Indiana University Health

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 48704 Based on documentation and interview, the facility failed to document the completeness of the transfer form in 3 of 12 transferred patient (Patient 2, 18, and 19) medical records reviewed, failed to complete a transfer form for 1 of 12 transferred patients (Patient 4) medical records reviewed, and failed to document risks of transfer in 1 of 12 transferred patient (Patient 19) medical records reviewed. Findings Include: 1. See findings cited at 42 CFR 489.24, A2409”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 48704 Based on documentation and interview, the facility failed to document the completeness of the transfer form in 3 of 12 transferred patient (Patient 2, 18, and 19) medical records reviewed, failed to complete a transfer form for 1 of 12 transferred patients (Patient 4) medical records reviewed, and failed to document risks of transfer in 1 of 12 transferred patient (Patient 19 ) medical records reviewed. Findings include: 1. Facility policy titled, Emergency Medical Treatment and Labor Act (EMTALA), Publication Date: 01/15/2025, indicated under VI. Procedures, III. Transfer, 2. The attached transfer form must be completed for each transfer, D. External Transfers, 1. Document the discussion and other pertinent information in the patient’s medical record. 2. Review of patient 2’s medical record indicated the following: a. The patient presented to the emergency room with chief complaint of intentional overdose on 05/24/2026. b. The transfer authorization form lacked documentation of patient’s risks. c. The patient was transferred for higher level of care. 3. Review of patient 4’s medical record indicated the following: a. The patient presented to the emergency room with chief complaint of suicidal ideations on 05/04/2026. b. MR lacked documentation of a transfer form. c. The patient was transferred to another facility for higher level of care. 4. Review of patient 18’s medical record indicated the following: a. The patient presented to the emergency room with chief complaint of facial burns on 05/04/2026. b. MR lacked documentation of risks on transfer form, discussed in provider notes; provider note lacked documentation of patient condition. c. The patient was transferred to another facility for higher level of care. 5. Review of patient 19’s medical record indicated the following: a. The patient presented to the emergency room with chief complaint of visual changes and dizziness on 05/05/2026. b. MR lacked documentation of risks and condition on transfer form, provider note lacked risks discussed with patient, provider note indicated patient stable. c. The patient was transferred to another facility for higher level of care. 6. Interview with A1 (Accreditation and Regulatory Consultant) on 07/09/2026 at approximately 4:15 p.m. indicated the following: a. Patient 2’s MR lacked documentation of risks and condition on transfer form. b. Patient 4’s MR lacked a transfer form. c. Patient 18’s MR lacked documentation of risks on transfer form, discussed in provider notes; provider note lacked documentation of patient condition. d. Patient 19’s MR lacked documentation of risks and condition on transfer form, provider note lacked risks discussed with patient, provider note indicated patient stable.”

“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: 48704 Based on document review and interview, the facility failed to ensure a completed document receipt of discharge instructions in 8 of 10 (Patients 1, 2, 3, 4, 5, 6, 7, and 8) medical records reviewed. Findings include: 1. Facility failed to follow policy titled, Discharge of Post-Anesthesia Patients, Publication Date: 07/30/2025, indicated under VI. Procedures, under H. Discharge Process, 4. Phase II RN and family/significant other responsible friend/family member will sign a paper copy of the discharge instructions and patient/family will be given a copy. 2. Review of patient 1’s medical record indicated the following: a. The patient was admitted on 11/25/2025. b. Medical record lacked documentation of the time under patient/representative signature on the discharge instructions signature page. c. The patient was discharged on 11/25/2025. 3. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 11/04/2025. b. Medical record lacked documentation of witness signature and date/time on the discharge instructions signature page. c. The patient was discharged on 11/04/2025. 4. Review of patient 3’s medical record indicated the following: a. The patient was admitted on 11/06/2025. b. Medical record lacked documentation of the time under patient/representative signature and witness signature on the discharge instructions signature page. c. The patient was discharged on 11/06/2025. 5. Review of patient 4’s medical record indicated the following: a. The patient was admitted on 11/04/2025. b. Medical record lacked documentation of the time under patient/representative signature and witness signature on the discharge instructions signature page. c. The patient was discharged on 11/04/2025. 6. Review of patient 5’s medical record indicated the following: a. The patient was admitted on 11/06/2025. b. Medical record lacked documentation of the date/time under patient/representative signature on the discharge instructions signature page. c. The patient was discharged on 11/06/2025. 7. Review of patient 6’s medical record indicated the following: a. The patient was admitted on 11/25/2025. b. Medical record lacked documentation of the date/time under patient/representative signature on the discharge instructions signature page. c. The patient was discharged on 11/25/2025. 8. Review of patient 7’s medical record indicated the following: a. The patient was admitted on 11/04/2025. b. Medical record lacked documentation of the date/time under patient/representative signature, witness signature and date/time on the discharge instructions signature page. c. The patient was discharged on 11/04/2025. 9. Review of patient 8’s medical record indicated the following: a. The patient was admitted on 11/25/2025. b. Medical record lacked documentation of the time under witness signature on the discharge instructions signature page. c. The patient was discharged on 11/25/2025. 10. Interview with A1 on 07/01/2026 at approximately 5:20 p.m. confirmed the above missing documentation in patient’s 1, 2, 3, 4, 5, 6, 7, and 8’s medical record.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing failed to document patient meal intake in 10 of 10 patient (Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) medical records reviewed. Findings include: 1. Facility policy titled, Guideline for Adult Academic Health Center PCU Standards of Care, Publication Date 10/29/2025, indicated under III. Guideline, Intake and Output, Document, All findings when assessments occur. 2. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 12/24/2025. b. Medical record lacked documentation of meal intake for the following: 12/26/2025 breakfast, lunch, and dinner; 12/27/2025 breakfast, lunch, and dinner; 12/28/2025 lunch and dinner; 12/29/2025 breakfast, lunch, and dinner; 12/30/2025 breakfast, lunch, and dinner; 12/31/2025 lunch and dinner; 01/01/2026 breakfast; 01/02/2026 breakfast, lunch, and dinner; 01/03/2026 dinner; 01/04/2026 breakfast, lunch, and dinner; 01/05/2026 lunch; 01/08/2026 breakfast, lunch, and dinner; 01/09/2026 breakfast and lunch; 01/10/2026 breakfast, lunch, and dinner; 01/11/2026 breakfast, lunch, and dinner; 01/12/2026 breakfast, lunch, and dinner; 01/13/2026 breakfast and lunch. c. Patient was discharged on 01/13/2026. Review of Patient 1’s medical record for second admission indicated the following: a. The patient was admitted on 01/29/2026. b. Medical record lacked documentation of meal intake for the following: 01/30/2026 lunch and dinner; 01/31/2026 breakfast, lunch, and dinner; 02/01/2026 lunch; 02/02/2026 breakfast, lunch, and dinner; 02/03/2026 breakfast, lunch, and dinner; 02/04/2026 breakfast, lunch, and dinner; 02/05/2026 breakfast, lunch, and dinner; 02/06/2026 breakfast, lunch, and dinner; 02/07/2026 breakfast, lunch, and dinner; 02/08/2026 breakfast, lunch, and dinner; 02/09/2026 lunch and dinner; 02/10/2026 breakfast, lunch, and dinner; 02/11/2026 dinner; 02/12/2026 breakfast and lunch; 02/13/2026 dinner; 02/14/2026 breakfast, lunch, and dinner; 02/15/2026 breakfast, lunch, and dinner; 02/16/2026 breakfast, lunch, and dinner; 02/17/2026 breakfast, lunch, and dinner; 02/18/2026 breakfast, lunch, and dinner; 02/19/2026 breakfast, lunch, and dinner; 02/20/2026 breakfast, lunch, and dinner; 02/22/2026 breakfast, lunch, and dinner; 02/23/2026 breakfast, lunch, and dinner; 02/24/2026 breakfast, lunch, and dinner; 02/25/2026 breakfast, lunch, and dinner; 02/26/2026 breakfast, lunch, and dinner; 02/27/2026 dinner; 02/28/2026 breakfast, lunch, and dinner; 03/01/2026 breakfast, lunch, and dinner; 03/02/2026 breakfast, lunch, and dinner; 03/03/2026 breakfast, lunch, and dinner; 03/04/2026 breakfast and lunch; and 03/05/2026 breakfast. c. Patient was discharged on 03/05/2026. 3. Review of patient 2’s medical record indicated the following: a. The patient was admitted on 12/23/2025. b. Medical record lacked documentation of meal intake for the following: 12/23/2025 dinner; 12/24/2025 breakfast, lunch, and dinner; 12/25/2025 lunch and dinner; 12/26/2025 lunch and dinner; and 12/27/2025 breakfast and lunch. c. The patient was discharged on 01/27/2026. 4. Review of patient 3’s medical record indicated the following: a. The patient was admitted on 12/19/2025. b. Medical record lacked documentation of meal intake for the following: 12/20/2025 dinner; 12/21/2025 breakfast and lunch. c. The patient was discharged on 12/21/2025. 5. Review of patient 4’s medical record indicated the following: a. The patient was admitted on 12/29/2025. b. Medical record lacked documentation of meal intake for the following: 12/31/2025 dinner. c. The patient was discharged on 01/02/2026. 6. Review of patient 5’s medical record indicated the following: a. The patient was admitted on 12/15/2025. b. Medical record lacked documentation of meal intake for the following: 12/17/2025 breakfast, lunch, and dinner; 12/18/2025 breakfast, lunch, and dinner; and 12/19/2025 breakfast. c. The patient was discharged on 12/19/2025. 7. Review of patient 6’s medical record indicated the following: a. The patient was admitted on 01/03/2026. b. Medical record lacked documentation of meal intake for the following: 01/04/2026 lunch; 01/05/2026 breakfast; and 01/06/2026 breakfast. c. The patient was discharged on 01/06/2026. 8. Review of patient 7’s medical record indicated the following: a. The patient was admitted on 01/29/2026. b. Medical record lacked documentation of meal intake for the following: 01/30/2026 breakfast, lunch, and dinner; 01/31/2026 dinner; 02/01/2026 breakfast, lunch, and dinner; 02/02/2026 breakfast and lunch. c. The patient was discharged on 02/02/2026. 9. Review of patient 8’s medical record indicated the following: a. The patient was admitted on 01/12/2026. b. Medical record lacked documentation of meal intake for the following: 01/12/2026 dinner; 01/13/2026 breakfast and lunch; 01/14/2026 breakfast and dinner; and 01/15/2026 lunch. c. The patient was discharged to home. 10. Review of patient 9’s medical record indicated the following: a. The patient was admitted on 01/21/2026. b. Medical record lacked documentation of meal intake for the following: 01/21/2026 lunch and dinner; and 01/22/2026 breakfast and lunch. c. The patient was discharged on 01/22/2026. 11. Review of patient 10’s medical record indicated the following: a. The patient was admitted on 01/08/2026. b. Medical record lacked documentation of meal intake for the following: 01/09/2026 dinner; 01/10/2026 breakfast, lunch, and dinner; 01/11/2026 breakfast and dinner; and 01/13/2026 breakfast and lunch. c. The patient was discharged on 01/13/2026. 12. Interview with A1 (Accreditation and Regulatory Senior Consultant) on 04/27/2026 at approximately 4:30 p.m. confirmed patient 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 medical records lacked documentation of meal intakes as indicated above.”

“Condition of Participation: Pharmaceutical Se CFR(s): 482.25 §482.25 Condition of Participation: Pharmaceutical Services. The hospital must have pharmaceutical services that meet the needs of the patients. The institution must have a pharmacy directed by a registered pharmacist or a drug storage area under competent supervision. The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service. This Condition is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to ensure the ordering provider was contacted to obtain order clarification prior to verifying a medication order dosage outside of the suggested dose range for 1 of 10 medical records reviewed. (P1) The cumulative effects of these systemic problems resulted in the facility’s inability to provide pharmaceutical services in a safe manner.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to ensure the ordering provider was contacted to obtain order clarification prior to verifying a medication order dosage outside of the suggested dose range for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,”Medication Administration and Management”, no policy number, publication date 05/08/2023, indicated under VI. PROCEDURES: PRESCRIBING. C. Medication orders will be entered into the hospital computer system. 2. If a medication order requires clarification, the provider should be contacted by the pharmacist. Providers are contacted by using the normal paging procedures. If a prescriber does not answer the page after a reasonable amount of time, the call-coverage system will be utilized. Clarified orders are noted as telephone orders and require subsequent authentication consistent with the verbal orders policy. 2. Review of P1’s MR (Medical Record) indicated on 3/1/25 at 11:15 am NP1 (Nurse Practitioner) electronically entered an order for Diazepam 1.1 mg (milligram)/kg (kilogram), 1.8 mg, 1.8 ml, TID (Three Times Daily). Alert history documentation dated 3/1/25 at 11:24 am indicated NP1 (Nurse Practitioner) overrode an alert for Diazepam indicating the 1.8 mg Orally TID (Three Times Day) was over the suggested dose range for the medication. Override reason listed as patient condition warrants dosage. The suggested daily dose range alerted was 0-1 mg/kg.(0-1.7 mg) for P1’s weight calculation (1.7 kg) on 2/26/25 at 10:22 am. Alert history documentation dated 3/1/25 at 11:29 am indicated PH1 (Pharmacist) overrode an alert for Diazepam indicating the 1.8 mg Orally TID (Three Times Day) was over the suggested dose range for the medication. Override reason listed as pharmacist clinical judgement. The suggested daily dose range alerted was 0-1 mg/kg.(0-1.7 mg) for P1’s weight calculation (1.7 kg) on 2/26/25 at 10:22 am. MAR (Medication Administration Record) indicated P1 received 1.8 mg of Diazepam orally (via Oralgastric tube) on 3/1/25 at 4:19 pm & 10:00 pm, and on 3/2/25 at 9:27 am, 3:21 pm, & 9:02 pm. Neurology note documentation dated 3/4/25 at 1:55 pm indicated P1 was started on diazepam, but due to an ordering error, P1 was given very supratherapeutic dosing over a day. 3. In interview on 4/7/26 at approximately 2:20 pm with PH1 (Pharmacist) confirmed he/she verified P1 diazepam order on 3/1/2025. PH1 endorsed he/she did notice the ordered dose was high. PH1 indicated he/she called to verify the ordered amount with NP1 (Nurse Practitioner). PH1 did not document the verification conversation with NP1. 4. In interview on 4/7/26 at approximately 2:35 pm with NP1 (Nurse Practitioner) confirmed diazepam is not a drug he/she normally prescribes. Unable to remember speaking with PH1 related to dose verification. Denied remembering alerts firing during ordering medication. Confirmed he/she entered order, no alerts fired that he/she could remember, does not remember overriding an alert, confirmed he/she did not believe that she had any contact with the verifying pharmacist but ultimately cannot recall.”

“ORGANIZATION OF RESPIRATORY CARE SERVICES CFR(s): 482.57(a) The organization of the respiratory care services must be appropriate to the scope and complexity of the services offered. This Standard is not met as evidenced by: 48704 Based on document review and interview, respiratory care failed to complete initial assessment and document shift assessments according to policy in 1 of 10 (Patient 5) medical records reviewed. Findings include: 1. Facility failed to follow policy titled, Protocol for Respiratory Care Assessment, Publication Date 09/22/2023, indicated under Procedures, C. Clinical Responsibilities, 1. Initial assessments will be completed within 2-4 hours of the original order. 2. Facility failed to follow policy titled, Scope of Assessment, Publication Date: 06/24/2024 under L. Respiratory Care Practitioners, b. Scope of Assessment, i. Informal assessments will be done at the time of the initial treatment and once per shift. 3. Review of patient 5’s medical record indicated the following: a. On 10/17/2025, patient was admitted to the progressive care unit for oropharyngeal bleeding. MR indicated the patient had a laryngectomy and a laryngectomy tube. A respiratory evaluation or assessment was ordered at 5:17 a.m. Medical record indicated the initial respiratory assessment was completed and emergency equipment was placed at the patient’s bedside at 2:01 p.m., approximately 8 hours and 44 minutes after patient’s admission and 4 hours 44 minutes after respiratory assessment provider order. Medical record lacked respiratory assessment and safety measures documentation for night shift. b. On 10/18/2025, medical record lacked respiratory care assessment which included safety equipment documentation for day and night shift. c. On 10/19/2025, medical record lacked respiratory care assessment which included safety equipment documentation for night shift. d. On 10/20/2025, medical record lacked respiratory care assessment which included safety equipment documentation for night shift. e. On 10/21/2025, medical record lacked respiratory care assessment which included safety equipment documentation for day shift. 4. Interview with A6 (Manager of Education, Respiratory Care) on 11/24/2025 at approximately 1:00 p.m. confirmed the respiratory assessment was ordered at 5:17 a.m. and initial assessment was completed and documentation of safety equipment at the bedside was at 2:01 p.m. approximately 8 hours and 44 minutes after admission and 4 hours and 44 minutes after the respiratory assessment order. At approximately 2:00 p.m. A6 confirmed respiratory care failed to document their shift assessments which included safety equipment on the following days and shifts: 10/17/2025, night shift; 10/18/2025, both day and night shift; 10/19/2025 night shift; 10/20/2025 night shift; and 10/21/2025 day shift.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure all complaint allegations were addressed for 1 of 10 patient (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled, Patient/Parent Rights and Responsibilities, Complaints, and Grievances, publication date 05/27/2025, indicated under IV. Definitions, Patient Grievance: 1. Any patient complaint that cannot be resolved promptly on the spot, by the patient care team members after escalating through immediate supervisor, their delegate, or clinical leadership. 2. Situations were patients call or write regarding concerns related to care or services that could not have been resolved during their stay. Under VI. Procedures, 3. If the complaint cannot be solved by team members immediately present, team members should contact their immediate supervisor, their delegate, or clinical leadership to address the patient/family concern and reach resolution. Unresolved complaints may become grievances, and the following procedures may apply if resolution is not achieved. 2. Review of Complaint and Grievances from 01/01/2025 to 07/27/2025 indicated there was a complaint filed on 05/29/2025 regarding patient 4’s care during the current and previous hospitalization. Report indicated concerns during previous hospitalization which included a medication error and an identified nurse making inappropriate comments; report lacked documentation regarding an allegation and no follow up was documented. 3. Interview with A3 (Accreditation and Regulatory Consultant) on 07/28/2025 at approximately 3:05 p.m. confirmed that Patient Advocacy indicated they did not send a formal response to the complaint filed on 05/29/2025 as it was considered a complaint as the patient was a current inpatient. A3 confirmed that the complaint had an allegation that lacked documentation of response and allegations were from previous hospitalization. 4. Interview C1 (Complainant) on 07/31/2025 at approximately 2:42 p.m. indicated that they did notify the Patient Advocacy line of concerns which included concerns from patient 4’s first hospitalization on 05/29/2025; C1 indicated all concerns in the formal complaint were not addressed and did not receive any documentation regarding the complaints.”

“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: 48704 Based on document review and interview, nursing services failed to administer medication as ordered for 1 of 10 (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled, Medication Administration and Management, publication date 05/08/2023, indicated under IV. Procedures, under B. The team member administering the medications must perform the 5 rights plus 4 checks (9 rights) on all medications prior to administering them to a patient. This includes right patient, right medication, right dose, right time, right route, right documentation, right action, right form, and right response. 2. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 04/04/2025. b. Medical record indicated on 04/08/2025 at 1:12 p.m. provider ordered Geodon 5 mg (milligrams) IV (intravenous) push one time dose. Medication administration record indicated the patient was administered Geodon 20 mg IV push at 2:49 p.m. Medical record indicated the patient became hypoxic and hypertensive. c. Patient was discharged on 05/07/2025 in stable condition. 3. Review of Incidents Reports from 01/01/2025 to 07/27/2025 indicated there was an incident report related to Patient 4 and a medication error on 04/08/2025. Report indicated that the N1 scanned the medication, nurse looked up to see how to dilute the medication and how to administer it. N1 indicated they diluted the medication and drew it up; administered the medication over 3 minutes as ordered. When N1 went to sign off the medication, they realized the dose needed to be entered and that the vial had more than ordered dose. 4. Interview with A8 (Executive Director of Pharmacy) on 07/28/2025 at approximately 3:02 p.m. confirmed that Geodon is packaged in a vial that is 20 mg/ml and that N1 administered the entire vial to the patient.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48704 Based on observation and interview, facility failed to maintain a clean environment for 4 of 20 patient rooms (B487, B489, B492, and B496) observed. Findings include: 1. Facility policy titled, ES Environmental Cleaning, published 01/09/2025, indicated under VI. Procedures, A. Cleaning Principles, 9. High dust horizontal surfaces and fixtures above shoulder height, including vents. Use an extension with the appropriate equipment such as a high duster or HEPA filtered vacuum. Replace microfiber high district cloth at the end of the day, when dirty and after each isolation room. Do not high dust over a patient area in an occupied room. 2. Observation on 07/28/2025 at approximately 3:10 p.m. observed visible, copious, and hanging dust from the ceiling vents which were located directly above the patient’s bed in the following rooms: B487, B489, B492, and B496 on the 4B unit. 3. Interview with A3 (Accreditation and Regulatory Consultant) and A10 (Manager of Environmental Services) on 07/28/2025 at approximately 3:30 p.m. confirmed the following rooms had visible copious hanging dust in the ceiling vents in patient rooms B487, B489, B492, and B496.”

“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: 48704 Based on document review and interview, nursing services failed to document pain assessment as ordered, pain assessment prior to pain medication administration, and document pain interventions and patient’s condition in 1 of 10 (Patient 1) medical records reviewed. The cumalative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 48704 Based on document review and interview, nursing services failed to document pain assessment as ordered, pain assessment prior to pain medication administration, and document pain interventions and patient’s condition in 1 of 10 (Patient 1) medical records reviewed. 1. Facility policy titled Pain Management, publication date: 02/17/2025, indicated under Procedures, C. Reassess and respond to patient’s pain plan throughout the Registered Nurse’s (RN) shift. Reassessment is based on intervention, delivery method, and progress towards functional goal. 2. Lippincott Procedures - Pain Assessment pediatric (lww.com): Pain Assessment, pediatric, Revised: May 19, 2025, under Introduction, A child’s pain should be reassessed at designated intervals according to the type of pain intervention used (for example by the oral, IV, or transdermal route) to evaluate progress toward pain management goals; under Documentation, reassessment findings (as indicated), description of behavior, positions of comfort, activity level, pain management interventions. The policy lacked what designated intervals were established for assessment. 2. Facility policy titled, Scope of Assessment, publication date: 06/27/2024, indicated under V. Policy Statements, B. Reassessments continue throughout hospitalization at regularly specified times to determine the patient’s response to treatment and/or when significant change occurs in the patient’s condition or diagnosis. 3. Facility policy titled, Medication Administration and Management, publication date: 05/08/2023 under Monitoring, A. All team members shall monitor and document as appropriate the effects of medications administered, 1. Effects of pain medication are documented consistent with pain reassessment procedures. 4. Review of Patient 1’s medical record indicated the following: a. The patient was admitted on 06/26/2025. b. Medical record indicated provider order on 06/26/2025 at 5:03 p.m. indicated pain assessment every 4 hours. At 11:19 p.m. the patient’s pain score was 10/10; MR lacked documentation of interventions and patient condition. c. On 06/27/2025 the patient’s pain was not assessed from midnight until 7:00 a.m. The medical record lacked documentation of the one of six ordered pain assessments. At 6:35 a.m. Hydromorphone 0.6 mg intravenous push was administered, medical record lacked documentation of pain assessment prior to administration of medication. At 7:00 a.m. the patient’s pain score was 8/10, the medical record lacked documentation of interventions. d. The patient was discharged on 06/28/2025 in stable condition. 5. Interview with A5 (Nursing Practice Manager) on 07/09/2025 at approximately 1:10 p.m. indicated that the facility’s policy does not specify when nursing is to reassess the patient’s pain level after administration of medication or interventions. A5 indicated that nursing is to utilize nursing judgement of when to reassess pain. A5 confirmed the above policies referenced designated times. 6. Interview with A2 (Manager of Accreditation and Regulatory) and A8 (8 East Manager) on 07/09/2025 at approximately 6:31 p.m. confirmed the above findings in patient 1’s medical record. 7. Interview with N2 (Registered Nurse) on 07/10/2025 at approximately 1:54 p.m. indicated they cared for patient patient 1 on 06/27/2025 and the patient had significant pain and pain control was a priority for the duration of their shift; N2 indicated the facility orientation did not include when to assess and reassess pain interventions. 8. Interview with N1 (Registered Nurse) on 07/17/2025 at approximately 5:02 p.m. indicated the facility orientation did not include when to assess and reassess pain interventions.”

“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: 48704 Based on document review and interview, nursing services failed to provide oral care for 5 of 10 (Patients 3, 4, 7, 9, and 10) medical records reviewed; and failed to document patient turn/repositioning and/or document how the patient was repositioned to prevent pressure injury in 1 of 10 (Patient 3) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“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: 48704 Based on document review and interview, nursing services failed to provide oral care for 5 of 10 (Patients 3, 4, 7, 9, and 10) medical records reviewed, and failed to document patient turn/repositioning or document how the patient was repositioned to prevent pressure injury in 1 of 10 (Patient 3) medical records reviewed. Findings include: 1. Facility policy titled Guideline for Patient Oral Care, Publication Date: 10/23/2023, indicated under III. Guideline, A. Toothbrushing is to be performed at a minimum of two times a day for all patients no matter their clinical status. B. Oral care is to be routinely performed based on patient status according to the minimum intervals outlined below: under column Patient Ventilated Patients, under column Oral Care Frequency, Every 2 to 4 hours; under column Patient, Intermediate Patients, under column Oral Care Frequency, Every 6 hours. 2. Facility policy titled Protocol for Adult Skin and Wound Care, publication date 06/24/2024, indicated under IV. PROTOCOL STATEMENTS, c. The protocol provides interventions to prevent or manage common clinical problems such as moisture associated skin damage, pressure injuries, and chronic wounds. Under HAPI - Skin Wound Algorithm, Is the patient at high risk for pressure injuries? Risk factors; Braden score greater than or less than 18 or sub scale greater than or less than 2, Yes, under Repositioning/Mobility: Turn/repositioning/reposition frequently according to patient condition. Under HAPI Skin Wound Treatment Algorithm under Unstageable, Relieve all pressure to area. 3. Review of Patient 3’s medical record indicated the following: a. The patient was admitted on 08/05/2024. b. On 08/06/2024 the provider ordered the patient nothing by mouth (NPO) at 7:55 p.m.; the order was discontinued on 08/07/2024 at 10:01 a.m.; the medical record lacked documentation of oral care, a total of 14 hours and 6 minutes, 2 oral care entries. The wound and ostomy team note indicated the sacrum on assessment had a clean, dry, and intact foam dressing in place, skin with generalized jaundice, sacrum and buttock nontender to palpation, and small oval diffuse purple wound noted on right buttock, not over bone, and etiology likely trauma. c. On 08/08/2024 the nursing flowsheet indicated the patient’s Braden score was 17; lacked documentation of patient turn at 6:24 a.m. d. On 08/09/2024 at 8:00 p.m. the nursing flowsheet indicated the patient’s Braden score was 17; the medical record indicated the patient was positioned on their back and not turned as indicated per patient’s Braden scale from 8:00 p.m. to 8/10/2024 at 4:28 a.m. e. On 08/10/2024 at 9:00 a.m. the nursing flowsheet indicated the patient’s Braden score was 18; the medical record lacked documentation of patient turning at 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m. and 7:00 p.m. At 8:00 p.m. the nursing flowsheet indicated the patient’s Braden score was 17; the medical record indicated the patient was positioned on their back and not turned as indicated per patient’s Braden scale from 8:00 p.m. to 8/11/2024 at 7:00 a.m. f. On 08/11/2024 at 8:00 p.m. the nursing flowsheet indicated the patient’s Braden score was 15; the medical record indicated the patient was positioned on their back and not turned as indicated per patient’s Braden scale from 8:00 p.m. to 8/12/2024 at 6:00 a.m. g. On 08/23/2024, the wound note indicated the patient’s sacral wound was unstageable. m. On 09/03/2024, the provider ordered the patient NPO 11:00 a.m.; the order was discontinued on 09/04/2024 at 11:23 a.m.; medical record lacked documentation of oral care, a total of 12 hours and 3 minutes, 2 oral care entries. h. On 09/24/2024, the provider ordered the patient NPO at 11:25 a.m. and the order was discontinued on 09/24/2024 at 9:06 p.m.; MR lacked documentation of oral care, a total of 1 hours and 3 minutes, 1 oral care entry. i. On 10/04/2024, the medical record indicated the provider ordered the patient NPO at 12:18 p.m., and the order was discontinued on 10/04/2024 at 11:10 p.m.; the medical record lacked documentation of oral care, a total of 11 hours and 52 minutes, 1 oral care entry. j. On 02/17/2025, the patient passed at 5:29 p.m. 4. Review of Patient 4’s MR indicated the following: a. The patient was admitted on 08/23/2024. b. On 08/24/2024, medical record indicated the provider ordered the patient to be NPO at 4:46 p.m. and the order was discontinued on 08/25/2024 at 09:39 a.m. c. Medical record lacked documentation of oral care from 08/24/2024 at 4:46 p.m. to 08/25/2024 at 5:00 p.m., a total of 24 hours and 14 minutes, 4 oral care entries. d. Patient was discharged on 09/06/2024. 5. Review of Patient 7’s MR indicated the following: a. The patient was admitted on 11/7/2024. b. On 11/07/2024, medical record indicated the provider ordered the patient to be NPO at 1:57 p.m. and the order was discontinued on 11/08/2024 at 6:30 a.m. c. Medical record lacked documentation of oral care from 11/07/2024 at 1: 57 p.m. to 11/08/2024 at 6:30 a.m., a total of 16 hours 33 minutes, 2 oral care entries. d. Patient was discharged on 11/11/2024. 6. Review of Patient 9’s MR indicated the following: a. The patient was admitted on 01/12/2025. b. On 01/12/2025, medical record indicated the provider ordered the patient to be NPO at 5:04 a.m. and the order was discontinued on 01/13/2025 at 4:36 p.m. c. Medical record lacked documentation of oral care from 01/12/2025 at 5:04 a.m. to 01/13/2025 at 4:36 p.m., a total of 35 hours 32 minutes, 5 oral care entries. d. The patient was discharged on 01/16/2025. 7. Review of Patient 10’s MR indicated the following: a. The patient was admitted on 12/31/2025. b. On 01/12/2025, medical record indicated the provider ordered the patient to be NPO at 11:20 a.m. and the order was discontinued on 01/13/2025 at 12:26 p.m.; on 01/13/2025, medical record indicated the provider ordered the patient to be NPO at 12:25 p.m. and the order was discontinued on 01/13/2025 at 4:49 p.m. c. Medical record lacked documentation of oral care from 01/12/2025 at 11:00 a.m. to 01/13/2025 at 1:00 p.m., a total of 26 hours, 4 oral care entries. d. The patient was discharged on 01/14/2025. 8. Review of Incidents Reports from 08/05/2024 through 03/31/2025 indicated an incident report dated 11/05/2024, a serious adverse event first reported on 08/23/2024 of deep tissue injury identified by wound nurse evaluation and assessed as unstageable by wound ostomy care nurse on 09/11/2024. 9. Interview with A1 (Manager of Accreditation and Regulatory Manager) and A2 (Clinical Nurse Specialist) at approximately 3:50 p.m. confirmed the above for patients 3, 4, 7, 9, and 10.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48061 Based on document review, the facility failed to provide a complete medial screening exam (MSE) and failed to follow policy related to withdrawal of care for 1 of 20 patients. (P1) Findings include: 1. Facility policy titled Emergency Medical Treatment and Labor Act (EMTALA) with publication date of 1/15/25 indicates on page 1 under policy statements “All patients who present to Indiana University Health for emergency care will receive a medial screening examination regardless of ability to pay.” Page 3 states “If a patient withdraws their request for examination or treatment, an appropriately trained individual from the emergency department team will attempt to discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department team member will: a. offer the patient further medical examination and treatment as may be requested to identify and stabilize an emergency medical condition; b. inform the patient of the benefits or (sic) the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment; and c. ask the patient to sign an informed consent noting the refusal to consent to examination and treatment. If the patient refuses to sign the form, a description of risks discussed and of the examination and/or treatment that was refused shall be documented on the form and in the medical record.” 2. Review of P1’s MR was reviewed and indicated the patient was 38 y/o (year/old) assessed at H1’s ED on 2/08/25 at approximately 12:30 pm, with diagnoses including but not limited to abdominal pain. a. Triage documentation dated 2/8/25 at 12:30 pm indicated P1 was seen by a nurse and reported a chief complaint of right lower abdominal pain and vomiting since 2/7/25, P1 reported he/she had a history of ovarian cyst rupture(s) with two prior cesarean sections. P1 reported taking a 5 mg-325 mg Norco prior to presenting at H1’s ED (Emergency Department) b. Physician order documentation dated 2/8/25 at 12:32 pm indicated STAT orders for urinary laboratory tests. Urinalysis results indicated a large presence of hemoglobin in P1’s urine and trace bacteria. c. Vital signs documentation dated 2/8/25 at 12:34 pm indicated P1’s vitals were as follows. Numerical pain reported score of 10/10. Temporal temperature of 36.1 degrees Celsius (equivalent to 96.98 degrees Fahrenheit). Respiratory rate of 19 br/min (breaths per minute). Systolic blood pressure 159 mmHg (millimeters of mercury) over 90 mmHg diastolic. Heart rate of 72 bpm (beats per minute). d. Triage nursing documentation dated 2/8/25 at 12:34 pm indicated P1 was ambulatory upon arrival to H1’s ED, had right lower quadrant pain since 2/7/25, and had an acuity score of 3. e. Physician order documentation dated 2/8/25 at 12:59 pm indicated STAT (Immediately) provider orders for CT (Computed Tomography) of the abdominal and pelvis with contrast, CMP (Comprehensive Metabolic Panel), Magnesium, and CBC (Complete Blood Count) laboratory blood tests. At 1:09 pm a medication order for 4 mg (milligrams) of Zofran was to be given IV Push once. At 2:00 pm medication orders for 1000 mg Tylenol once by mouth, 800 mg Ibuprofen once orally, 4 mg orally disintegration Zofran once under the tongue, and 5 mg oxycodone once orally were ordered NOW. These orders were not completed prior to the patient leaving d/t (due/to) lack of bed availability in the ED. The patients pain of 10/10 was not addressed prior to leaving facility. f. Provider note documentation dated 2/8/25 at 1:01 pm indicated P1 was given an MSE (Medical Screening Exam) by PA1 (Physician Assistant Certified). P1’s screening was performed in the triage area of the ED because all ED rooms were currently housing ED patients. P1’s MSE indicated P1 reported to PA1 right flank pain times one day, pain was associated with nausea and vomiting, P1 reported to Pa1 he/she trialed NORCO (Hydrocodone and Acetaminophen) without success prior to presenting to H1. P1 was alert and oriented times 3, his/her abdomen was soft, non-tender, non-distended, was without rebound tenderness, had no guarding with bowel sounds present. P1 had a normal mental status and was ambulatory with a steady gait. P1 did have right flank tenderness with a 10/10 reported pain score. Medical decision-making included orders for imaging to rule out cyst/torsion, and laboratory blood and urine tests. The most likely cause of pain was anticipated to be kidney stone based on hematuria and flank pain. P1 was placed in the ED waiting room after MSE to await an open bed. Orders were placed for imaging, bloodwork, and IV (Intravenous) anti-emetic medication. g. Provider note documentation dated 2/8/25 at 2:03 pm indicated H1’s ED did not currently have available rooms in the ED. Unfortunately, facility staff are unable to administer medications to patients in the waiting room, which PA1 discussed with P1 on initial evaluation. PA1 evaluated P1 in the triage room to expedite his/her evaluation and care. P1 and family requesting Tramadol currently; pt and family discussed with nursing staff that pain medications cannot be administered in the waiting room d/t safety concerns. Family asked if they would be seen quicker if they called 911, and discussed with nursing staff that they would still be triaged according to severity of illness. PA1 offered Tylenol, Ibuprofen, and PO (by mouth) Zofran at that time. P1 and family have left the waiting room. P1 was believed to have eloped. Upon P1’s assessment, h. ED Nursing Progress Note dated 2/8/25 at 2:27 pm indicated P1 was laying on the lobby floor screaming. Upon N1’s (Registered Nurse) arrival, family of P1 asking for Tramadol to be given in the lobby. N1 explained to P1 and family that Tramadol would not be given in the lobby and would need to be given in a room when available for safety purposes. P1’s family stated that the patient needed the medicine now and that the family member would call 911 to get a room in the back. P1’s family member was informed there were not currently available beds in the ED at that time, P1 had already been triaged, placed in the waiting room, and would come back to the waiting room via EMS (Emergency Medical Services) if 911 was called. PA1 had previously evaluated P1 in triage, urine tests were collected and sent per provider order, and imaging was ordered. P1 greeted by PD1 (Security Officer). P1 ambulated out of the ED to car displaying a steady gait with family members to another hospital. Family member stated he/she “will be filling out the survey”, i. The medical record lacked documentation that the patient was taken to an ED room for complete MSE and further care. j. The medical record lacked documentation that facility followed policy related to withdrawal of treatment for patient P1.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 49709 Based on document review, observation, and interviews, the facility failed to maintain a clean and sanitary environment by not ensuring patient rooms on 6-south were cleaned daily in 2 of 12 days reviewed (02/21/2025 & 02/24/2025); and failed to ensure soap was replaced in accordance with policy in 7 of 12 days reviewed (02/17/2025, 02/18/2025, 02/212025, 02/22/2025, 02/23/2025, 02/24/2025, and 02/27/2025). Findings include: 1. Policy/procedure titled, “ES Environmental Cleaning,” Publication date 01/09/2025; indicated under V. Policy Statements: G. Occupied inpatient rooms should be cleaned on a daily basis. 2. Policy/procedure titled, “ES Environmental Cleaning,” Publication date 01/09/2025; indicated under VI. Procedures: E. Hospital additional locations: b. Public areas such as lobbies, waiting rooms, chapel and public restrooms. 2. Follow the general cleaning principles. A. Cleaning Principles: 4. Assess the room: a. determine what needs to be replaced such as paper towels, toilet paper, soap, alcohol hand rub, and sharps containers fill level. 3. Review of the environmental service daily cleaning logs for 6-south, lacked documentation of a cleaning log for all patient rooms on 6-south as follows: a. No documentation of cleaning on 02/212025 and 02/24/2025. 4. Review of the environmental service daily cleaning logs, lacked documentation of a cleaning log for the public restrooms on 6-south as follows: a. No documentation on 02/17/2025, 02/18/2025, 02/212025, 02/22/2025, 02/23/2025, 02/24/2025, and 02/27/2025. 5. On 03/18/25 at approximately 3:00 p.m. this surveyor, accompanied by A1 and A2, was given a tour of 6-south. While interviewing P12, this surveyor observed the floor was dirty.”

“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: 48061 Based on document review and interview, facility nursing staff failed to obtain and document daily patient weights, failed to obtain and document orthostatic blood pressure readings, and failed to document urine output every 8 hours as ordered by provider in 1 of 10 patient medical records reviewed. (P1) The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to document and/or resolve patient complaints in a timely manner and failed to notify patient advocacy of a patient complaint and/or grievance as policy indicates in 1 of 10 patients. (P1) Findings include : 1. Facility policy titled,”Patient/Parent Rights and Responsibilities, Complaints and Grievances”, no policy number, last revised 06/22/2023, indicated under VI: PROCEDURES: B. Patient Complaint Process. 1. When a patient voices a complaint, the team members immediately present should solve the complaint promptly. Issues such as unanswered questions, change in bedding, housekeeping, immediate care issues such as pain control, and food services are examples of complaints that may be addressed and resolved quickly. 3. If the complaint cannot be solved by team members immediately present, the team members should contact their immediate supervisor, their delegate, or clinical leadership to address the patient/family concern and reach resolution. If the leader is unable to resolve the issue, he/she can refer the complaint to the Patient Relations for assistance. Unresolved complaints may become grievances, and the following procedures may apply if resolution is not achieved. 2. Review of facility complaint and/or grievance log indicated P1 was listed once on 9/23/24. P1 called patient advocacy to report his/her complaints related to lack of nursing care ordered by physician. Patient advocacy relayed the information to A4 (Manager of Clinical Operations) who then rounded on the patient addressing his/her concerns. This complaint was documented as closed on 9/23/24. This log lacked documentation of P1’s initial complaints without complaint resolution from 9/19/24. This log lacked P1 concerns being escalated to a grievance. 3. In an interview on 2/7/25 at approximately 3:50 pm with A4 (Manger Clinical Operations) confirmed A5 (Clinical Manager of Operations Bone Marrow Transplant) contacted him/her on 9/19/24 to relay P1’s complaints of lack of nursing care. These concerns were unable to be resolved and were not escalated to patient advocacy but should have been. A4 confirmed he/she received an email from Patient Advocacy on 9/23/24 after the patient called to complain about lack of nursing care. A4 then rounded on the patient and listened his/her concerns at the bedside.”

“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: 48061 Based on document review and interview, facility nursing staff failed to obtain and document daily patient weights, failed to obtain and document orthostatic blood pressure readings, and failed to document urine output every 8 hours as ordered by physician or provider in 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled,” Documentation Standards”, no policy number, last revised 08/05/2024, indicated under V. POLICY STATEMENTS: A. GENERAL DOCUMENTATION STANDARDS. 1. Registered Nurses are accountable for the patient assessment and documentation process. 2. Review of P1’s MR (Medical Record) indicated physicians orders for the following: On 9/16/24 at 11:37 am indicated physician orders for strict intake and output to be documented every 8 hours. On 9/17/24 at 8:00 am orders for Blood Pressure and Pulse Lying and Standing every 24 hours (orthostatic blood pressure),and a daily weight every 24 hours. MR for P1 lacked the following documentation for physician orders. Oral Intake: I&O documented on 9/16/24 at 9:00 pm. No further I&O documented until 9/17/24 at 6:00 am I&O documented on 9/17/24 at 7:00 pm. No further I&O documented until 9/18/24 at 5:00 am. I&O documented on 9/18/24 at 6:00 pm. No further I&O documented until 9/19/24 at 3:00 am. I&O documented on 9/19/24 at 7:00 pm. No further I&O documented until 9/20/24 at 5:00 am. I&O documented on 9/20/24 at 10:00 pm. No further I&O documented until 9/21/24 at 6:00 am. I&O documented on 9/21/24 at 3:00 pm. No further I&O documented until 9/22/24 at 10:00 am. I&O documented on 9/28/24 at 6:00 pm. No further I&O documented until 9/24/24 at 5:00 am. I&O documented on 9/30/24 at 7:00 pm. No further I&O documented until 10/1/24 at 4:00 am. I&O documented on 10/1/24 at 9:00 pm. No further I&O documented until 10/2/24 at 5:00 am. I&O documented on 10/2/24 at 8:00 pm. No further I&O documented until 10/3/24 at 5:00 am. I&O documented on 10/5/24 at 9:00 pm. No further I&O documented until 10/6/24 at 5:00 am. I&O documented on 10/6/24 at 4:00 pm. No further I&O documented until 10/7/24 at 7:00 am. Urine Output: I&O documented on 9/21/24 at 4:00 pm. No further I&O documented until 9/22/24 at 4:00 pm. I&O documented on 10/2/24 at 9:00 pm. No further I&O documented until 10/3/24 at 4:00 am. Documentation of ordered daily weights for dates 9/19/24, 9/21/24, 9/22/24, 9/23/24, and 10/1/24. Documentation of completed blood pressures laying and standing (orthostatic blood pressure) every 24 hours for dates 9/19/24, 9/20/24, 9/22/24, and 10/1/24. 3. In interview on 2/7/25 at approximately 11:00 am with A5 (Clinical Manager of Operations Bone Marrow Transplant) confirmed daily weights, strict intake and output, and orthostatic blood pressures lying and standing for P1 were not completed by facility nursing staff for dates including but not limited to 9/19/24, 9/21/24, 9/22/24, 9/23/24, and 10/1/24 but should have been.”

“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: 48704 Based on document review and interview, nursing services failed to document patient turn/repositioning or document how the patient was positioned to prevent pressure injury in 1 out of 10 patient (Patient 4) medical records reviewed. Findings include: 1. Facility policy titled Protocol for Adult Skin and Wound Care, last publication date 06/24/2024, indicated under IV. PROTOCOL STATEMENTS, c. The protocol provides interventions to prevent or manage common clinical problems such as moisture associated skin damage, pressure injuries, and chronic wounds. Under HAPI - Skin Wound Algorithm, Is the patient at high risk for pressure injuries? Risk factors; Braden score greater than or less than 18 or sub scale greater than or less than 2, Yes, under Repositioning/Mobility: Turn/repositioning/reposition frequently according to patient condition. Under HAPI Skin Wound Treatment Algorithm under Unstageable, Relieve all pressure to area. 2. Review of Patient 4’s medical record indicated the following: a. The patient was admitted on 01/11/2024 and the medical record indicated the patient did not have a pressure injury or wound present upon admission. b. On 01/11/2025, the Braden score was 9; the medical record lacked documentation of patient turn/repositioning/repositioning at 7:02 p.m. c. On 01/13/2025, the Braden score was 14; the medical record indicated in the patient’s turn/repositioning flowsheet that the patient required complete assistance but lacked documentation of how the patient was repositioned to prevent pressure injuries at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. The Pressure Injury Assessment flowsheet indicated at 4:00 p.m. the patient had a deep tissue pressure injury. The wound note per physical therapy indicated the patient had a deep tissue pressure ulcer to the right buttock/coccyx. d. On 01/15/2025, the Braden score was 14; the medical record lacked documentation of patient turn/repositioning/repositioning at 6:00 a.m. e. On 01/16/2025, the Braden score was 13; the medical record indicated in the patient turn/repositioning flowsheet that the patient required complete assistance but lacked documentation of how the patient was repositioned to prevent pressure injuries at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. f. On 01/19/2025, the Braden score was 17; the patient’s turn/repositioning flowsheet indicated the patient was turn/repositioning at 9:00 a.m., next turn/repositioning was documented at 11:52 a.m., 52 minutes late and medical record lacked documentation of patient turn/repositioning/repositioning at 7:00 p.m. g. On 01/20/2025, the Braden score was 17; the medical record lacked documentation of patient turn/repositioning at 11:00 a.m., 1:00 p.m., 3:00 p.m., and 5:00 p.m., and 7:00 p.m. h. On 01/22/2025, the Braden score was 14 for the day shift; the medical record lacked documentation of patient turn/repositioning at 8:00 a.m., 1:00 p.m., 3:00 p.m. The Braden score for the night shift was 17; the medical record lacked documentation of patient turn/repositioning at 8:00 p.m., and 10:00 p.m. i. On 01/23/2026 The Braden score was 17 from the night shift; the medical record lacked documentation of patient turn/repositioning at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m. The Braden score for the day shift was 14; the medical record lacked documentation of patient turn/repositioning at 8:00 a.m., 10:00 a.m. The medical record indicated the patient’s position was not changed, and patient remained on their back at 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. j. On 01/24/2025, the Braden score was 16 for day shift; the medical record indicated the patient’s position was not changed, and patient remained on their back at 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m. The Braden score was 17 for night shift; the medical record lacked documentation of patient turn/repositioning at 7:00 p.m. and indicated the patient’s position was not changed, and patient remained on their back at 8:00 p.m., and 10:00 p.m. k. On 01/25/2025, the Braden sore was 17 for night shift; the medical record indicated the patient’s position was not changed, and patient remained on their back at 12:00 a.m., 2:00 a.m., 4:00 a.m., and 6:00 a.m. The Braden score was 16; the medical record lacked documentation of patient turn/repositioning at 10:00 a.m.,12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. l. On 01/26/2025, the Braden score was 14 for day and night shift; the medical record lacked documentation of patient turn/repositioning at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. m. On 01/27/2025 the Braden score was 14 for night shift; the medical record lacked documentation of patient turn/repositioning at 12:00 a.m., 2:00 a.m., and 5:00 a.m. The Braden Score was 17 for day shift; the medical record indicated the patient’s position was not changed, and patient remained on their back at 7:00 a.m., 9:00 a.m. and lacked documentation of patient turn/repositioning at 11:00 a.m. 3. Interview with A6 (Clinical Nurse Specialist) on 02/04/2025 at 1:15 p.m. indicated the following: a. If the patient’s Braden score is 18 or less, the patient is repositioned every two hours. Staff should document the position of the patient and how the patient was turn/repositioning. This documentation assists the staff on how the patient was previously repositioned, ensuring that the patient repositioned with each turn/repositioning to assist with prevention of pressure injury. Staff can document that the patient refused to reposition. b. Confirmed the findings related to Patient 4, which included lack of documentation of turn/repositioning, documentation of the patient’s reposition, and documentation that the patient’s position was not changed, and patient had remained on their back.”

“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: 49709 Based on document review, the registered nurse failed to implement additional pain intervention or contact patient provider after ineffective initial pain intervention in 1 of 10 patient medical records (MR) reviewed (P5). Findings include: 1. Review of policy/procedure “Pain Management,” last approved 02/08/2022, indicates the following: VI. Procedure: C. Reassess and respond to patient’s pain plan throughout RN’s shift. 5. If current pain management plan not effective, consider implementation of additional interventions if appropriate or contact patient’s provider. 2. MR indicated P5’s initial pain assessment was completed at 12:10 p.m., patient rated their pain 9/10. They were given pain medication at 1:12 p.m. P5 pain reassessment indicated pain level 8/10. No further pain interventions or physician notification regarding ineffective pain management were completed.”

“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: 48704 Based on document review and interview, nursing services failed to document vital signs as ordered per provider in 1 out of 10 patient (Patient 5) medical records reviewed. Findings include: 1. Review of patient 5 medical record indicated provider order on 10/29/2024 indicated vital signs to be taken every 4 hours; medical record lacked the 4:00 a.m. vital signs on 11/01/2024. 2. Interview with A4 (Registered Nurse, Accreditation and Regulatory Compliance Consultant) on 12/02/2024 at approximately 2:25 p.m. confirmed vital signs were not completed as ordered on 11/01/2024 at 4:00 a.m.”

“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: 48061 Based on document review and interview, facility nursing staff failed to notify a provider of a new and/or ongoing pressure injuries, failed to document every 2-hour turning and/or repositioning of a patient, and failed to document every 4-hour head-to-toe skin assessments for 1 of 10 medical records reviewed. (P1) See tag A0395. The cumulative effects of these systemic problems resulted in the facility’s inability to provide nursing care in a safe manner.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff failed to notify a patients family member or POA (Power of Attorney) of a new pressure injury and evolving of an existing pressure injury for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Patient/Parent Rights and Responsibilities, Complaints and Grievances”, no policy number, publication date 06/22/2023, indicated under Your rights as a patient: As a patient of this facility, you have the right: To participate in decisions about care, treatment and services, which may include family and loved ones, as permitted by the patient or decision maker; this includes the development and Implementation of an Inpatient treatment or care plan, outpatient treatment or care plan, pain management plan and discharge plan. To be informed of outcomes of care, treatment and services, including unexpected outcomes. 2. Review of P1’s MR (Medical Record) indicated the following: Nursing documentation dated 9/15/2024 at 8:00 pm indicated P1’s skin was intact with no skin symptoms. On 9/16/2024 P1’s skin was assessed at midnight, 4:00 am, and 8:00 am as intact with no skin symptoms. On 9/17/2024 a stage 2 pressure injury, full thickness, red, blisters noted above the pressure ulcer, with erythema was documented as present upon admission at 12:00 pm. Physical Therapy note documentation dated 9/17/2024 at 1:31 pm indicated P1’s skin integrity annotation as Per nursing skin auditor N9 (Registered Nurse), patient has a stage 2 pressure injury on sacrum. Physician note documentation dated 9/18/2024 indicated P1’s child who is also the patient’s POA had a discussion with the medical provider about the patient’s disposition and plan of care. P1’s skin was documented as warm. This note lacked documentation about a sacral pressure injury. Wound consult note documentation dated 9/18/2024 indicated two wounds were present near the sacrococcygeal area. One more distally which was staged at two and the proximal was staged as a 3. The measurement for this wound was 4.5 x 3.5 cm (centimeters) (Proximal Wound). The distal wound was cleansed, and the zinc barrier cream was applied and left open to air. Wound progress note documentation dated 10/10/2024 indicated P1 developed a deep tissue injury to the left medial great toe over a bunion. This wound measured 2 cm by 2 cm, purple in color, and was intact. P1’s sacral stage 3 evolving deep tissue injury present on admission measured 2.5 cm by 3.3 cm, was yellow and red in color, and had evidence of re-epithelialization. P1’s MR lacked nursing reporting skin issues to provider and provider notification to the patients child of ongoing and new pressure injuries. 3. In an interview on 12/4/24 at approximately 2:46 pm am with A2 (Clinical Nurse Specialist) confirmed P1’s medical record did not, but should have contained physician notification of advancing staging of P1’s stage 2 sacral wound to a stage 3 sacral wound, nor was a provider notified of the new pressure injury to the left medial great toe and should have been. 4. In a telephone interview on 12/4/24 at approximately 2:29 pm with MD1 (Medical Doctor) confirmed he/she wasn’t notified by nursing that P1 had a sacral wound nor that P1 developed a new pressure injury on his/her toe. MD1 also confirmed he/she did not recall having a conversation with P1’s child regarding these wounds.”

“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: 48061 Based on document review and interview, facility nursing staff failed to notify a provider of a new and/or ongoing pressure injuries, failed to document every 2-hour turning and/or repositioning of a patient, and failed to document every 4-hour head-to-toe skin assessments for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Escalation of Patient Safety Concerns”, no policy number, publication date 03/05/2022, indicated under VI. PROCEDURES: A. The registered nurse (RN) recognizes a change in the patient’s condition requiring provider intervention. B. The RN is responsible for communicating changes in the patient’s condition that may require specific treatment to the provider and following the attached escalation guides as warranted. (Appendix A) 2. Facility policy titled, “Documentation Standards”, no policy number, publication date 08/05/2024, indicated under V. POLICY STATEMENTS: A. GENERAL DOCUMENTATION STANDARDS. 1 Registered Nurses are accountable for the patient assessment and documentation process. 2. Document assessment parameters pertinent to the patient;s specific condition when the patient’s physical assessment/reassessment fall outside of the defined normal limits. 3. Facility standards of care titled, “AAHC Standards of Care for RNs - PCU”, no policy number, updated 2024, indicated under Frequency/Task and Minimum Documentation: Q (every) 2 hrs. Vital Signs, Neurological checks, if ordered, Turn, reposition (HOB 30 degrees or greater as applicable, document which side patient is turned, IV access site assessment, Restraints safety checks, Patient safety checks, Toileting, ROM, food/fluid, Pain score if on continuous pain infusion(e.g., Epidural, Ketamine, end-of-life medications), Flap checks, if ordered. Q 4 hrs., Head-to-toe assessment (skin, wounds, drains/tubes, incisions, Document FIO2/delivery source/device, Pain assessment/sedation/POSS, Patient-controlled Epidural anesthesia (PCEA), vital signs Q 4 hrs, HR, RR, SpO2, Signs iAware: review and sign, Intake and output assessment (drains, tubes, feeds, PO), Vital signs, Empty drains and document. 4. Review of P1’s MR indicated that Nursing documentation dated 9/15/2024 at 8:00 pm indicated P1’s skin was intact with no skin symptoms. On 9/16/2024 P1’s skin was assessed at midnight, 4:00 am, and 8:00 am as intact with no skin symptoms. On 9/17/2024 a stage 2 pressure injury, full thickness, red, blisters noted above the pressure ulcer, with erythema was documented as present upon admission at 12:00 pm. Wound consult note documentation dated 9/18/2024 indicated two wounds were present near the sacrococcygeal area. One more distally which was staged at two and the proximal was staged as a 3. The measurement for this wound was 4.5 x 3.5 cm (centimeters) (Proximal Wound). Wound progress noted documentation dated 10/10/2024 indicated P1 developed a deep tissue injury to the left medial great toe over a bunion. This wound measured 2 cm by 2 cm, purple in color, and was intact. P1’s sacral stage 3 evolving deep tissue injury present on admission measured 2.5 cm by 3.3 cm, was yellow and red in color, and had evidence of re-epithelialization. P1’s MR lacked every 4-hour skin assessments including but not limited to 9/23/24 at 4:00 pm, 9/25/25 at Midnight, and 4:00 am, 9/27/24 at 8:00 pm, and 9/28/2024 at Midnight and 4:00 am, lacked patient turning and/or position changes every 2 hours that included but were not limited to: 9/20/2024 MR as P1’s position was indicated as on his/her back, with no documentation of position change or patient refusal noted; 9/25/2024 as P1 was on his/her left side from 6:00 am -6:00 pm no documentation of position change or patient refusal noted; on 9/26/2024 P1 positioned on left side from 6:00 am - 6:00 pm, no documentation of position change or patient refusal noted; 10/13/2024 lacked turning/positioning documentation from 9:00 am to 8:00 pm. P1’s MR lacked nursing reporting skin issues to provider. 5. In an interview on 12/4/24 at approximately 2:46 pm am with A2 (Clinical Nurse Specialist) confirmed P1’s medical record did not, but should have contained physician notification of advancing staging of P1’s stage 2 sacral wound to a stage 3 sacral wound, nor was a provider notified of the new pressure injury to the left medical great toe and should have been. Confirmed facility nursing staff should have, but did not, document required positioning/turning every 2 hours and every 4-hour skin assessments for P1. 6. In interview on 12/9/2024 at approximately 2:40 pm with N3 (Registered Nurse) confirmed nursing staff are to turn patients every two hours and assess skin every 4 hours. Documentation is to be completed by nursing for both turns and skin assessments.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to complete a significant event report related to pressure injuries for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Patient Incident and Significant Even Management”, no policy number, publication date 09/11/2022, indicated under VI. PROCEDURES: C. Patient Disclosure of Significant Events. When a significant event results in an unanticipated patient outcome, the patient and/or the patient’s family should be informed as soon as reasonably possible. The unanticipated patient outcome should be discussed with the family by the attending physician or his or her designee. Prior to discussing the unanticipated outcome with the patient and/or patient’s family, the attending physician or designee may consult with Risk Management, hospital administration, or legal counsel. Refer to Patient Disclosure of Serious Clinical Adverse Events for specific information. 2. Review of P1’s MR indicated that Nursing documentation dated 9/15/2024 at 8:00 pm indicated P1’s skin was intact with no skin symptoms. On 9/16/2024 P1’s skin was assessed at midnight, 4:00 am, and 8:00 am as intact with no skin symptoms. On 9/17/2024 a stage 2 pressure injury, full thickness, red, blisters noted above the pressure ulcer, with erythema was documented as present upon admission at 12:00 pm. Wound consult note documentation dated 9/18/2024 indicated two wounds were present near the sacrococcygeal area. One more distally which was staged at two and the proximal was staged as a 3. The measurement for this wound was 4.5 x 3.5 cm (centimeters) (Proximal Wound). Wound progress noted documentation dated 10/10/2024 indicated P1 developed a deep tissue injury to the left medial great toe over a bunion. This wound measured 2 cm by 2 cm, purple in color, and was intact. P1’s sacral stage 3 evolving deep tissue injury present on admission measured 2.5 cm by 3.3 cm, was yellow and red in color, and had evidence of re-epithelialization. P1’s lacked nursing reporting skin issues to provider. 3. Incident Report/Complaint/Grievance log were reviewed for the months of 6/1/24-12/1/24. P1 was listed on the incident log on 10/9/2024 in relation to developing a hospital acquired pressure injury to his/her left great toe. This incident report lacked physician notification and family notification. Review of incident reports lacked documentation of P1 sacral pressure injury and family notification of this pressure injury. 4. In an interview on 12/4/24 at approximately 2:46 pm am with A2 (Clinical Nurse Specialist) confirmed P1’s medical record did not but should have contained physician notification of advancing staging of P1’s stage 2 sacral wound to a stage 3 sacral wound, nor was a provider notified of the new pressure injury to the left medical great toe and should have been.”

“ADEQUACY OF LABORATORY SERVICES CFR(s): 482.27(a) The hospital must have laboratory services available, either directly or through a contractual agreement with a certified laboratory that meets the requirements of part 493 of this chapter. This Standard is not met as evidenced by: 44532 Based on document review and interview the facility failed to ensure laboratory services dispensed the incorrect blood product in 1 (one) of 10 (ten) patient medical records reviewed. (P1) Findings: 1. Review of P1 Medical Record (MR) Nurses Narrative Note regarding Packed red blood cells (PRBC) transfusion dated 07/22/2024 at 1349 hours indicated that the blood arrived on the unit and was verified: blood to patient name band and used two patient identifiers (medical record number/date of birth) by two Registered Nurses. P1 had PRBCs started at approximately 0940 hours, at 1130 hours nurse received a call from the blood bank for the blood product to be suspended due to wrong antigen marker being placed on the blood bag. P1 was transfused a total of 27.6 ml (milliliters) of blood product. P1 received Rh positive blood and needed Rh negative blood product. 2. On 11/27/2024 at 1445 N3 (Laboratory Technician) indicated that the blood bank incorrectly marked the PRBC blood component with Rh negative and released to the PICU to administer to P1.”

“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: 48704 Based on document review and interview, nursing services failed to document blood administration, document fall risk assessments, and vital signs as ordered in 1 out of 10 patient medical records reviewed (Patient 5). Findings Include: 1. Facility policy titled, Blood and Blood Component Administration, Publication Date 10/31/2023, indicated under VI. Procedures, D. Minimum Documentation Requirements, 2. Pre-transfusion vital signs: a. Between 1 and 60 minutes prior to initiating the transfusion (“Start time”), a trained clinical team member must take and record vital signs., 3. 15 Minutes vital signs: a. Between the first 10 and 20 minutes of the transfusion, the transfusionist must take and record vital signs; 6. For all transfusions being documented on the Transfusion Document., a. All the following blanks must be filled out to be considered complete: 3. Pre-transfusion vital signs, time, and first initial and last name of team member recording., 4 Start date and time, 5. Fifteen (15) minute vital signs, time, and first initial and last name of transfusionist/team member recording, 6. Signature with credentials of who performed mid-way assessment., 8. Stop date and time., 9. Amount of product transfused in mL (or indicate ALL if whole unit transfused); 10. Post-transfusion vital signs, time, and first initial and last name of team member recording. 2. Facility policy titled, Fall Prevention, Publication Date 10/17/2023, indicated under VI. Procedures, Assessment, A. Fall Risk assessment should be completed: b. once per shift. 3. Review of Patient 5’s medical record indicated the following: a. Provider order on 02/22/2024 indicated vital signs to be taken every 2 hours; medical record lacked 6 out 12 sets of vital signs on 03/01/2024, 5 out of 12 sets of vital signs on 03/02/2024, 7 out of 12 sets vital signs on 03/03/2024, and 3 out of 12 sets of vital signs on 03/04/2024. b. Provider ordered transfusion of 1 unit of blood on 03/01/2024 at 8:18 a.m. MR indicated the start time for the blood infusion was 11:20 a.m. and medical record lacked documentation of pre-transfusion vitals. c. Provider ordered transfusion of 1 unit of blood on 03/04/2024 at 10:12 a.m. Medical record indicated unit of blood was verified by two Registered Nurses at 10:41 a.m. and documented as transfused; medical record lacked documentation of the following: pre-transfusion, 15 minute, and post transfusion vital signs; start and stop times of the transfusion; mid-way assessment; and amount of product transfused. d. Medical record lacked documentation of shift fall assessments on the following shifts: 03/01/2024 day and night shift, 03/02/2024 day and night shift, 03/03/2024 day and night shift, and 03/04/2024 day shift. 4. Interview with A2 (Clinical Nurse Specialist) and A3 (Manager of Accreditation and Regulatory) on 10/21/2024 at approximately 5:10 p.m. confirmed the following: a. Provider order on 02/22/2024 indicated vital signs to be taken every 2 hours; medical record lacked 6 out 12 sets of vital signs on 03/01/2024, 5 out of 12 sets of vital signs on 03/02/2024, 7 out of 12 sets vital signs on 03/03/2024, and 3 out of 12 sets of vital signs on 03/04/2024. b. Medical record lacked documentation of pre-transfusion vitals for blood administered on 03/01/2024. c. Medical record lacked documentation of the following: pre-transfusion, 15 minute, and post transfusion vital signs; start and stop times of the transfusion; mid-way assessment; and amount of product transfused for the transfusion of 1 unit of blood on 03/04/2024 at 10:12 a.m. d. Medical record lacked documentation of shift fall assessments on the following shifts: 03/01/2024 day and night shift, 03/02/2024 day and night shift, 03/03/2024 day and night shift, and 03/04/2024 day shift.”

“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: 49709 Based on document review and interview, nursing services failed to administer medications at standardized times/frequencies in 3 of 10 patient medical records (MR) reviewed (P1, P5, and P10). Findings include: 1. Review of policy/procedure “Medication Administration Times - System,” indicates the following: V. Policy Statements: A. Standardized times/frequencies for the administration of medication will be coordinated in order to provide safe, practical and optimal therapeutic results. F. Time-critical medications should be administered within 30 minutes before or 30 minutes after the scheduled dosing time, for a total window that does not exceed 1 hour. 1. Time-critical medications are typically those that are entered with interval frequencies six times a day or more frequent every 4 hours (Q4H), every 2 hours (Q2H)). G. Non time-critical medications should be administered within 1 hour before or 1 hour after the scheduled dosing time for a total window that does not exceed 2 hours. 1. Non time-critical medications are those entered with interval frequencies less frequent than six times a day (e.g., every 6 hours (Q6H), every 8 hours (Q8H), every 12 hours (Q12H)) or those entered with timed frequencies (e.g., three times a day (TID), twice a day (BID). 2. Review of P1’s MR indicated the following: On 07/14/24 at 2152 hours P1 had an order to receive acetaminophen 1000 mg orally every 8 hours (Q8H); on 07/14/24 P1 received a dose of acetaminophen at 2352 hours with their next dose due at 07/15/24 at 0752 hours; MR indicated on 07/15/25 P1 was given a dose of acetaminophen at 0535 hours with the next dose due at 1335 hours; MR indicated on 07/15/25 P1 was given acetaminophen at 1951 hours. 3. Review of P5’s MR indicated the following: On 06/12/24 P5 had an order to receive tamsulosin 0.4 mg orally daily and famotidine 20 mg orally (BID). On 06/12/24 P5 received a dose of famotidine at 0959 hours with their next dose due at 2100 hours; MR indicated on 06/12/24 P5 was given a dose of famotidine at 2215 hours. On 06/13/24 P5 had an order to receive acetaminophen 1000 mg orally three times a day (TID) and dronedarone 400 mg orally BID. On 06/15/24 P5 received a dose of acetaminophen at 2122 hours with next dose due on 06/16/24 at 0900 hours. MR indicated on 06/16/24 P5 was given a dose of acetaminophen at 1003 hours. On 06/15/24 P5 received a dose of dronedarone at 2122 hours with next dose due on 06/16/24 at 0900 hours. MR indicated on 06/16/24 P5 was given a dose of dronedarone at 1003 hours. On 06/14/24 P5 had an order to receive apixaban 2.5 mg orally BID, polyethylene glycol 3350 17 GM orally BID, senna (senna (sennosides) - 8.6 mg oral tablet) 2 tablets orally BID, and levothyroxine 150 micrograms (mcg) orally daily. On 06/15/24 P5 received a dose of apixaban at 2122 hours with next dose due on 06/16/24 at 0900 hours. MR indicated on 06/16/24 P5 was given a dose of apixaban at 1003 hours. On 06/15/24 P5 received a dose of famotidine at 2122 hours with their next dose due 06/16/24 at 0900 hours. MR indicated on 06/16/24 P5 was given a dose of famotidine at 1003 hours. On 06/15/24 P5 received levothyroxine at 0616 hours with their next dose due on 06/16/24 at 0600 hours. MR indicated on 06/16/24 P5 was given a dose of levothyroxine at 0452 hours with their next dose due 06/17/24 at 0600 hours. MR indicated on 06/17/24 P5 was given a dose of levothyroxine at 0303 hours. On 06/15/24 P5 received a dose of polyethylene glycol 3350 at 2122 hours with their next dose due 06/16/24 at 0900 hours. MR indicated on 06/16/24 P5 was given a dose of polyethylene glycol 3350 at 1003 hours. On 06/15/24 P5 received a dose of senna at 2122 hours with their next dose due 06/16/24 at 0900 hours. On 06/16/24 P5 received a dose of senna at 1003 hours. On 06/15/24 P5 received a dose of tamsulosin at 2122 hours with their next dose due 06/16/24 at 0900 hours. MR indicated on 06/16/24 P5 was given a dose of tamsulosin at 1003 hours. On 06/17/24 P5 received a dose of acetaminophen at 0922 hours with the next dose due at 1500 hours. MR indicated on 06/17/24 P5 was given a dose of acetaminophen at 1648 hours. 4. P10’s Medication Administration Record (MAR) indicated the following: On 08/21/24 P10 had an order to receive docusate-senna (docusate-senna 50 milligrams (mg) - 8.6 mg oral tablet) 2 tablets orally twice a day (BID), enoxaparin 40 mg subcutaneous injection BID, losartan 50 mg orally daily, and methocarbamol 1500 mg orally every 6 hours (Q6H). On 08/21/24 P10 received a dose of docusate-senna at 2214 hours with next dose due on 08/22/24 at 0900 hours; MR indicated on 08/22/24 P10 was given a dose of docusate-senna at 1435 hours. On 08/21/24 P10 received a dose of enoxaparin at 2214 hours with next dose due 08/22/24 at 0900 hours; MR indicated on 08/22/24 P10 received a dose of enoxaparin at 1435 hours. On 08/22/24 P10 had an order to receive tamsulosin 0.8 mg orally daily; MR indicated losartan was given at 1435 hours; MR indicated it should have been given at 0900 hours. On 08/22/24 P10 received a dose of methocarbamol at 0113 hours with next dose due at 0713 hours; MR indicated methocarbamol was given at 1322 hours. On 08/22/24 MR indicated tamsulosin was given at 1435 hours; MR indicated it should have been given at 0900 hours. On 08/23/24 P10 received a dose of methocarbamol at 1719 hours with next dose due at 2319 hours; MR indicated on 08/24/24 P10 received a dose of methocarbamol at 0025 hours. 5. Interview with A2 (Master of Science in Nursing [MSN], RN) on 10/16/24 at approximately 10:00 a.m., confirmed P1, P5, and P10 did not receive prescribed medications at prescribed times. 6. Interview with A6 (Unit Manager) on 10/16/24 at approximately 3:15 p.m., indicated they have an hour before or after the administration time to give a scheduled medication. 7. Interview with A7 (Registered Nurse [RN] Charge Nurse) on 10/16/24 at approximately 3:20 p.m., indicated they have 30 minutes to 1 hour before or after the administration time to give a scheduled medication.”

“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: 49709 Based on document review and interview, nursing services failed to ensure supervision of nursing care by failing to perform one of the 5 rights, right dose, for 1 medical record (MR) reviewed (P9); and failed to ensure completion of an incident report (IR) related to patient leaving against medical advice (AMA) in 1 out of 10 patient MRs reviewed (P9). Findings include: 1. Facility Policy/procedure titled, “Medication Administration and Management,” publication date 05/08/2023, indicates the following: VI. Procedures: Administration: B. The team member administering medications must perform the 5 rights plus 4 checks (9 rights) on all medications prior to administering them to a patient. This includes right patient, right medication, right dose, right time, right route, right documentation, right action, right form, and right response. If bar code scan technology is available, scan patient identification band and patient medication. 2. Facility Policy/procedure titled, “Patient Leaving Against Medical Advice (AMA),” publication date 02/01/2023 indicates under: Policy: VI. PROCEDURES: A. The patient requests to leave AMA. 5. Complete an incident report in the web-based incident reporting system. 3. Review of P9 MR indicated the patient was admitted on 08/27/24: a. On 08/27/24 at 1202 hours P9 had orders to be nothing by mouth (NPO) except sips of water and Lactated Ringers 110 milliliters (ml) per hour, continuous infusion. On 08/27/24 MR indicated 605.57 ml was infused. Per order, it should have infused 1320 ml over 12 hours. On 08/28/24 at 0826 hours, P9 had an order for clear liquid diet, start no fluid restrictions, and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV (Intravenous) continuous 84 ml per hour. On 08/28/24 MR indicated 1218.42 ml was infused over 24 hours. Per order, it should have infused 2016 ml over 24 hours. On 08/29/24 at 0721 hours, P9 had an order for full liquid diet, no fluid restrictions, and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 42 ml per hour. On 08/29/24 MR indicated 606.49 ml was infused. Per order, it should have infused 1008 ml over 24 hours. On 08/30/24 at 0528 hours, P9 had an order to be NPO except ice chips and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 84 ml per hour. On 08/30/24 MR indicated 470.24 ml was infused. Per order, it should have infused 2016 ml over 24 hours. On 08/31/24 at 0528 hours, orders continue from 08/30/24, NPO except ice chips and Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 84 ml per hour. On 08/31/24 MR indicated 782.85 ml was infused. Per order, it should have infused 2016 ml over 24 hours. On 09/01/24 at 1737 hours, P9’s diet was changed to NPO except medications, Dextrose 5% Sodium Chloride 0.45% PREMIX + Potassium Chloride PREMIX IV continuous 125 ml per hour. On 09/01/24 MR indicated 0 ml was infused. Per order, it should have infused 3000 ml over 24 hours. b. P9 MR indicated on discharge summary P9 requested to leave F1 against medical advice (AMA). MR indicated P9 had the capacity to leave AMA; they signed the AMA form and left. P9 was not medically ready to leave, but left AMA, not tolerating PO and with concern for anastomotic stricture. 4. Review of Incident Report Logs from 03/05/24 - 09/05/24 lacked trends related to allegations and indicated there were no incidents related to patients reviewed. 5. Interview with A1 (Manager Accreditation & Regulatory), on 10/08/24 at 4:15 p.m., confirmed there were no IR’s related to P9 leaving AMA. 6. Interview with A2 (Clinical Nurse Specialist), on 10/08/24 at 4:30 p.m., confirmed P9’s IV fluids were not given per physician order.”

“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: 48704 Based on document review and interview, nursing services failed to administer pain medication as scheduled in 1 out of 10 (patient 2) patient medical records reviewed; failed to document the epidural bag ran empty and the total dose amount of medication delivered via a Patient Controlled Epidural Analgesia (PCEA) pump per policy in 1 out of 10 (patient 2) patient medical records reviewed; failed to obtain a provider order for surgical wound dressing change in 1 out of 10 (patient 2) patient medical records reviewed; and failed to document 7 out of 14 daily bed linen changes and 6 out of 14 baths in 1 out of 10 (patient 2) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to ensure that quality Nursing Services were provided.”

“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: 48704 Based on document review and interview, nursing services failed to administer pain medication as scheduled in 1 out of 10 (patient 2) patient medical records reviewed; failed to document the epidural bag ran empty and the total dose amount of medication delivered via a Patient Controlled Epidural Analgesia (PCEA) pump per policy in 1 out of 10 (patient 2) patient medical records reviewed; failed to obtain a provider order for surgical wound dressing change in 1 out of 10 (patient 2) patient medical records reviewed; and failed to document 7 out of 14 daily bed linen changes and 6 out of 14 baths in 1 out of 10 (patient 2) medical records reviewed. 1. Facility policy titled, Medication Administration Times - System, Publication Date: 01/19/2023, indicated under VI. Procedures, F. Time-critical medications should be administered within 30 minutes before or 30 minutes after the scheduled dosing time, for a total window that does not exceed 1 hour.; 1. Time-critical medications are typically those that are entered with interval frequencies six times a day or more frequent (Q4H, Q2H etc.). 2. Facility Policy titled, Epidural and Intrathecal Analgesia: Patient Care and Monitoring, Publication Date: 07/18/2023, indicated under VI. Procedures B. Patient Controlled Epidural Analgesia (PCEA), 4. Total Patient Controlled Epidural Analgesia (PCEA) dose delivered is documented at the end of each RN shift (whether 4 hours, 8 hours, 12 hours, etc.) and with each change of caregiver (transfers to another unit). This Total Drug Delivered is cleared from the pump. 3. Facility document titled, 5 South PCA (Patient Care Assistant) Documentation Responsibilities - Every Shift, indicated under Hygiene, Routine Hygiene: linen changed, CHG treatment, dressing, hair care, eye care, etc. If patient refuses a bath/CHG treatment, document as “refused” & escalate to RN., Q 24 hours. 4. Facility document titled, 4S Support Staff Expectations 2024, indicated every patient should receive a CHG treatment every 24 hours and oral care. These must be documented. 5. Facility document titled, Surgical wound dressing application, Revised May 20, 2024, under Implementation, Verify the practitioner’s order for specific wound care medications and instructions. 6. Review of Patient 2’s medical record indicated the following: a. Medical provider ordered Oxycodone 10 mg PO (by mouth) Q (every) 4 hours on 08/28/2024 at 6:00 p.m. The medication administration record indicated the following doses were not administered as ordered: on 08/29/2024 the medical record lacked documentation that the 10:00 a.m. and 2:00 p.m. doses were administered, the 6:17 p.m. dose was administered 12 hours, 19 minutes late; On 08/30/2024, the medical record lacked documentation that the 2:00 a.m. dose was administered, the 4:58 a.m. dose was administered 7 hours, 36 minutes late; the 10:39 a.m. dose was administered 1 hour, 41 minutes late; On 08/31/2024, the 2:28 a.m. dose was administered 1 hour, 4 minutes late and the 6:34 p.m. dose was administered 45 minutes late; On 09/01/2024, the 3:18 a.m. dose was administered 42 minutes late, the 2:59 p.m. dose was administered 1 hour, 6 minutes late; On 09/02/2024, the 3:18 a.m. dose was administered 1 hour, 36 minutes late, the 2:54 p.m. dose was administered 25 minutes late, and the 8:06 p.m. dose was administered 42 minutes late; On 09/03/2024, the 8:50 a.m. dose was administered 33 minutes late; On 09/06/2024, the medical record lacked documentation that the 6:44 a.m. dose was administered; On 09/08/2024, the 8:34 p.m. dose was administered 41 minutes late; On 09/09/2024, the 5:51 a.m. dose was administered 1 hour, 36 minutes late and the 3:07 p.m. dose was administered 19 minutes late; On 09/11/2024, the 11:43 a.m. dose was administered 50 minutes late. b. Medical record indicated anesthesia placed a fentanyl 100 micrograms (mcg) / 2 ml epidural on 08/29/2024. The Patient Controlled Epidural Analgesia (PCEA) settings were a continuous rate of 8 ml/hour, with a patient-controlled dose of 4 ml every 20 minutes with a lockout of 25 ml/h. Medical record anesthesia note indicated that the patient’s epidural bag ran empty on 09/03/2024. MR lacked nursing documentation that the epidural bag ran dry, that anesthesia was notified, and the total amount of medication delivered at the end of the shift on 09/03/2024. c. Medical record provider notes indicated that the patient was to receive surgical dressing changes every other day and as needed after the 08/30/2024 initial dressing change. Medical record lacked orders for surgical dressing changes. d. Daily linen changes and CHG/bath treatment were not documented on the following dates: i. 08/29/2024 lacked linen changes and CHG treatment. ii. 08/30/2024 lacked linen change. iii. 08/31/2024, 09/05/2024, 09/06/2024, 09/07/2024 and 09/09/2024 lacked documentation of linen change and CHG/bath treatment. 7. Interview with A3 (Clinical Nurse Specialist) and A5 (Manager of Accreditation and Regulatory Compliance) on 09/26/2024 at approximately 10:30 a.m. confirmed patient 2’s medical record lacked the documentation as indicated above.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 48061 Based on documentation review and interview the facility failed to follow their policy ensuring a surrogate decision maker was included in and/or notified of the patient’s plan of care for 1 of 10 medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Patient/Parent Rights and Responsibilities, Complaints and Grievances”, no policy number, publication date 06/22/2023, indicated under Your rights as a patient: To participate in decisions about care, treatment and services, which may include family and loved ones, as permitted by the patient or decision maker; this includes the development and implementation of an inpatient care plan, outpatient treatment or care plan, pain management plan and discharge plan. To be informed of outcomes of care, treatment and services, including unexpected outcomes. 2. MR documentation for P1 indicated on 7/18/24 at 4:54 pm indicated P1 wished to remain full code and wanted his/her ex-spouse to be the medical decision maker of him/her because was unable to speak for themselves. Social Work note documentation dated 7/18/24 at 6:48 pm indicated social work staff confirmed with P1’s ex-spouse that the patient did not have an advance directive prior to being sedated and intubated. The patient’s ex-spouse was provided an overview of the roles/responsibilities of a surrogate decision maker and an overview of the State’s Consent Law. It was then determined that P1’s only living child declined the role of surrogate decision maker, P1’s parents and/or siblings were no longer living, and the patient had no other living relatives. Due to this, P1’s ex-spouse was made the surrogate decision maker for the patient. Procedure note documentation dated 7/20/24 indicated the patient was extubated on 7/19/24 then became hemodynamically unstable on 7/21/24 requiring reintubation, central line placement, and arterial line placement. MR (medical record) for P1 lacked documented of prior notification to his/her surrogate decision maker on 7/19/24 of the plan to extubate P1, and lacked documentation of notification on 7/20/24 of an update to his/her surrogate decision maker of patient’s care plan related to P1 being extubated on 7/19/24. 3. In telephone interview on 8/22/2024 at approximately 12:51 pm with A1 (Manager of Accreditation & Regulatory) confirmed there was no documented family/surrogate decision maker notification related to P1’s extubation on 7/20/2024.”

“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: 41134 Based on document review and interview, the facility nursing staff failed to initiate intravenous fluids per hospital policy and protocols for 1 (P1) of 10 medical records reviewed; and failed to document patient intake and output per for 1 (P1) of 10 medical records reviewed. Findings Include: 1. Facility policy “Documentation Standards”, published 08/05/2024, indicated under Section V, General Documentation Standards, 1. Registered Nurses are accountable for the patient’s assessment and documentation process. 2. Medical record (MR) review indicated P1’s GJ (gastrojejunostomy) tube became clogged on 07/03/2024 at 1000 hours during RN2, Registered Nurse, shift, feeding was paused at this time. An existing tubefeeding orderset provider signed on 06/24/2024 included the facility “Core Diabetes Application” protocol as part of the tubefeeding order set. This indicated that D10W (dextrose) fluids should be started at a rate of 80 mL (milliliter) per hour rate immediately, due to stopping GJ feeding. MR indicated on 6/24/2024 at 1710 hours, intravenous fluids were not started until RN1, Registered Nurse discovered that tube feeding had been paused, and no fluids were running. The MR lacked documentation of patient intake/output as ordered during the timeframe of 07/03/2024 through 07/04/2024, by Facility nursing staff. 3. At 1645 hours on 08/14/2024, per interview with RN2, confirmed they did not run D10W fluids per protocol when the tube clogged on 07/03/2024. RN2, Registered Nurse, stated they had not received instructions to do so, and was unaware of the orderset for tubefeeding that included the facility “Core Diabetes Application” procedure that specifies that D10W should be run at a 80 mL per hour rate when tubefeeds are suspended. Additionally, RN2, Registered Nurse was not able to discuss why P1’s intake and output for 07/03/2024 through 07/04/2024 was not documented.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 41134 Based on document review and interview, the facility staff failed to provide the patient and receiving facility, accurate information regarding diet and tubefeeding orders for 1 (P1) of 10 medical records reviewed. Findings Include: 1. Facility policy “Patient Transfers”, published 12/13/2022, indicated on page 4, D. External Transfers, 1. Provider responsibilities, c. Enter the discharge order and specify the required transfer team skill level, level of monitoring, etc. d. Complete discharge summary, e. Complete Electronic Discharge Instructions. 2. Sending unit responsibilities, a. Complete RN review of discharge instructions. d. Collaborate with ICM on who will copy all pertinent portions of the medical record to send with the patient. 2. Medical record (MR) review for P1 on 06/12/2024 indicated that the patient was on a clear liquid diet, and was receiving continuous tubefeeding of Osmolite 1.5 with a target rate of 50 mL (milliliter) per hour. P1’s discharge order, inpatient discharge instructions, and transfer documentation on 06/12/2024, indicated that P1 was on a regular diet, with no tubefeeding orders or instructions. 3. Review of Facility Risk department incident review indicated on 06/17/2024 it was observed that a regular diet, and no tubefeeding or medication orders were included on the discharge orders by MD1 (Medical Doctor, Internal Medicine) on 06/12/2024. 4. At 1745 hours on 08/14/2024, per interview with A3, Manager, Accreditation and Regulatory, confirmed that MD1’s discharge orders, and the inpatient discharge instructions provided to F3 (Extended Care Facility) on 06/12/2024 indicated that P1 was on a regular diet at discharge. The same instructions do not indicate any tubefeeding instructions, when P1 was actually on a clear liquid diet and tubefeedings.”

“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: 48704 Based on document review and interview, nursing services failed to complete fall risk shift assessments in 6 of 10 (Patients 2, 4, 6, 7, 8, and 9) medical records reviewed. Findings include: 1. Facility policy titled, Fall Prevention, published 10/17/2023, indicated under VI. Procedures, Assessment, A. Fall Risk assessment should be completed: b. Once per shift. 2. Review of Patient 2’s medical record lacked documentation of fall risk shift assessments on 02/03/2024 night shift and 02/04/2024 day shift. 3. Review of Patient 4’s medical record lacked documentation of fall risk shift assessments on 03/23/2024 night shift, 03/24/2024 day shift, and 03/24/2024 night shift. 4. Review of Patient 6’s medical record lacked documentation of a fall risk shift assessment on 03/27/2024 night shift. 5. Review of Patient 7’s medical record lacked documentation of fall risk shift assessments on 04/15/2024 night shift, 04/19/2024 day shift, 04/21/2024 day shift, and 04/22/2024 night shift. 6. Review of Patient 8’s medical record lacked documentation of fall risk shift assessments on 04/10/2024 night shift, 04/11/2024 night shift, 04/26/2024 day shift, 04/26/2024 night shift, 04/27/2024 day shift, 04/27/2024 night shift, 04/28/2024 day shift, 04/28/2024 night shift, 05/10/2024 day shift, 05/11/2024 day shift, 05/14/2024 day shift, and 05/16/2024 night shift. 7. Review of Patient 9’s medical record lacked documentation of fall risk shift assessments on 05/07/2024 day shift, 05/11/2024 day shift, and 05/12/2024 night shift. 8. Interview with A3, (Clinical Nurse Specialist), on 07/31/2024 at approximately 4:55 p.m. confirmed Patients 2, 4, 6, 7, 8, and 9’s medical record lacked documentation of fall risk assessments as indicated above.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48704 Based on document review and interview, the facility failed to renew restraint order every 4 hours in 1 of 2 patient (Patient 6) medical records reviewed, failed to document patient assessment to determine renewal of restraint order within 4 hours of initial placement in 1 of 2 patient (Patient 6) medical records reviewed, failed to document 15-minute monitoring safety checks for 1 of 2 patient (Patient 6) medical records reviewed, failed to document the 1 hour face to face assessment after restraint placement for 1 of 2 patient (Patient 1) medical records reviewed, failed to document the patient’s behavior response to the restraint intervention for 1 of 2 patients (Patient 6) medical records reviewed, failed to document reassessment and rationale for continued use after the initial restraint placement for 1 of 2 patients (Patient 6) medical records reviewed, and failed to ensure appropriate staff initiated application of restraints in 1 of 2 patient (Patient 6) medical records reviewed. The cumulative effects of these systemic problems resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to renew restraint order every 4 hours in 1 of 2 patient (Patient 6) medical records reviewed. Findings include: 1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 6. The need to continue or ability to discontinue restraints/seclusion renewal process: When the order is near age appropriate renewal, RN assesses patient for readiness to discontinue. a. If patient meets criteria for discontinuation, end restraint or seclusion intervention and document. b. If patient needs to remain in restraints/seclusion, contact LIP to share findings and request renewal. c. Repeat process as needed for up to 24 consecutive hours; Adults (18 or older), renew every 4 hours. 2. Review of Patient 6’s medical record indicated on 04/05/2024 at 2:55 a.m. the provider ordered application of four point/four extremities restraints for violent behavior; restraints applied to patient at 3:06 a.m. On 04/05/2024 the medical record indicated the provider ordered four point/four extremities restraints at 7:55 a.m. Medical record lacked documentation the restraints were completely removed prior to and/or at the expiration time of 4 hours of the initial order. Medical record indicated the renewal order was 5 hours after the initial restraint order. 3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6’s medical record lacked documentation that the restraints were completely removed from patient after 4 hours of initial application and the restraint renewal order not completed within 4 hours of initial restraint placement.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to document patient assessment to determine renewal of restraint order within 4 hours of initial placement in 1 of 2 patient (Patient 6) medical records reviewed and failed to document 15-minute monitoring safety checks for 1 of 2 patient (Patient 6) medical records reviewed. Findings include: 1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 6. The need to continue or ability to discontinue restraints/seclusion renewal process: When the order is near age appropriate renewal, RN assesses patient for readiness to discontinue. a. If patient meets criteria for discontinuation, end restraint or seclusion intervention and document. b. If patient needs to remain in restraints/seclusion, contact LIP to share findings and request renewal. c. Repeat process as needed for up to 24 consecutive hours; Adults (18 or older), renew every 4 hours; 8. Monitoring includes: d. Minimum documentation of on-going monitoring, i. Every fifteen (15) minutes team members documents elements focused on Patient Safety. 2. Review of Patient 6’s medical record indicated on 04/05/2024 at 2:55 a.m. the provider ordered application of four point/four extremities restraints for violent behavior; restraints applied to patient at 3:06 a.m. On 04/05/2024 the medical record indicated the provider ordered four point/four extremities restraints at 7:55 a.m. Medical record lacked documentation of an assessment to determine the continuation of restraints within 4 hours after initial application; Medical record indicated on 04/05/2024 at 3:05 a.m. restraints were applied and removed on 04/05/2024 at 9:37 a.m and lacked documentation of the 15-minute monitoring safety checks for duration the restraints were applied. 3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6’s medical record lacked documentation of patient assessment to determine renewal of restraint order and lacked documentation of 15-minute monitoring patient safety checks for the duration the restraints were applied.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(i) When restraint or seclusion is used, there must be documentation in the patient’s medical record of the following: The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to document the 1 hour face to face assessment after restraint placement for 1 of 2 patient (Patient 1) medical records reviewed. Findings include: 1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 5. Perform Face to Face evaluation within 1 hour. b. The face-to-face evaluation shall be completed within 1 hour of the patient being restrained or secluded and include the following: i. The patient’s immediate situation. ii. The patient’s reaction to the intervention., iii. The patient’s medical and behavioral condition including a review of systems assessment, behavioral assessment, and an assessment of the patient’s history including drugs, medications, and recent lab results etc that may contribute to their violent or self-destructive behavior. (CMS), iv. The need to continue or terminate the restraint and/or seclusion. 2. Review of Patient 1’s medical record indicated that the patient was placed in 4-way restraints on 04/05/2024 at 6:05 p.m., and the medical record lacked documentation of the 1-hour face to face assessment. 3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 11:15 a.m. confirmed that patient 1’s MR lacked documentation of the 1-hour face to face assessment.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to document the patient’s behavior response to the restraint intervention for 1 of 2 patients (Patient 6) medical records reviewed and failed to document reassessment and rationale for continued use after the initial restraint placement for 1 of 2 patients (Patient 6) medical records reviewed. Findings include: 1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under VI. Procedures, C. Use of Physical Restraints, Seclusion, Chemical Restraint, or Hold for Violent Behavior, 8. Monitoring includes: c. Decision to Continue or Discontinue; The need for continued restraint use is determined by assessing the presence or absence of the circumstance triggering the restraint use. Possible assessment include patient’s mental status, cognitive functioning, level of distress or agitation and continued presence of the medical device that triggered restraint application. d. Minimum documentation of on-going monitoring, i. Every fifteen (15) minutes team members documents elements focused on Patient Safety; ii. Every one (1) hour staff assigned to the patient documents the above elements and additional Patient Comfort elements; iii. Every one (1) hour RN assigned to the patient documents decision to continue or discontinue 2. Review of Patient 6 medical record indicated that the patient was placed in 4-way restraints on 04/05/2024 at 3:05 a.m. and removed on 04/05/2024 at 9:37 a.m.; the medical record lacked documentation of the of the patient’s response to the restraint intervention for the duration of the restraint were applied and lacked documentation of the reassessment to continue the restraints after the initial restraint placement. 3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6’s medical record lacked documentation of patient’s response to the restraint intervention for the duration of the restraints were applied and lacked documentation of the reassessment to continue the restraints after the initial restraint placement.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f) Restraint or Seclusion: Staff Training Requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to ensure appropriate staff initiated application of restraints in 1 of 2 patient (Patient 6) medical records reviewed. Findings include: 1. Facility Policy titled, Use of Restraints and Seclusion, Publication Date 05/26/2022, indicated under Forms/Appendices, Attachment, Role-Based Responsibilities, Column, Role: Attending MD, Licensed Independent Practitioner (LIP), RN, LPN, CAN, PCA, PCI, CTUS, EMT (at the direction of a RN), and Ancillary Therapy Roles (PT, RT, OT); Column, Initiate: Attending MD, Licensed Independent Practitioner (LIP), and RN. 2. Review of Patient 6’s medical record indicated that S2 (Behavioral Health Technician) documented the initial placement of restraints on 04/05/2024 at 3:06 a.m. 3. Interview with A3 (Clinical Nurse Specialist) on 07/08/2024 at approximately 1:20 p.m., confirmed that patient 6’s medical record indicated the initiation of the restraints was documented by S2 (Behavioral Health Therapist) who cannot initiate restraints.”

“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: 48061 Based on document review and interview, facility nursing staff failed to complete and/or document daily CHG (Chlorhexidine Gluconate) bathing for 3 of 10 medical records reviewed (P1, P2, and P9); and failed to replace external urinary catheters for 2 of 10 medical records reviewed. (P1 and P9) Findings Include: 1. The facility policy titled, “Chlorhexidine Gluconate Bathing”, no policy number, publication date 12/01/2022, indicated under: V. POLICY STATEMENTS. B. A daily chlorhexidine gluconate bathing treatment will be given to all adult patients in participating units unless contraindicated. 2. Manufacturer instructions for use titled, “Sage PrimaFit External Urine Management for the Female Anatomy”, no policy number, publication year 2023, indicated under: Placement. Step 12. Replace device every 12-24 hours, or if soiled with stool or bodily fluids other than urine. Dispose of device per hospital protocol and local regulations. 3. MR for P1 was reviewed and indicated P1’s MR lacked documentation of required CHG bathing for dates 6/7/24, 6/8/24, 6/9/24, and lacked documentation that his/her external urinary catheter was changed every 12-24 hours per the manufacturer’s instructions for use on days 6/8/24-6/9/24. 4. MR for P2 was reviewed and indicated P2’s MR lacked documentation of required CHG daily bathing for dates 6/26/24, 6/28/24, 6/29/24, and 6/30/24. 5. MR for P9 was reviewed and indicated P9’s MR lacked documentation of required CHG bathing for dates 6/1/24, 6/4/24, 6/23/24, 6/24/24, and lacked documentation that his/her external urinary catheter was changed every 12-24 (twenty-four) hours per the manufacturer’s instructions for dates 6/5/24, 6/6/24, 6/19/24, 6/20/24, 6/23/24, 6/24/24, 6/25/24, and 6/26/24. 6. In an interview on 7/2/24 at approximately 3:40 pm with A3 (Clinical Nurse Specialist) confirmed daily chlorhexidine bathing treatments were not completed daily for patients P1, P2, and P9 in participating unit and external urinary catheter replacements were not completed every 12-24 hours per facility policy and/or manufacturer’s instructions for use indicated but should have been for P1 and P9.”

“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: 48061 Based on document review and interview, the facility failed to provide care in a safe setting by not ensuring the intended dose of medication was ordered for 1 of 10 patient medical records reviewed. (P1) Findings include: 1. The facility policy titled, “Patient/Parent Rights and Responsibilities, Complaints and Grievances”, no policy number, publication date 06/22/2023, indicated patient’s have the right to receive appropriate and compassionate care at all times. 2. The facility policy titled, “Medication Administration and Management”, no policy number, publication date 05/08/2023, indicated it is the provider’s responsibility to communicate complete information when ordering medications. Elements of a complete medication order include dose of medication. 3. Medical Record review for P1 indicated on 8/16/23 an order for IVIG (Intravenous Immune Globulin) 15 gm (grams) was ordered to be given to the patient by MD1 (Medical Doctor). On 8/16/23 at 8:44 am the patient received one dose of 15 gm (grams) IVPB (Intravenous Piggyback) of Immune Globulin (IVIG) NF-Gammunex-C [Immune Globulin (Human) Caprylate/Chromatography]. 4. Grievance documentation dated 9/1/23 indicated MD1 spoke with the P1’s parent to relay it was his/her intent to give the patient 5 gm of IVIG, MD1 inadvertently entered 15 gm by mistake on the order set, and the patient did experience side effects and was subsequently hospitalized post infusion from 8/17/23-8/20/23. On 9/5/23 risk management staff spoke to pharmacy staff which confirmed the dose of 15 gm of IVIG was within normal dose range according to the P1’s documented weight, but was not MD1’s intended dose for the patient. On 9/12/23 risk management confirmed that a medication error occurred since 5 gm was the intended dose, not the ordered dose of 15 gm. 5. In an interview on 3/11/24 at approximately 3:05 pm with A7 (Director of Pharmacy) confirmed P1 had a documented weight in the system at the time of order entry, there is a wide range of dosing for IVIG, no flags would have fired for pharmacy for the ordered 15 gm amount ordered for the patient based on weight based dosing of IVIG, and common side effects of IVIG are consistent with the patient’s at the time of admission to H1 on 8/17/23”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to meet the frequency of therapy visits in the treatment plan in 1 of 10 (patient 9) medical records reviewed. Findings include: 1. Review of patient 9’s medical record lacked documentation of three physical therapy visits per the initial evaluation and treatment plan on 11/24/2023, which indicated four visits per week. a. Patient was seen for three visits between 12/1/2023 to 12/7/2023. b. Patient was seen for two visits between 12/8/2023 to 12/15/2023. 2. Interview with A7 (Director of Acute Care) on 12/28/2023 at approximately 3:30 pm confirmed Patient 9’s medical record lacked documentation of three required physical therapy visits to meet treatment plan and frequency and documentation for reason visit was missed.”

“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: 48061 Based on document review and interview nursing staff failed to document bathing, linen changes, and physician notification for 1 of 10 patients. (P10) Findings Include: 1. Facility policy titled, “Chlorhexidine Gluconate Bathing”, no policy number, publication date 12/01/2022, indicated a daily Chlorhexidine Gluconate bathing treatment was given to all adult patients in participating units unless contraindicated and to document the CHG treatment in the medical record. 2. Review of P10’s medical record (MR) indicated the following: A. Order written on 10/25/23 at 11:59 am indicated the physician was to be called if the systolic blood pressure (SBP) was below 90 mmhg (millimeters of mercury) and/or a temperature above 38.6 degrees Celsius (C). B. MR for P10 had a recorded temperature of 38.8 C at 2:59 am on 10/29/23, 39.2 C at 8:02 pm on 10/30/23, and a SBP of 87 at 4:00 am on 11/1/23. C. MR for P10 lacked documentation of the physician notification per order for systolic blood pressure (SBP) below 90 mmhg (millimeters of mercury) and/or a temperature above 38.6 degrees Celsius (C). D. MR for P10 lacked of documentation patient bathing on 10/25/23, 10/27/23 and 10/29/23. E. MR for P10 lacked of documentation linen changes on 10/27/23, 10/29/23, and 10/31/23. 3. In interview on 12/4/23 at approximately 4:30 pm with staff member A10 (Nurse Manager) indicated CHG bathing/ baths and linen changes are to be completed daily. 4. In interview on 12/4/23 at approximately 4:35 pm with staff member A3 (Clinical Nurse Specialist) indicated CHG bathing/baths and linen changes should have been completed daily for this patient and were not. 5. In interview on 12/4/23 at approximately 11:20 pm with staff member A4 (Clinical Nurse Specialist) confirmed there was no nursing documentation that a physician had been called for the P10’s temperature of 38.8 C at 2:59 am on 10/29/23, 39.2 C at 8:02 pm on 10/30/23, and a SBP of 87 at 4:00 am on 11/1/23.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48061 Based on document review and interview the facility failed to document daily room cleaning for 9 of 9 days. Findings Include: 1. Facility policy titled, “Procedure : Daily Cleaning Order”, PolicyStat ID 8741500, last revised 10/28/2020, indicated all patient rooms, whether isolation rooms or not, should be cleaned following the standard precautions. Order of Cleaning: Interact/Empty Trash/Linen, Dust with damp microfiber cloth, Clean and Disinfect, Bathroom, Floor, and Inspection. This policy was in effect on P10’s dates of stay 10/25/23-10/28/23. There was no new policy for P10’s dates of stay 10/29/23-11/2/23. 2. In Interview on 12/18/23 at 9:18 am with A1 (Manager of Accreditation and Regulatory) indicated there were no logs kept showing daily room cleaning for P 10 on dates 10/25/23- 11/2/23. 3. In Interview on 12/22/23 at approximately 11:50 am with A11 (EVS Director) confirmed each employee should turn in a completed checksheet at the end of each shift, there have been no changes or updates to the facility policy titled, “Procedure : Daily Cleaning Order”, but the date needs to be renewed, and he/she does not have completed checklists available and/or ready for P10’s hospital length of stay.”