and discontinuation of oxygen therapy. Supplemental O2 may be increased as clinically indicated by respiratory or nursing staff only. If the prescribed oxygen produces an saturation of peripheral oxygen (SpO2) less than 90% (unless the physician’s order specifies otherwise), the liter flow or FiO2 needed to achieve an SpO2 of 90% is determined by adjusting the flow or percentage of oxygen and measuring the clinical response via pulse oximetry. The physician will be contacted when the results of the oxygen therapy assessment indicate a need to increase the liter flow by three liters or more to achieve the same SpO2. The Assessment and Reassessment policy read, reassessment is to be ongoing and may be triggered by pertinent data that may include, but are not limited to: early physiological monitoring systems, acute change in patient condition and/or change in diagnosis, response to plan of care/treatment plan. This may necessitate the need for other disciplines (i.e.: dietary, therapies, respiratory, case management) to be notified The Clinical Assessment and Reassessment Guideline policy read, problem focused reassessment every shift (can be delegated to a designee with required RN assessment required daily) and as the patient ’ s condition warrants. References: The patient care technician (PCT) job description read, the PCT delivers high quality, patient-centered care by performing a variety of delegated basic patient care services related to common nursing functions and activities of daily living. Participates in the implementation of nursing care plans by performing direct and indirect patient care under the supervision of the licensed nurse. Provides or assists with non-medicated support care, including non-sterile dressing changes, skin protection, application of heat or ice, and venous compression devices The State Board of Nursing certified nurse aide (CNA) scope of practice read, the CNA, when deemed competent by a registered nurse (RN) or advanced practice registered nurse (APRN), in good faith may perform the following tasks only for clients/patients with stable health conditions and who are not considered high risk: (5) Administration of oxygen as authorized by a health care provider. The Colorado Revised Statutes, ARTICLE 255: NURSES AND NURSE AIDES read, in no event may a registered nurse or certified midwife delegate to another person the authority to select medications if the person is not, independent of the delegation, authorized by law to select medications. Delegated tasks must be within the area of responsibility of the delegating nurse or certified midwife and must not require any delegatee to exercise the judgment required of a nurse or certified midwife. The delegating nurse or certified midwife is solely responsible for determining the required degree of supervision the delegatee will need, after an evaluation of the appropriate factors, which include but are not limited to the following: (a) The stability of the condition of the patient; (d) Whether the delegated task has a predictable outcome. 1. The facility failed to ensure patients received oxygen according to a provider’s order, documented interventions and change in the patient’s condition, and ensured continuous pulse oximetry monitoring was provided to high risk patients. Additionally, the facility failed to ensure staff performed care within their scope of practice. A. Observations i. On 7/10/24 at 2:25 p.m., observations were conducted in the progressive care unit (PCU). Observations revealed patient care technician (PCT) #1 at the nursing station. PCT #1 reported to the nursing staff they were concerned about walking Patient #1. PCT #1 stated they had been titrating Patient #1’s oxygen for most of the shift related to the patient’s pulse oximetry and shortness of breath. ii. On 7/10/24 at 2:28 p.m., observations were conducted in room 4309. Observation revealed PCT #1 unhooked Patient #1’s nasal cannula from the wall supplied oxygen and placed the patient on a portable oxygen tank. The observations on 7/10/24 were in contrast to the PCT job description which read, the PCT participated in the implementation of nursing care plans and performed direct and indirect patient care under the supervision of the licensed nurse. Provided or assisted with non-medicated support care. The observations on 7/10/24 were also in contrast to the Oxygen/Therapeutic Gas Administration and Humidification policy read, supplemental O2 may be increased as clinically indicated by respiratory or nursing staff only. The observations on 7/10/24 were also in contrast to the State Board of Nursing certified nurse aide (CNA) scope of practice which reach read, the CNA when deemed competent by a RN or APRN in good faith may have performed the following tasks only for clients/patients who had stable health conditions and who are not considered high risk: administration of oxygen as authorized by a health care provider. B. Document Review i. Medical record review revealed Patient #1 was admitted to the ICU on 7/3/24 for community-acquired pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation (a sudden worsening of breathing) and was transferred to the progressive care unit (PCU) on 7/8/24. Further review of the medical record review revealed, on 7/3/24 at 11:55 a.m., Patient #1 had an active order for heated high flow oxygen. There was no evidence in the medical record the patient had an order to titrate oxygen. This was in contrast to the observation on 7/10/24 which showed the patient on wall supplied oxygen rather than heated high flow oxygen. Wall-supplied oxygen was delivered through hospital outlets at low to moderate flow rates without heating or humidification, while heated high-flow oxygen was delivered via specialized system at high flow rates with heating and humidification ii. Review of Patient #1’s telemetry record revealed on 7/10/24 between the hours of 12:00 a.m. and 3:00 p.m. the patient’s SpO2 dropped below 87% 11 times. There was no evidence in the medical record that medical interventions had been documented, the provider had been notified, or the nurse had performed a reassessment. Further review of the telemetry record revealed a gap in continuous pulse oximetry on 7/9/24 for approximately 40 minutes. There was no evidence in the medical record the telemetry department notified the patient nurse. This was in contrast to the Assessment and Reassessment policy which read, reassessment was ongoing and could be triggered by pertinent data, including early physiological monitoring systems, acute changes in patient condition or diagnosis, and response to the plan of care or treatment plan. This was also in contrast to the Clinical Assessment and Reassessment Guideline policy which read, a problem focused reassessment was conducted every shift and as the patient ’ s condition warranted. C. Interviews i. On 7/11/24 at 8:30 a.m., an interview was conducted with Patient #1. Patient #1 stated they had difficulty breathing and shortness of breath since their admission. Patient #1 stated PCT #1 and RN #3 titrated their 02 the day prior with little to no relief. Patient #1 stated they continued to have shortness of breath and was concerned that their care was not progressing. ii. On 7/10/24 at 2:35 p.m., an interview was conducted with PCT #1. PCT #1 stated they titrated Patient #1 oxygen throughout the shift and would report the change to the RN. PCT #1 stated they titrated the patient’s oxygen from five liters to nine liters during lunch due to the patient experiencing shortness of breath. PCT #1 stated they had told the nurse after they had titrated the oxygen and it was the responsibility of the nurse to document the change. PCT #1 stated it was common practice for PCTs to titrate oxygen. PCT #1 stated they were unaware of any risks for oxygen administration. iii. On 7/10/24 at 2:50 p.m., an interview was conducted with RN #3. RN #3 stated Patient #1 had an order for high flow oxygen. RN #3 stated Patient #1’s pulse oximetry was not stable and required the staff to titrate the oxygen throughout the shift. RN #3 stated they were busy during their shift and did not always have time to access Patient #1 when their pulse oximetry was low. RN #3 stated when they were busy they allowed experienced PCTs titrate oxygen. RN #3 stated they titrated Patient #1 oxygen throughout the shift and did not document the titration in the patient’s medical record. iv. On 7/11/24 at 9:15 a.m., an interview was conducted with PCT #2. PCT #2 stated they would titrate the oxygen by one liter at a time and continued to increase the oxygen until the shortness of breath subsided. PCT #2 stated they would change the patient from nasal to a simple face mask if the increased amount of oxygen failed to stabilize their pulse oximetry. PCT #2 stated it was common practice for PCTs to titrate oxygen. PCT #2 stated they would not document the titration of the oxygen as that was the nurse’s responsibility. PCT #2 stated they would only document the oxygen with the patient’s routine vital signs. The interviews with PCT #1, PCT #2, and RN #3 were in contrast to the PCT’s job description which read, the PCT participated in the implementation of nursing care plans and performed direct and indirect patient care under the supervision of the licensed nurse. Provided or assisted with non-medicated support care The interviews with PCT #1, PCT #2, and RN #3 were also in contrast to the Oxygen/Therapeutic Gas Administration and Humidification policy which read, supplemental O2 may be increased as clinically indicated by respiratory or nursing staff only. The physician was contacted when the results of the oxygen therapy assessment indicated a need to increase the liter flow by three liters or more to achieve the same SpO2. The interviews with PCT #1, PCT #2, and RN #3 were also in contrast to the State Board of Nursing certified nurse aide (CNA) scope of practice which reach read, the CNA, when deemed competent by a RN or APRN, in good faith may have performed the following tasks only for clients/patients who had stable health conditions and who are not considered high risk: administration of oxygen as authorized by a health care provider. The interviews with PCT #1, PCT #2, and RN #3 were in contrast to the Colorado Revised Statutes, ARTICLE 255: NURSES AND NURSE AIDES which read, the registered nurse could not delegate the authority to select medications to another person if that person was not independently authorized by law to select medications. Delegated tasks needed to be within the delegating nurse area of responsibility and could not require the delegatee to exercise the judgment of a nurse. The delegating nurse was solely responsible for determining the necessary degree of supervision for the delegatee after evaluating factors such as the stability of the patient’s condition and the predictability of the delegated task’s outcome. v. On 7/11/24 at 12:12 p.m., an interview was conducted with RN #4. RN #4 stated oxygen should not be titrated without an order. RN #4 stated PCTs were not allowed to titrate oxygen. RN #4 stated PCTs were not clinically trained to titrate the patients oxygen. RN #4 stated PCTs could administer too much oxygen to the patient, which decreased their respiratory drive, which could lead to retained carbon dioxide and respiratory arrest. RN #4 stated it was important to document changes in oxygen administration to see trends in how the patient was doing. RN #4 stated providers needed to see if the patient’s oxygen had been changed to evaluate the patient’s response to their treatment. RN #4 stated if the nursing staff did not document the change in the patient’s condition, the healthcare team might not provide appropriate interventions and the patient could decompensate. vi. On 7/10/24 at 4:12 p.m., an interview was conducted with respiratory manager (Manager) #5. Manager #5 stated oxygen was considered a medication. Manager #5 stated that increasing the rate of flow and amount of oxygen for a COPD patient could decrease the respiratory drive and cause the patient to go into respiratory arrest. vii. On 7/10/24 at 3:05 p.m., an interview was conducted with the director of telemetry (Director) #6. Director #6 stated that patients should have had the correct oxygen order. Director #6 stated patients should have a titrated oxygen order. Director #6 stated it was outside of the PCTs’ scope of practice to titrate the patients’ oxygen. Director #6 stated PCTs did not have the clinical knowledge to assess the patient and determine the patient’s oxygen needs. Director #6 stated it was the nurse’s responsibility to titrate the patient’s oxygen, evaluate the intervention, and document the response in the medical record. viii. On 7/11/24 at 3:50 p.m., an interview was conducted with the director of patient safety (Director) #9. Director #9 stated Patient #1 did not have an order to titrate oxygen. Director #9 stated that the patient’s medical record had lacked documentation indicating that the oxygen for Patient #1 had been titrated during the day shift on 7/10/24. Director #9 stated that the telemetry department had informed nursing staff of a gap in continuous pulse oximetry monitoring on 7/9/24 at 10:00 p.m. because Patient #1’s battery had died and needed to be replaced. Director #9 stated the gap in continuous pulse oximetry had been estimated at 40 minutes. The interview with Director #9 was in contrast with the telemetry notification log, which did not show that the telemetry department had notified the nursing staff about the need to replace the continuous pulse oximetry monitor battery. ix. On 7/11/24 at 12:39 p.m., an interview was conducted with hospitalist (Provider) #7. Provider #7 stated oxygen should only have been titrated by the respiratory therapist, registered nurse, or provider. Provider #7 stated it was important for patients to receive oxygen as ordered by the prescriber. Provider #7 stated that patients on oxygen should have had an oxygen titration order. Provider #7 stated if staff did not document the titration and delivery of oxygen, they would not have been able to assess the patient’s response to treatment, potentially affecting the care received. Additionally, Provider #7 stated without being notified of changes in the patient’s condition, they would not have been able to effectively treat the patient. x. On 7/15/24 at 10:54 a.m., an interview was conducted with chief nursing officer (CNO) #8. CNO #8 stated all PCTs at the facility were required to have a CNA certification. CNO #8 stated that oxygen was considered a medication. CNO #8 stated patients should have had the correct oxygen order. CNO #8 stated patients should have had a titrated oxygen order. CNO #8 stated only the nurse or respiratory therapist should have titrated the patient’s oxygen, with documentation in the medical record. CNO #8 stated the physician should have been contacted when the oxygen therapy assessment indicated a need to increase the liter flow by three liters within a 12-hour shift. CNO #8 stated if the patient was off continuous pulse oximetry, the telemetry department should have called the nurse to notify them. CNO #8 stated that the facility’s telemetry escalation pathway required immediate intervention within five minutes. CNO #8 stated that it was important to maintain continuous pulse oximetry to monitor the patient and identify changes in condition. Interviews with the hospital leadership were in contrast to the observations performed on 7/10/24 where PCT #1 reported titrating Patient #1’s oxygen. Interview with the hospital leadership was in contrast the the interviews with PCT #1, PCT #2, and RN #3 who stated PCTs routinely titrated patients’ oxygen levels.”

“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: 47959 Based on the manner and degree of the standard-level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Condition of Participation: NURSING SERVICES was out of compliance. A-0395 A registered nurse must supervise and evaluate the nursing care for each patient: Based on document review and interviews, the facility failed to ensure interventions were implemented to protect skin integrity for patients who were at risk of pressure injuries in two of two patients reviewed with risk for skin breakdown (Patients #4 and #5).”

“REHABILITATION SERVICES CFR(s): 482.56 If the hospital provides rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services must be organized and staffed to ensure the health and safety of patients. This Condition is not met as evidenced by: 47959 Based on the manner and degree of the standard-level deficiency referenced to the Condition, it was determined the Condition of Participation §482.56 Condition of Participation: REHABILITATION SERVICES was out of compliance. A-1132 Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. Based on document review and interviews, the facility failed to obtain a provider order before a procedure was performed on a patient in one of one patients reviewed who underwent a wound debridement (Patient #4).”

“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: 47959 Based on document review and interviews, the facility failed to ensure interventions were implemented to protect skin integrity for patients who were at risk of pressure injuries in two of two patients reviewed with risk for skin breakdown (Patients #4 and #5). Findings include: Facility policy: The Pressure Injury Prevention and Management policy read, all patients will be evaluated for skin breakdown and reassessment of skin risk will occur, at a minimum of once per shift. Regardless of risk, standard-of-care pressure injury prevention elements should be implemented for all patients. Reference: The Elton B. Stephens Company (EBSCO) Information Services Dynamic Health Database, 2024, for adult pressure injury, provided by the facility, read, pressure injury prevention focused on risk assessment, skin care, nutrition, positioning, and mobilization. Skin care-related prevention included frequent skin assessments and minimizing skin exposure to moisture, urine, and stool by using barrier products. Positioning and mobilization-related prevention included frequent repositioning to alleviate pressure. The Pressure Injury Prevention and Wound Care education tool, provided by the facility, read, interventions for pressure injury were to ensure registered nurses (RNs) and other care team members turn patients frequently (every two hours), update the care plan, and document the interventions according to facility policy. 1. The facility failed to ensure patients at risk of pressure injuries were monitored and had implemented interventions to protect the patient’s skin integrity. A. Record Review i. Medical record review revealed Patient #4 was admitted to the intensive care unit (ICU) on 10/10/23 for shortness of breath and sepsis (a severe infection in the body) related to Clostridiodes difficile (C.diff). Patient #4 had a stage I pressure injury (pressure-related alteration of intact skin) on their right heel and a stage III pressure injury (a full-thickness loss of skin in which fat tissue is visible) on their sacrum (tailbone). The skin risk assessment done on the day of admission (10/10/23) revealed the patient was at risk for a pressure injury due to their limited bed mobility, nutritional status, and moist skin condition. Patient #4 was transferred to a cardiac medical stepdown unit on 10/25/23 because the ICU level of care was no longer needed for their medical condition. Medical record review of the nursing documentation in Patient #4’s medical record revealed Patient #4’s skin was not assessed every shift per facility policy on 10/10/23, 10/24/23, 10/25/23, 10/28/23, 11/5/23, 11/6/23, and 11/7/23. Furthermore, the medical record revealed no evidence that Patient #4 was repositioned or turned off their pressure injury 24 days between 10/11/23 and 11/10/23. Additional medical record review revealed Patient #4 had orders for a skin barrier cream to be applied to the pressure injury daily and as needed. A review of nursing documentation in Patient #4’s medical record revealed 19 days between 10/11/23 and 11/10/23 that Patient #4 did not receive the skin barrier cream as ordered by the provider. ii. Medical record review revealed Patient #4 was readmitted to a medical unit within the facility on 11/15/23 with hematuria (blood in the urine). A review of the nursing documentation revealed Patient #4 had a stage III pressure injury on their sacrum and the skin risk assessment done on the day of admission (11/15/23) revealed the patient was at risk for a pressure injury due to their limited bed mobility, nutritional status, and moist skin condition. The medical record review of Patient #4 revealed the skin risk assessment was not completed for the day shift on 11/16/23 per facility policy. Further review of nursing documentation revealed Patient #4 was not repositioned on 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/20/23, 11/21/23, and 11/22/23. iii. Medical record review revealed Patient #4 was readmitted to the facility’s step-down unit on 11/27/23 for hematuria. A review of nursing documentation revealed Patient #4 had a stage III pressure injury on their sacrum and the skin risk assessment completed on the day of admission (11/27/23) revealed the patient was at risk for a pressure injury due to their limited bed mobility, nutritional status, and moist skin condition. The medical record review of Patient #4 revealed the skin risk assessment was not completed on 11/29/23 and 12/6/23 per facility policy. Further review of nursing documentation revealed Patient #4 was not repositioned during the night shifts of 11/27/23, 11/28/23, 11/30/23, 12/4/223, and 12/5/23. Additionally, Patient #4 was not repositioned during the day shifts of 11/29/23, 11/30/23, 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/6/23. iv. Medical record review revealed Patient #5 was admitted to the ICU on 2/9/24 with increased symptoms (change in mental status and ability to walk) of a subdural hematoma (bleeding under the skull) as a result of a fall. The skin risk assessment completed on 2/10/24 revealed Patient #5 was on bedrest and was at risk for a pressure injury due to their limited bed mobility. Medical record review of the nursing documentation in Patient #5’s medical record revealed Patient #5’s skin was not assessed on the evening shift. Further record review revealed Patient #5 was not turned or repositioned on 2/11/24 during the evening shift. This was in contrast to the Pressure Injury Prevention and Management policy which read, all patients were to be evaluated and reassessed for risk of skin breakdown at a minimum of once per shift. Additionally, standard-of-care pressure injury prevention elements were to be implemented for all patients, regardless of skin risk. This was in further contrast to the EBSCO national guidelines followed by the facility which read, skin care-related prevention included frequent skin assessments and minimized skin exposure to moisture, urine, and stool through the use of barrier products. Positioning and mobilization-related prevention included frequent repositioning to alleviate pressure. This was also in contrast to the Pressure Injury Prevention and Wound Care education tool which read, staff were to turn patients frequently (every two hours), update the care plan, and document the interventions according to facility policy. B. Interviews i. On 2/12/24 at 9:30 a.m., an interview was conducted with RN #8. RN #8 stated patients’ skin was checked at the beginning of the shift during report with the on-coming and off-going shifts. RN #8 stated a skin risk assessment tool was used to determine the level of risk for a pressure injury and a score of 18 or less was considered a risk that needed special interventions for pressure injury prevention. RN #8 stated patients who were not turned risked pressure injuries that caused infections or delayed the discharge. RN #8 stated patients also experienced an increased risk of sepsis and mortality rate (death) when they were not turned every two hours. ii. On 2/12/24 at 10:00 a.m., an interview was conducted with RN #9. RN #9 stated skin assessments were done each shift. RN #9 stated patients who were immobile, bedridden, or had diabetes were at the greatest risk for pressure injuries and needed to be turned every two hours. RN #9 stated turning patients every two hours was important because immobility led to wounds that became infected and went to the bone. RN #9 stated patients were asked if they wanted to reposition when staff checked on patients hourly. RN #9 stated when skin assessments were not performed, there was a risk of a pressure injury not being noticed and treated. iii. On 2/14/24 at 3:06 p.m., an interview was conducted with RN #5. RN #5 stated a patient who was turned every two hours to help prevent pressure injury was a standard of care for patients who were at risk for pressure injuries. RN #5 stated they used wedges to support patients on their sides and knew when a patient was turned because they remembered where the wedges were with the previous turn. RN #5 stated there was no place for documentation when a patient was turned and documentation was not required. RN #5 stated they were unsure if patients were turned every two hours when RN #5 was not involved in the care of the patient. iv. On 2/15/24 at 10:25 a.m., an interview was conducted with RN #10. RN #10 stated patients were turned every two hours. RN #10 stated patients were turned every three to four hours if they refused to be turned every two hours. RN #10 stated it was not documented in the medical record when a patient refused to be turned. RN #10 stated not all nurses documented the pressure injury interventions every two hours in the medical record because it was the expected standard of care. RN #10 stated it was important for patients to be turned every two hours because it prevented additional pressure injuries that led to sepsis. RN #10 stated pressure injury intervention documentation was important because if it was not documented, it was not performed. RN #10 stated when the documentation was not completed, the care team was unable to see the full care of the patient which affected future decisions for the patient’s care. v. On 2/14/24 at 2:33 p.m., an interview was conducted with ICU nurse manager (Manager) #6. Manager #6 stated interventions for pressure injuries were used on all patients, regardless of the skin assessment risk for pressure injury. Manager #6 stated all patients needed to be turned or repositioned every two hours for the prevention and treatment of pressure injuries. Manager #6 stated if a patient had pressure injury wounds and was malnourished, the patients were turned every hour. Manager #6 stated staff documented by exception, if an intervention was a standard of care, or a condition was within normal limits, it was not documented. Manager #6 stated a patient turned every two hours was a standard of care practice and therefore, was expected to be performed. Manager #6 stated there was no place to document pressure injury interventions in the medical record except in the skin assessment area. Manager #6 stated they had no way to determine if patients were turned except in follow-up conversations with the staff. Manager #6 stated it was important to document when patients were turned because if it was not documented, it could not be verified that it was performed. Manager #6 stated patients were at risk of further skin breakdown (pressure injuries), delayed discharge, infection, and death when they were not turned every two hours. Manager #6 stated pressure injuries were potentially lifelong events for patients. vi. On 2/13/24 at 1:49 p.m., an interview was conducted with the director of education (Director) #7. Director #7 stated patient pressure injury interventions were not documented every two hours. Director #7 stated the documentation was completed every shift. Director #7 stated the staff knew the standard of care was to turn the patients every two hours based on education provided during orientation and yearly competency education. Director #7 stated it was better practice to document every two hours because it demonstrated the care the patient received. vii. On 2/15/24 at 10:40 a.m., an interview was conducted with assistant chief nursing officer (ACNO) #11. ACNO #11 stated the documentation for pressure injury interventions every two hours was charted once a shift because it was considered to be a standard level of care for pressure injury prevention. ACNO #11 stated staff documented by exception and were expected to document when the standard of care was not met. ACNO #11 stated facility leadership ensured patients were turned every two hours when they rounded on the units and watched the care provided by the staff. ACNO #11 stated not all staff were observed and documentation in the medical record showed the patients were turned every two hours. ACNO #11 stated when the documentation was not completed, it was assumed to not have been performed. This was in contrast to the Pressure Injury Prevention and Wound Care education tool which read, staff were to turn patients frequently (every two hours), update the care plan, and document the interventions according to facility policy.”

“ORDERS FOR REHABILITATION SERVICES CFR(s): 482.56(b) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 47959 Based on document review and interviews, the facility failed to obtain a provider order before a procedure was performed on a patient in one of one patients reviewed who underwent a wound debridement (Patient #4). Findings include: Facility Policies: The Conservative Sharp Debridement policy read, a Certified Wound, Ostomy, and Continence Nurse (CWOCN), Certified Wound Care Nurse (CWCN), Physical Therapist (PT), or provider will be consulted by a provider with an order for evaluation and treatment or conservative sharp debridement of wound(s). The Pressure Injury Prevention and Management policy read, a stage I pressure injury was non-blanchable erythema of intact skin. A stage III pressure injury was a full-thickness skin loss in which fat tissue was visible. References: The Colorado Revised Statutes 2023 Title 12 Professions and Occupations Article 285: Physical Therapists and Physical Therapist Assistants (scope of practice) read, a physical therapist is authorized to perform wound debridement under a physician’s order. The Rules and Regulations of the Medical Staff read, all orders for treatment, diagnostic tests, drugs, biologicals, operative and special procedures must be entered into the electronic health record (EHR). An order requesting a consult must be present in the EHR and identify the consultant. 1. The facility failed to ensure an order was obtained before a wound debridement was performed on a patient. A. Record Review i. Medical record review revealed Patient #4 was admitted on 10/10/23 for shortness of breath and sepsis (a severe infection in the body) related to Clostridiodes difficile (C.diff). Patient #4 had a stage I pressure injury (pressure-related alteration of intact skin) on their right heel and a stage III pressure injury (a full-thickness loss of skin in which fat tissue is visible) on their sacrum (tailbone). The medical record review revealed Patient #4 had a conservative sharp debridement (a procedure to remove nonviable [dead] tissue from a wound with a scalpel, forceps, and scissors) performed by physical therapist (Therapist) #1 on 11/4/23. Additional medical record review revealed there was no provider order for the procedure. The conservative sharp debridement procedure continued to be performed daily on Patient #4 through 11/9/23 by Therapists #1, #2, and #3. Further medical record review revealed Patient #4 was readmitted to the facility on 11/15/23 with hematuria (blood in the urine). Medical record review revealed Patient #4 continued to need pressure injury treatment for the pressure injury on their sacrum. Patient #4 had a conservative sharp debridement performed by Therapist #3 on 11/16/23 and 11/21/23 with no provider order. B. Interviews i. On 2/14/24 at 10:08 a.m., an interview was conducted with Therapist #2. Therapist #2 stated conservative sharp debridement was performed on patients with pressure injury wounds that had nonviable tissue in the wound. Therapist #2 stated the procedure was performed at the bedside and included a scalpel and forceps. Therapist #2 stated providers wrote the orders for physical therapy evaluation and treatment. Therapist #2 stated the only necessary order was for evaluation and treatment because the physical therapists were providers who assessed and treated patient conditions. Therapist #2 stated they added debridement to the patient’s plan of care as a necessary intervention for wound care. Therapist #2 stated physical therapy was consulted by wound care nurses when conservative sharp debridement was needed. Therapist #2 stated the risks of debridement were bleeding, infection, cuts to viable (live) tissue, and pain for the patient. Therapist #2 stated the importance of provider orders for wound debridement was the physician oversight they provided. Therapist #2 also stated facility policies required provider orders and physical therapists used their clinical judgment for conservative sharp debridement under the evaluation and treatment orders. This was in contrast to the Conservative Sharp Debridement policy which required an order from the provider to perform conservative sharp debridement. ii. On 2/14/23 at 3:06 p.m., an interview was conducted with registered nurse (RN) #5. RN #5 stated the medical provider ordered the consultation for the wound care staff to evaluate and treat the patients. RN #5 stated an RN was able to consult for wound care if the patient had a pressure injury which existed at the time of admission, but the provider was still responsible to have awareness of the patient’s condition and sign the order. RN #5 stated wound debridement was done by the physical therapists and could not be done without a provider order. RN #5 stated it was important to have the order for debridement because it ensured the patient received what they needed for treatment and protected the patient from harm. iii. On 2/14/24 at 10:44 a.m., an interview was conducted with the director of rehabilitation (Director) #4. Director #4 stated physical therapists needed a consult order from the provider. Director #4 stated once the evaluation and treatment order was received from the physician, the physical therapist assessed the patient and wrote the patient’s plan of care for the wound. Director #4 stated the physical therapists used their clinical judgment to determine when the wound needed additional or different treatment but also deferred to the physician when conservative sharp debridement was used. Director #4 stated it was important to have provider orders because they provided physician oversight for the care of the patient. The risk of a procedure performed without a provider order was harm to the patient if the provider did not want the procedure performed. The medical record review and interviews were in contrast to the facility’s Conservative Sharp Debridement policy which read, a physical therapist would be consulted by a provider with an order for conservative sharp debridement of wounds. Additionally, they were in contrast to the Colorado Revised Statutes 2023 Title 12 Professions and Occupations Article 285: Physical Therapists and Physical Therapist Assistants scope of practice which read a physical therapist was authorized to perform wound debridement under a physician’s order. Furthermore, they were in contrast to the facility’s Rules and Regulations of the Medical Staff which read all orders for treatment, special procedures, and consultations were to be entered into the EHR by the provider.”