Willis Knighton Medical Center

“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: 51596 Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure to: 1. Ensure the Admission and Nursing Physical Assessment was initiated within 4 hours of admission as per hospital policy for 1 (#1) of 3 sampled patients; 2. Ensure I&O was monitored and recorded as ordered for 3 (#1, #2, and #3) of 3 sampled patients; and 3. Ensure use of compression stockings were documented each shift as ordered for 1 (#3) of 1 sampled patient who was ordered to have compression stockings. 1. Failure to ensure the Admission and Nursing Physical Assessment was initiated within 4 hours of admission Review of the hospital’s policy titled “Nursing Process Implementation: Assessment, Planning, Implementation and Evaluation” revised 01/2025, revealed the following: (1a) The Admission Assessment and Nursing Physical Assessment will be initiated within 4 hours of admission. Review of Patient #1’s medical record revealed an admission date of 07/14/2025 at 7:58 PM. Further review revealed Patient #1’s Admission Assessment was initiated on 07/15/2025 at 8:25 AM. In an interview on 08/11/2026 at 12:06 PM, S8IC confirmed the above-mentioned findings and that Patient #1’s Admission Assessment was not initiated within 4 hours of admission, but should have been. 2. Failure to ensure I&O was monitored and recorded as ordered Review of the hospital’s policy titled “Intake and Output Policy” revised 07/2025, revealed the following: (1) I&O is to be maintained on all patients with continuous IV’s, indwelling catheters, dialysis patients, and others as indicated. (2) It is the Nurse’s responsibility to record I&O. (2a) I&O information can be gathered by the RN, LPN, or CNA and documented in the computer by the nurse or designee. (2a.ii) I&O should be documented as soon as possible. (2a.iii) I&O should be totaled at the end of the shift. (2a.iv) The 24 hour total will be documented at 6 a.m. Patient #1 Review of Patient #1’s medical record revealed an admission date of 07/14/2025 at 7:58 PM and discharge date of 07/16/2025 at 6:48 PM. Further review revealed the following order dated 07/15/2025 at 6:56 PM: - Measure Intake and Output Q4Hrs. Review of Patient #1’s I&O record failed to reveal documentation of I&O Q4Hrs. In an interview on 08/11/2026 at 12:30 PM S8IC confirmed the above-mentioned finding and that Patient #1’s I&O was not monitored and recorded as ordered, but should have been. Patient #2 Review of Patient #2’s medical record revealed an admission date of 08/08/2026 at 4:57 PM. Review of Patient #2’s admission orders revealed the following order: - Monitor I&O per policy. Review of Patient #2’s I&O record failed to reveal documentation of I&O every shift. In an interview on 08/11/2026 at 2:01 PM S14SC revealed I&O was to be documented “every shift” confirmed the above-mentioned finding and that Patient #2’s I&O was not monitored and recorded every shift, but should have been. Patient #3 Review of Patient #3’s medical record revealed an admission date of 07/12/2025 at 9:44 PM. Review of Patient #3’s I&O record failed to reveal documentation of I&O every shift. In an interview on 08/12/2026 at 11:00AM S5CNO confirmed the above-mentioned finding and that Patient #3’s I&O was not monitored and recorded every shift, but should have been. 3. Ensure use of anti-embolic stockings was documented each shift as ordered Review of Patient #3’s orders revealed the following orders dated 07/13/2025 at 12:47 AM: - Apply anti-embolic stockings below knee; and - Graduated anti-embolic stocking management every shift. Review of Patient #3’s graduated anti-embolic stocking management record failed to reveal documentation of anti-embolic stockings each shift. In an interview on 08/12/2026 at 11:15 AM S14SC confirmed the above-mentioned findings and confirmed use of anti-embolic stockings had not been documented every shift, but should have been.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 51596 Based on record review and interview, the hospital failed to ensure the nursing plan of care was initiated within 12 hours of admission as per hospital policy for 1 (Patient #1) of 3 sampled patients. Findings: Review of the hospital’s policy titled “Nursing Process Implementation: Assessment, Planning, Implementation and Evaluation” revised 01/2025, revealed the following: (2a) A Plan of Care is developed by the RN during the initial admission process. (2b) The nurse will individualized and initiate the plan within 12 hours of admission. Review of Patient #1’s medical record revealed an admission date of 07/14/2025 at 7:58 PM. Further review revealed the nursing plan of care was initiated on 07/15/2025 at 8:42 AM. In an interview on 08/11/2026 at 11:45 AM, S5CNO confirmed the above-mentioned findings and that nursing staff had not initiated a plan of care within 12 hours of admission, but should have.”

“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: 51596 Based on record review and interview, the nursing staff failed to ensure medications were administered in accordance with physician orders and hospital policy. This deficient practice was evidenced by: 1. Failure to ensure documentation of pain intervention reassessment as per hospital policy for 1 (Patient #1) of 3 sampled patients; 2. Failure to administer SS insulin pre meals as ordered for 1 (Patient #2) of 3 sampled patients; and 3. Failure to develop a policy regarding the timing of AC glucose testing and timing of administration of the sliding scale insulin in relation to the meal.. Findings: 1. Ensure documentation of pain intervention reassessment as per hospital policy Review of the facility’s policy titled “Nursing Pain Management Policy” revised 05/08/2026 revealed the following, in part: POLICY: To establish guidelines for comprehensive pain assessments and pain intervention reassessments. (2) Pain intervention reassessment is recommended as follows: (2b) Within 1 hour after administration of oral medication. (2c) Document reassessment. Review of Patient #1’s medical record revealed the following ordered dated 07/14/2025: Tramadol 50mg oral bid prn moderate to severe pain (5-10). Review of Patient #1’s 07/15/2025 MAR revealed Tramadol 50mg p.o. was provided on 07/15/2025 at 12:16 AM for pain 5/10. Pain intervention reassessment was documented at 2:31 AM, 2 hours and 15 minutes after the medication had been provided. Further review of Patient #1’s 07/15/2025 MAR revealed Tramadol 50mg p.o. was provided on 07/15/2026 at 7:38 AM for pain 9/10. Pain intervention reassessment was documented at 9:14 AM, 1 hour and 36 minutes after the medication had been provided. In an interview on 08/11/2026 at 12:26 PM, S5CNO confirmed Patient #1’s pain intervention reassessment had not performed within one hour, but should have been. 2. Failure to administer SS insulin pre meals as ordered; and 3. Failure to develop a policy regarding the timing of AC glucose testing and timing of administration of the sliding scale insulin in relation to the meal. Review of Patient #2’s medical record revealed Humalog Low Dose SUBQ PRE MEALS was ordered on 08/08/2026 at 4:59 PM. Review of the Low Dose SS revealed SS insulin was required for glucose > 151 mg/dL. Review of Patient #2’s glucose record dated 08/09/2026 revealed the following: 8/09/2026 11:50 AM - 317 mg/dL; and 08/09/2026 2:45 PM - 390 mg/dL. Review of Patient #2’s 08/09/2026 Humalog MAR revealed the following: 08/09/2026 1:28 PM - 6U given; and 08/09/2026 4:53 PM - 7U given. In an interview on 08/11/2026 at 2:50 PM, S5CNO confirmed Patient #2 had not received SS insulin before meals as ordered, but should have. S5CNO confirmed the facility did not have a policy regarding the timing of AC insulin in relation to glucose testing and/or meal consumption.”

“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: 17450 Based on record review and interview, the hospital failed to ensure that issues/complaints made by a patient’s family member were identified as a grievance and that the grievance process was followed for 1 (Patient #1) of 3 sampled patients whose records were reviewed. Findings: Review of policy titled, Complaint and Grievance Policy, (updated 02/16/2026) revealed in part that complaints are any concern expressed by a patient, visitor, or other representative that is addressed and promptly resolved at the same time the concern is expressed by the applicable department personnel present/available. The policy further stated that a grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient’s representative, regarding the patient’s care (when the complaint is not resolved at the time of the complaint by staff present). It is a grievance if the complaint cannot be resolved at the time of the complaint by the staff present, the complaint requires investigation, or the complaint requires further actions for resolution. Review of the medical record for Patient #1 revealed the patient had an admission date of 12/23/2025 and received a craniotomy on 12/26/205 due to a brain mass. Review of the grievance log dated December 2025 to present revealed no grievances documented regarding Patient #1. Review of a physician progress note dated 12/26/2025 at 7:55 AM revealed in part that the patient’s nurse notified the physician (hospitalist) that the patient was having an active seizure, as he was post craniotomy. Further review of the note revealed that the patient’s wife mentioned to the physician that the patient was supposed to be on a Decadron (steroid) taper from 6mg every 4 hours to 4mg every 6 hours. The physician noted that this information was also verified from the neurosurgeon’s note. The progress note further stated that Decadron could not be found as an active medication in the chart and was not given in at least 29-30 hours. The note further stated that the patient was transferred to ICU and Decadron 6mg every 6 hours would be started. Review of a Safety Event Entry form, dated 12/31/2025, revealed in part that the date of event was 12/26/2025 at 7:00 AM. The description of the event revealed in part that Patient #1’s wife expresses concerns over conflicting information from physicians regarding the patient having seizures or not, and whether 100% of the brain tumor was removed. The patient’s wife also stated that she felt that a med error was made due to concerns that Decadron was not given per the neurosurgeon’s orders. The note stated that the neurosurgeon, neurologist and oncologist talked to the patient’s wife on 12/31/2025 regarding initial path reports. The note further revealed that the family still lacks clarity with seizure issues. The form indicated that actions were taken immediately following the event. The actions taken were documented as, notified the physician and the department manager (no names documented). Review of the form titled Follow-up to Safety Event, dated and signed by S3Med/Surg Manager on 01/25/2026 revealed in part that Patient #1 was transferred to 3 East from SICU and began having seizure like episodes. The patient’s wife was concerned over his ordered medications. The patient was transferred back to SICU after being on 3 East for approximately 7 hours. The following morning, S3Med/Surg Manager was notified about the patient’s wife being upset about 3 East care. S3Med/Surg Manager went to SICU and the patient’s wife stated that medications were not given as ordered. The note stated they reviewed the physician orders together and no medications were withheld. There was no further investigation documented. There was no documented evidence that the concerns made by Patient #’1s wife on 12/26/2025 were immediately addressed, investigated or that the grievance process was initiated. The above follow-up note indicated that S3Med/Surg Manager did not talk to the patient’s wife until the following morning. On 02/23/2026 at 11:00 AM, interview with S2Director of Quality confirmed that the concerns voiced by Patient #1’s wife should have been identified as a grievance. When asked if these concerns required investigation and interviews that could not be resolved at the time of the complaints (per policy), S2Director of Quality stated yes. When asked if the grievance process was followed, S2Director of Quality stated no.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes by failing to thoroughly investigate complaints made by a patient’s wife related to the failure to administer ordered medications (Patient #1). Findings: Review of the medical record for Patient #1 revealed the patient had an admission date of 12/23/2025 and received a craniotomy on 12/26/205 due to a brain mass. Review of physician orders dated 12/24/2025 at 10:30 AM, written by S4Neurosurgeon, revealed Decadron (steroid) 6mg IV every six hours times two doses. The doses were administered and the last dose was given on 12/24/2025 at 8:12 PM. Review of a physician progress note by S4Neurosurgeon dated 12/25/2025 at 10:54 AM revealed in part to continue steroids 6mg every 6 hours and start tapering 4mg every 6 hours tomorrow. Review of the physician orders revealed this order was not put into the electronic medical record system. The patient had no current orders for steroids at this time, and the last dose was on 12/24/2025 at 8:12 PM. Review of a physician progress note by S4Hosptialist dated 12/25/2025 at 12:44 PM revealed in part to continue steroids and begin tapering dosage. There were no orders written by this physician on this date. Review of a physician progress note dated 12/26/2025 at 7:55 AM revealed in part that the patient’s nurse notified the physician (hospitalist) that the patient was having an active seizure, as he was post craniotomy. Further review of the note revealed that the patient’s wife mentioned to the physician that the patient was supposed to be on a Decadron (steroid) taper from 6mg every 6 hours to 4mg every 6 hours. The physician noted that this information was also verified from the neurosurgeon’s note. The progress note further stated that Decadron could not be found as an active medication in the chart and was not given in at least 29-30 hours. The note further stated that the patient was transferred to ICU and Decadron 6mg every 6 hours would be started. On 02/24/2026 at 11:30 AM, interview with S1CNO and S2Director of Quality confirmed that the neurosurgeon wanted the patient to continue steroids, at a tapering dose, but did not input an order into the electronic medical record. They further confirmed that steroids should be tapered and not immediately stopped, as occurred with Patient #1 on 12/24/2025. They stated that the nurses should have identified that the steroids were not tapered and should have notified the physician, but they did not. They stated that a thorough investigation was not conducted related to the wife’s complaint of withheld medications (steroids). When asked if any education had been conducted with the nurses related to this issue, they stated no. Further interview with S1CNO on 02/24/2026 at 11:40 AM revealed that upon further review of the electronic medical record, it was determined that the physcian did order the patient to continue steroids on 12/24/2025, but input the electronic order incorrectly, leading to Patient #1’s steroids being stopped suddenly and not tapered. When asked if any education had been provided the physician regarding this issue, S1CNO stated no.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 20310 Based on record review and interview, the hospital failed to provide the patient with a written notice of its response to and resolution of a grievance filed by 1 of 1 patients (#1) reviewed. Findings: Review of the hospital’s Policy and Procedure for Customer Comments, Complaints and Grievances (revised 07/24) revealed, in part... Written Notice - Administrative representatives will have the final responsibility for the resolution of the grievance, as well as provision of wtitten notice to the patient. The complainant will be provided with a copy of the written response. The response will contain the required information outlined in the Conditions of Participation. Further review of the policy revealed no clear timeline for the written response to the complainant when the grievance has been resolved. Review of the written grievance filed by Patient #1 dated 07/24/2025 at 08:26am revealed she requested a written response within 14 days. Review of the grievance investigation revealed the investigation was completed on 07/28/2025. Further review revealed no documented evidence that a written response had been sent to Patient #1 as of 08/11/2025. On 08/11/2025 at 3:30pm, an interview with S1Quality Director confirmed that no written notice of the grievance resolution had been sent to Patient #1. She further confirmed that the policy needed revisions for clarification of written notice timeframes, but confirmed that a written response should have been sent within 7 days of the completion of the investigation.”

“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: 36293 Based on policy review, record review and interview, the hospital failed to ensure patient complaints, requiring further investigation, were recognized as grievances. This deficient practice was evidenced by failing to correctly identify patient grievances for 1 (#2) of 2 patients reviewed for complaints/grievances from a total patient sample of 3 (#1, #2, #3). Findings: Review of the hospital’s Occurrence Reporting Procedures policy revealed in part: 1. Actual event - when something happens that is unexpected and undesirable ... Reportable events involving injury or potential injury to patients or visitors may include, but are not limited to: ...patient leaving AMA (Against Medical Advice) or elopement ... Review of the hospital’s Policy and Procedure for Customer Comments, Complaints and Grievances revealed in part: A grievance is defined as a formal written, or verbal complaint that is made to the facility by a patient, visitor, or support person (when the complaint is not resolved at the time of the complaint by staff present) ... Guidelines-Staff Receives Complaint - Document all pertinent information in the on-line reporting system: Feedback Manager. Processing Grievances - If a complaint cannot be resolved immediately by staff present, it becomes a grievance and follows the grievance process. The complaint will be flagged as a grievance in the online reporting system, Feedback Manager. Grievance Resolution - A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf. Review of Patient #2’s medical record revealed in part: date of birth 01/05/2018. Admit 06/19/2024 with diagnoses of nausea, vomiting and diarrhea. The patient has a history of bowel intussusception, and small bowel obstruction. History and Physical not completed. Patient left AMA. Discharge Summary - Patient left AMA with parents before being seen. Nursing Notes dated 06/20/2024 at 07:00 - Patient’s mom voiced concern regarding patient’s care. Mom stated if S1Physician was not available, she would like to go to Hospital B. Nurse informed patient’s mother that S1Physician was not on call today. Charge nurse and house supervisor made aware. S2Physician notified. Parents do not want patient to be transferred, they will discharge out. Nursing unable to convince mother to keep patient inpatient or to wait and see S2Physician. Mother states they are leaving and going straight to Hospital B Emergency Room. 07:52 a.m. Call to S2Physician. 7:55 a.m. Nurse spoke with mother and relayed S2Physician wanted patient transfer via ambulance. Mother still states she wants to leave and is going immediately to Hospital B. Review of the hospital’s patient discharge list for June 2024 revealed Patient #2 was discharged 06/20/2024 with a discharge disposition listed as “AMA”. Review of the hospital’s Occurrence Reporting Logs and the hospital’s Grievance Logs failed to reveal Patient #2. In an interview on 07/02/2024 at 12:05 p.m., S3SVP Quality acknowledged an Occurrence Report was not made and stated this occurrence was a reportable event and would have been identified as a grievance if the occurrence was reported according to policy.”