Lake Regional Health System

“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: 46856 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment during a medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#27) of 27 Emergency Department (ED) records reviewed from 02/04/25 through 08/04/25. This failed practice had the potential to cause harm to all patients who presented to the ED. Findings included: Review of the hospital’s policy titled, “Transfer Policy and Procedure,” revised 09/23/24, showed this hospital shall provide “emergency services and care” within the capability of its facilities and staff to any individual who requests services, examination, or treatment, at a dedicated ED of the hospital. “Emergency services and care” means an appropriate medical screening examination and evaluation within the capability of the hospital’s facility, including ancillary services routinely available to the ED, by an emergency provider, attending physician, on-call provider, and/or qualified registered nurse (RN) under an approved protocol to determine whether an “emergency medical condition” exists. Emergency services and care shall be provided, and if an EMC exists, stabilizing treatment shall be provided, or an appropriate transfer made pursuant to this policy. An EMC means a medical condition that manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Please refer to A-2406 for further details.”

“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: 46856 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment during a medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#27) of 27 Emergency Department (ED) records reviewed from 02/04/25 through 08/04/25. This failed practice had the potential to cause harm to all patients who presented to the ED. Findings included: Review of the hospital’s policy titled, “Transfer Policy and Procedure,” revised 09/23/24, showed this hospital shall provide “emergency services and care” within the capability of its facilities and staff to any individual who requests services, examination, or treatment, at a dedicated ED of the hospital. “Emergency services and care” means an appropriate medical screening examination and evaluation within the capability of the hospital’s facility, including ancillary services routinely available to the ED, by an emergency provider, attending physician, on-call provider, and/or qualified registered nurse (RN) under an approved protocol to determine whether an “emergency medical condition” exists. Emergency services and care shall be provided, and if an EMC exists, stabilizing treatment shall be provided, or an appropriate transfer made pursuant to this policy. An EMC means a medical condition that manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Review of Patient #27’s ED medical record showed: - On 08/02/25 at 1:27 PM, a 68-year-old female presented to the ED with a chief complaint of shortness of breath and food aspiration (inhalation of foreign material into the lungs). - She had a history of trachobronchomalacia (TBM, condition where the windpipe and bronchial tubes [airways leading to the lungs] close down or collapse, causing difficulty with breathing), chronic obstructive pulmonary disease (COPD, lung disease that prevents normal airflow and breathing) and interstitial lung disease (group of conditions that cause inflammation and progressive scaring of lung tissue). - Her home medications included diphenhydramine (medication used to treat itching, insomnia, and allergic reactions) 25 milligrams (mg) every six hours as needed, and Dilaudid (medication used to treat severe pain) two mg every three hours as needed for cough. - At 1:29 PM, her vital signs (VS, measurement of the body’s most basic functions: blood pressure [BP] normal between 90/60 and 120/80; pulse normal 60 to 100 per minute; respiration rate [RR] normal 12 to 20 breaths per minute; and body temperature, normal 97.8 to 99 degrees) were BP 141/80, pulse 96, RR 26, temperature of 98.6 degrees, and an oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) of 98%. She was on room air (not receiving supplemental oxygen). She reported a pain level of seven out of 10 on the pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible). - Staff N, ED Physician, documented that Patient #27 believed that she may have inhaled part of her breakfast sandwich, and had been uncomfortable since then. Historically, her TBM was managed with intravenous (IV, in the vein) diphenhydramine and IV Dilaudid for pain. She reported that she had taken her usual two mg of Dilaudid every three hours at home and a dose of diphenhydramine prior to her arrival at the hospital. Her respiratory exam showed normal lung sounds and noisy breathing, which was the patient’s baseline. She did not appear distressed, spoke in full sentences, drank a carbonated beverage without difficulty and her oxygen saturation was 100% on room air. - Throughout her ED visit, her oxygen saturation never dropped below 98%, and she was not placed on supplemental oxygen. - At 1:39 PM, Staff P, ED RN, administered 50 mg of diphenhydramine and one mg of Dilaudid intramuscularly (IM, within the muscle). - Staff N, ED Physician, documented that shortly after the medications were administered, the patient became annoyed and upset when she was informed that there was nothing else to offer her. She was told that her condition was chronic and if she did aspirate some of her breakfast sandwich, there was nothing they could do about it. She was advised to go home and take her home medications. At that time, she became more agitated, yelled at staff and threatened legal action. Her actions exhibited that she was able to breathe well. Staff N noted that Patient #27 had been seen in multiple hospitals previously and had been to Hospital B earlier that day. Patient #27’s husband demanded that she be placed on high-flow oxygen, even though it was not indicated. The patient was escorted from the hospital as she did not exhibit an emergent medical condition (EMC) and had been stabilized appropriately. Staff N documented that Patient #27’s behavior was consistent with drug seeking behavior when she did not receive the treatment she wanted, despite the medications that were administered. The patient had inappropriate expectations of the hospital in being able to direct her care and obtain opioids (highly addictive narcotics) on demand. Staff N suspected that Patient #27 had sought opioids at other hospitals. When escorted from the ED, she verbally threatened staff members, her and her husband’s behavior raised concerns for potential violence. - At 2:14 PM, Staff P, ED RN, documented that Patient #27 was medically cleared by the provider. When discharge orders were received, Patient #27 hyperventilated (breathe at an abnormally rapid rate, so increasing the rate of loss of carbon dioxide) and requested high-flow oxygen therapy and pain medication. Patient #27’s husband yelled at Staff P and other staff members. Security was called and remained at the patient’s bedside while discharge education was provided. - At 2:23 PM, Staff P, ED RN, documented that Patient #27 did not want discharge education. Patient #27’s husband called Staff P a bitch and a witch. He then threatened to have his lawyer sue her. Patient #27 was aggressive with security. She ripped off the blood pressure cuff, telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) wires, and pulse oximeter (a machine that monitors the percentage of oxygen in the bloodstream, a normal reading would be 95 to 100 percent), then briskly walked out of the ED. She was followed by security. - There were no orders for any diagnostic testing. Review of Patient #27’s Hospital B ED medical record showed: - On 08/02/25, she presented with a chief complaint of aspiration of food with a worsened cough. She said she had similar symptoms in the past and typically required high flow oxygen. - At 3:54 PM, her VS in triage were BP 160/90, pulse 102, RR 24, oxygen saturation 98%, and temperature 98.2 degrees. - A chest x-ray (test that creates pictures of the structures inside the body-particularly bones) was ordered and was negative. Blood tests showed no abnormalities other than mild anemia (low amounts of oxygen rich blood, causes paleness and weakness), which was consistent with previous results. - An Ears, Nose and Throat (ENT, a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck) specialist was consulted for an evaluation. A flexible laryngoscopy (a procedure to examine the back of the throat) was performed and was within normal limits. There was no evidence of an obvious foreign body in the upper airway. ENT recommended evaluation for a foreign body via a computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs, and tissues in the body) scan with inspiratory and expiratory views to assess for airway collapsibility and foreign bodies. If a foreign body triggered her shortness of breath, it would likely have been relatively deep into her bronchial tree. Recommendations included an admission to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for observation, due to her new significant supplemental oxygen requirement. - Critical Care Internal Medicine was consulted and documented that there was no indication for a Medical ICU admission or bronchoscopy (procedure to insert a camera down the windpipe to visualize the inside of the windpipe or lungs). The patient was not hypoxic (not enough oxygen reaching the cells and tissues in the body) and was on room air. The high flow oxygen was for comfort only. - Patient #27 received Dilaudid and diphenhydramine for her persistent cough and was placed on high flow oxygen. Her symptoms immediately improved. - The CT showed no aspiration, and she did not meet the threshold for excessive dynamic airway collapse (collapse and narrowing of the windpipe by 50% or more). - Patient #27 was admitted to the Progressive Care Unit (PCU, a telemetry monitored unit that provides care for adult patients requiring continuous cardiac monitoring) for further evaluation and treatment of her symptoms. - On 08/03/25, a Respiratory Therapist (RT, a healthcare professional who specializes in the diagnosis, treatment, and management of respiratory conditions) documented that Patient #27 presented with a persistent uncontrolled cough. Patient #27 stated that her cough was relieved with the use of high flow oxygen. As ordered, high flow oxygen was initiated, and Patient #27’s cough greatly improved. She was gradually weaned off the high flow oxygen back to room air. - Throughout her hospitalization, her oxygen saturation never dropped below 93%. - At 4:00 PM, she was discharged. Review of the hospital’s undated and untitled security report, showed on 08/02/25 at approximately 2:06 PM, Staff O, Security Officer (SO), received a call from ED staff and asking officers to respond because Patient #27’s husband had become loud. Staff Q, SO, responded first, and approached Patient #27’s room. Her husband made the comment, “Are you here for me?” Staff Q responded that he was there to monitor the situation. Patient #27’s husband stated, “what situation?” He then turned to Patient #27 and said, “he is here for me.” Staff O arrived a short time later and went to the nurses’ station, where Staff N, ED Physician, and Staff P, ED RN, advised that Patient #27 would be discharged from the ED. Staff P entered Patient #27’s room and tried to explain to Patient #27 that she was being discharged. Patient #27 and her husband immediately became irate. The husband was on the left side of the bed, Staff P was on the right side of the bed, with Patient #27 lying on the bed. The patient’s husband stepped closer to the bed, prompting Staff Q to step forward and put his arm up towards Staff P to prevent her from being struck. Later, Staff Q stated that he thought the husband was going to reach across the bed towards Staff P. The husband called Staff P a “bitch” and stated “You are throwing us out! I am going to sue!” Staff Q informed the patient and her husband that she was discharged. Patient #27 then ripped off her heart monitor leads and tried to get out of bed. She was asked if she wanted a wheelchair, and she said yes. Staff O left briefly to get a wheelchair. When he returned, Patient #27 had pulled off her hospital gown, exposing her breasts. She then yelled at Staff O “Got a good look?” At that time, Staff P and Staff Q, exited the area and shut the curtain behind them. Staff P offered to read the discharge orders to the patient, but she declined. Patient #27 got fully dressed and exited the room. She was asked if she wanted to sit in the wheelchair and she declined. She then said, “Apparently I am fine.” She then walked toward the nurse’s station to leave the ED area. Staff Q attempted to tell her that she was going the wrong way and followed her. Her husband and Staff O also followed her. Staff Q glanced back at them and Patient #27’s husband yelled at him. Staff O told the husband to keep walking, and the husband puffed up his chest at Staff O and yelled at him “Are you threatening me?” Staff O told him no and that he needed to keep walking. They continued to walk until they approached the triage area, where Patient #27 stopped and grabbed the handrail. She was asked if she wanted a wheelchair and she yelled out “No, I don’t want your stuff!” Her husband held her by the arm and helped her walk out of the ED. As they walked out, they yelled at other patients and visitors that they should just leave the hospital. When they got outside the ED door, Staff Q offered to provide the hospital’s patient advocate information, but they declined. Staff Q asked if they wanted the discharge orders, and Patient #27’s husband said no, but Patient #27 said she wanted it as proof she was there, and took it from Staff Q. Later, Staff P reported Patient #27 had initially came in and requested pain medication, specifically Dilaudid. Patient #27 was administered a shot of Dilaudid at Staff N’s orders. After the medication, Patient #27 demanded she be placed on “high flow oxygen.” Staff P advised Staff O, that Patient #27 needed to be discharged because there was nothing wrong. During a telephone interview on 08/13/25 at 11:30 AM, Staff P, ED RN, stated that Patient #27 was a “frequent flyer.” On 08/02/25, she was placed in one of the trauma rooms by the triage nurse. She went in and hooked the patient up to the heart monitor, got her changed into a gown, and then Patient #27’s husband provided her history. Patient #27 indicated that Dilaudid was the only thing that made her throat feel better. She had a port (small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood), but it was not accessed during her ED visit. Her “VS were perfect,” her oxygen saturation was 100% the entire time. Staff P “knew there was no airway compromise.” She contacted Staff N, ED Physician, who advised her to administer one mg of Dilaudid and 50 mg of diphenhydramine IM, and not to access the patient’s port. Patient #27 said she had never had an IM injection before. Staff P explained that there was no need to access the port and that the IM medication would last longer. Patient #27 had a home prescription for two mg of Dilaudid every three hours. Staff P administered the ordered medications and within five minutes, Patient #27 said that she wasn’t any better and the medications weren’t working. Staff P informed Staff N of the situation and that Patient #27’s airway was open. Patient #27 started to hyperventilate and demanded Staff N come in to assess her. Patient #27’s husband got agitated, and security was called to be on standby. Staff N told Patient #27 that he was not going to give her anything else. Patient #27’s husband called Staff P a “witch” and a “bitch,” and Patient #27 yelled and screamed full sentences. Patient #27 then took off her gown and “flashed” security and the patient in the other bed in the room. She then walked out of the room, breasts “flailing,” and put on her shirt. Staff P and security asked Patient #27 if she wanted her discharge instructions. She refused and “walked briskly” toward the ED exit. Her husband walked back toward security in an aggressive manner, then Patient #27 and her husband walked out without any further problems. Patient #27 had been seen at Hospital B earlier that morning and had stated she had been to other places too. Lake Regional Health System’s pulmonologist (a physician who specialized in lung issues) had fired the patient over a year ago and refused to see her. Patient #27 was seen, assessed, and treated. Her airway was not compromised, she spoke in full sentences and yelled at security. Patient #27 and her husband were flagged in the electronic medical record system as aggressors. After they left, Staff P notified the supervisor that Patient #27 would likely complain. During a telephone interview on 08/13/25 at 11:13 AM, Staff O, SO, stated that on 08/02/25, he got a call around 2:00 PM from the ED unit secretary regarding a visitor that was loud, and staff wanted security to respond. He was on another unit and notified Staff Q, SO, who arrived in the ED first. The patient was in one of the rooms that had two beds separated by a curtain, with a double door that was always left open. Staff Q reported that when he arrived, Patient #27’s husband asked if he was “there for me.” Staff Q told him he was there to monitor the situation. Staff O arrived at the ED nurse’s station, and Staff N, ED Physician, came by to speak with Staff P, ED RN. Staff N said to discharge Patient #27. Staff P, Staff O, and Staff Q entered the her room. Patient #27’s husband was on the left side of the bed, Staff P was on the right side. Staff P told Patient #27 that she was being discharged. Patient #27 and her husband became “irate.” Her husband stepped toward the bed and Staff P. Staff Q put an arm out to block Staff P from the husband. The patient sat up and ripped off the leads of her heart monitor. Staff O asked if she needed a wheelchair, she said yes, so he exited the room to get one. He believed Staff Q and Staff P stayed in the room, along with another patient that was in the other bed. When he returned, the patient was “topless” and asked Staff O “if he got a good look.” Staff O and Staff Q stepped back and closed the curtains. When the patient exited the room, Staff O asked if she needed a wheelchair, and she said “No, apparently I’m fine.” She turned the wrong direction to exit the ED, and Staff Q followed her. The husband and Staff O followed behind them. Staff Q looked back, and Patient #27’s husband asked if he threatened him. Staff O said no, they were there for the discharge. Patient #27 grabbed the handrail and “looked like she was going to collapse, like she was in pain or something.” Staff O asked her if she needed a wheelchair, and she said no. Her husband grabbed her by the arm and assisted her out of the ED. Patient #27 and her husband “screamed” as they walked out the door and said phrases such as “F this place.” Outside the ED, Staff O asked her if she wanted the patient advocate’s phone number, and she declined. He asked if she wanted her discharge papers, and the patient grabbed them. Then she and her husband left. Staff O then went to talk to Staff N and Staff P, who said the patient was seeking pain medications. They administered her pain medications IM, but the patient wanted them through her IV. The patient also wanted high flow oxygen. Staff P tried to get the patient to sign her discharge paperwork, but the patient refused. During a telephone interview on 08/14/25 at 10:40 AM, Staff N, ED Physician, stated that Patient #27 came in with a chief complaint of trouble breathing and noisy respirations. She had a history of TBM which was “a rare thing,” associated with noisy breathing, specifically on inhalation, like stridor. Staff N did not know if there was any surgical treatment for the condition, but the primary treatment was symptom management. Patient #27 was anxious, which made her breathing noisier. She spoke in full sentences and had normal oxygenation. He asked her what helped her feel better, and she said Dilaudid and diphenhydramine, so he ordered that as an IM injection. He did not believe she had IV access at that time. Approximately 15-20 minutes after the medications were given, the patient demanded another dose. Per community record review, the patient had a history of going to multiple hospitals and had been at Hospital B within the past 24 hours. She had a home prescription for Dilaudid every three hours, had presented to two EDs within 24 hours, and “that’s a problem.” The patient was told that they would not encourage drug seeking behavior and to follow up with her primary doctor. The patient then threatened staff. She put together “long sentences in colorful language.” Staff N had “never had anyone in respiratory distress yell in long sentences like she did.” Based on her presentation, Staff N did “not believe” that Patient #27 “had an EMC that needed management in the hospital.” Her oxygen saturations were okay, she had no signs or symptoms of an infection. Staff N did not think labs or diagnostic imaging was indicated because Patient #27 had a “functionally normal exam.” The first few hours after food aspiration were not long enough to get aspiration pneumonia. If she had aspirated some food, they “would not be able to retrieve it. Inhaled food goes to the right bronchial stem and either gets coughed up or absorbed by the body.” She was not symptomatic. Staff P, ED RN, later told him that the patient “flashed her breasts” when she was being discharged. From her records, it looked like Patient #27 went to Hospital B “in July to catch the new residents, who give out more narcotics.””

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to: - Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the screen of the computer for one current patient (#23) of two insulin administrations observed. (A-0405) - Ensure insulin prepared from a multi-dose vial was properly labeled for two current patient (#13 and #23) of two insulin administrations observed. (A-0405) - Safely secure medications when the medications were left unattended on top of a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) in a patient room for one current patient (#16) of seven medication administrations observed. (A-0405) - Properly administer medications when they documented the medications prior to giving them to three current patients (#13, #14, #15) of seven medication administrations observed. (A-0405) The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 05/07/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included insulin administration education to all nursing staff who were qualified to administer medications. This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services. Please refer to A-0405.”

“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: 47504 Based on observation, interview, record review and policy review, the hospital failed to: - Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the screen of the computer for one current patients (#23) of two insulin medication administrations observed. - Ensure insulin prepared from a multi-dose vial was properly labeled for two current patients (#13 and #23) of two insulin administrations observed. - Safely secure medications when the medications were left unattended on top of a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) in a patient room for one current patient (#13) of seven medication administrations observed. - Properly administer medications when they documented the medications prior to giving them to three current patients (#13, #14 and #15) of seven medication administrations observed. Findings included: Review of hospital policy titled, “Medication Administration Nursing,” revised on 01/30/25, showed: - Medications should be returned to the medication room if they are not administered. - Medications should not be administered if they are not properly labeled. - During the administration of medications, the patient’s identification band is scanned and along with the medication package. - Record in the patient’s record the time of any medication administration. Observation on 05/06/25 at 9:00 AM, Staff AA, RN, withdrew two units of insulin in a syringe from a multi-dose vial. She did not label the syringe and was walking towards Patient #13’s room when Staff # O, Educator, stopped Staff AA and told her she needed to put a label on the syringe. During concurrent observation and interview on 05/06/25 at 12:30 PM, with Staff T, RN, showed Staff T, RN, standing outside of Patient #23’s room with an unlabeled syringe sitting on top of the WOW. Staff T indicated the syringe contained insulin and she had a bar code label attached to the computer that she used for scanning insulin. During an interview on 05/06/25 at 12:35 PM, Staff Q, Director, stated she was aware that staff used barcode labels attached to their computers for scanning insulin. The expectation per policy was to label each individual syringe with the appropriate insulin barcode that would be scanned at the bedside when the insulin was administered. During an interview on 05/06/25 at 1:30 PM, Staff D, Chief Nursing Officer (CNO), stated that nurses should label all insulin syringes with the corresponding barcode. Barcode labels should not be attached to the computers for repeated scanning when administering insulin to multiple patients. Observation on 05/06/25 at 8:40 AM, showed Staff N, RN, preparing to administer medications to Patient #13. Applesauce was required for Patient #13’s medications. Staff N left Patient #13’s medications unattended on top of the WOW in Patient 13’s room when she exited the room to obtain the applesauce. Observation on 05/06/25 at 9:00 AM, showed Staff N, RN, documented the administration of medications prior to administering them to Patient #13. Observation on 05/06/25 at 9:15 AM, showed Staff N, RN, documented the administration of medications prior to administering them to Patient #14. Observation on 05/06/25 at 9:55 AM, showed Staff N, RN, documented the administration of medications prior to administering them to Patient #15. During an interview on 05/06/25 at 1:30 PM, Staff D, CNO, stated nurses should not document a medication was given prior to actually administering the medication to the patient. Nursing staff should not leave medications unattended at any time.”