Shore Medical Center

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50613 Based on observations, staff interviews, review of facility documents and review of nationally recognized guidelines, it was determined that the facility failed to ensure that temperature and humidity were monitored and maintained within established parameters, in accordance with facility policy. Findings include: Facility policy titled, “Temperature and Humidity Recording (undated) stated, “...1. Current guidelines for temperature range between 68 [degrees] and 73 [degrees] F[Fahrenheit] (20-23[degrees]C [Celsius]) with a corresponding relative humidity of 35 % [percent] to 60 % in the Operating Room ... 3. Log records at the end of the month will be forwarded to the Chief Engineer in Plant Operations. Data trending and analysis will be discussed in the Infection Prevention Committee ...4. Readings (temperature and/or humidity) falling out of current guidelines will prompt the following: an action plan will be completed to assess condition ...A service request ticket should be placed stating out of compliance for plant ops and documented on comment line that it was done ...Ventilation Table ...Operating Rooms ...Temperature (F/C) 68-73 (20-23)... Relative Humidity (%) 35-60 ...[name of facility] is required to follow 2006 AIA [American Institute of Architects] guidelines ... Universal Temperature/Humidity/Tissue Testing/Negative Pressure Room Log ...Action Plan for out of range humidity and temperature: 1. Assess all sterile supplies in area for signs of moisture/staining 2. Notify supervisor 3. Enter a problem ticket with plant operations stating the reading is out of range and document on the column above ...” On 08/10/26 at 10:27 AM, a tour of the Operating Room [OR] Suite was conducted, accompanied by Staff (S)3 and S11. S11 explained the charge nurse is responsible for documenting the temperature and humidity of each OR daily prior to the first case of the day. S11 stated that no cases had been delayed or cancelled due to issues with temperature and humidity. At 10:42 AM, an interview was conducted with S4, who stated that as the charge nurse, one of his/her responsibilities was to check and document the temperature and humidity in all operating room areas. S4 stated that when the humidity was elevated, the temperature would be “bumped up” to try to lower the humidity. S4 stated that if the humidity did not decrease, Plant Operations would be notified, and Plant Operations could adjust the temperature remotely. S4 stated that there had been problems with elevated humidity throughout the summer; however no surgical cases needed to be delayed or cancelled because of the high levels. S4 stated that he/she rechecked the readings after temperature adjustments but did not document the recheck. At 11:05 AM, an interview was conducted with S5. S5 stated that service requests related to temperature and humidity are not usually received, however one was received on 08/07/26 for high humidity levels in all rooms. On 08/07/26 the humidity levels were: OR 1 (71%), OR 2 (66%), OR 3 (63%), OR 4 (69%), OR 5 (66%), OR 6 (68%), OR 7 (67%) and OR 8 (68%). S5 stated that the OR staff “like the rooms cold, and every time they lower the temperature the humidity goes up. The thermostats should be locked so they can’t touch them.” S5 was asked how the issue of high humidity was resolved on 08/07/26 and stated “it was over 90 degrees outside that day; I’m not surprised the rooms were out of range. The OR temperatures are set at 72 degrees, but the staff change it. For example, the temperature in OR 1 was 65 degrees when the humidity reading was taken at 70%. The staff needs to stop touching the thermostat.” The temperature and humidity logs for the OR suite for the month of August was requested and reviewed. The logs indicated the humidity levels were out of range on the following dates: OR 1: 08/01/26 (62%), 08/03/26 (64%), 08/05/26 (62%), 08/06/26 (64%), 08/07/26 (71%), 08/10/26 (70%). OR 2: 08/03/26 (63%), 08/04/26 (65%), 08/05/26 (62%), 08/06/26 (66%), 08/07/26 (66%), 08/09/26 (73%), 08/10/26 (69%). OR 3: 08/03/26 (62%), 08/05/26 (65%), 08/07/26 (63%). OR 4: 08/03/26 (63%), 08/04/26 (61%), 08/05/26 (62%), 08/06/26 (72%), 08/07/26 (69%), 080/9/26 (73%), 08/10/26 (69%). OR 5: 08/03/26 (64%), 08/06/26 (64%), 08/07/26 (66%). OR 6: 08/03/26 (63%), 08/05/26 (61%), 08/06/26 (61%), 08/07/26 (68%), 08/10/26 (61%). OR 7: 08/04/26 (63%), 08/05/26 (64%), 08/06/26 (62%), 08/07/26 (67%). OR 8: 08/01/26 (70%), 08/03/26 (64%), 08/05/26 (68%), 08/06/26 (66%), 08/07/26 (68%), 08/10/26 (70%). OR 9: 08/02/26 (63%), 08/03/26 (62%). At 12:33 PM, S11 was asked if Plant Operations was notified of any of the out-of-range humidity readings, and he/she provided a Service request form dated 08/07/26 at 6:28 AM, that stated, “Description: high humidity in all rooms.” At 1:00 PM, S11 confirmed that Plant Operations was not contacted for any of the other out of range readings. S1 revealed that the temperature and humidity results are not analyzed monthly and results are not shared with any hospital committees. The Infection Prevention Committee meeting minutes for 2025 and 2026 were requested. S1 provided meeting minutes dated 12/18/25, 05/06/26, and 07/08/26. Review of the meeting minutes provided did not identify documentation of a Plant Operations or Environment of Care report in which analysis and trending of the operating room temperature and humidity would be discussed. At 2:30 PM, S1 confirmed that the facility protocol states that out of range humidity levels are to be reported to the plant operations department, and the OR department did not consistently report the readings.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 50613 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that temperature and humidity data were routinely trended, analyzed and discussed by the Infection Prevention Committee, in accordance with facility policy. Findings include: Facility policy titled, “Temperature and Humidity Recording (undated) states, “ ...1. Current guidelines for temperature range between 68 [degrees] and 73 [degrees] F[Fahrenheit] (20-23[degrees]C [Celsius] with a corresponding relative humidity of 35 % [percent] to 60 % in the Operating Room ... 3. Log records at the end of the month will be forwarded to the Chief Engineer in Plant Operations. Data trending and analysis will be discussed in the Infection Prevention Committee ...4. Readings (temperature and/or humidity) falling out of current guidelines will prompt the following: an action plan will be completed to assess condition ...A service request ticket should be placed stating out of compliance for plant ops and documented on comment line that it was done ...Ventilation Table ...Operating Rooms ...Temperature (F/C) 68-73 (20-23)... Relative Humidity (%) 35-60 ...[name of facility] is required to follow 2006 AIA [American Institute of Architects] guidelines ... Universal Temperature/Humidity/Tissue Testing/Negative Pressure Room Log ...Action Plan for out of range humidity and temperature: 1. Assess all sterile supplies in area for signs of moisture/staining 2. Notify supervisor 3. Enter a problem ticket with plant operations stating the reading is out of range and document on the column above ...” On 08/10/26 at 10:42 AM, an interview was conducted with S4, who stated that as the charge nurse, one of his/her responsibilities was to check and document the temperature and humidity in all operating room areas. S4 stated that when the humidity was elevated, the temperature would be “bumped up” to try to lower the humidity. S4 stated that if the humidity did not decrease, Plant Operations would be notified, and Plant Operations could adjust the temperature remotely. S4 stated that there had been problems with elevated humidity throughout the summer; however no surgical cases needed to be delayed or cancelled because of the high levels. The temperature and humidity logs for the OR suite for the month of August was requested and reviewed. The logs indicated that the humidity levels were out of range on the following dates: OR 1: 08/01/26 (62%), 08/03/26 (64%), 08/05/26 (62%), 08/06/26 (64%), 08/07/26 (71%), 08/10/26 (70%). OR 2: 08/03/26 (63%), 08/04/26 (65%), 08/05/26 (62%), 08/06/26 (66%), 08/07/26 (66%), 08/09/26 (73%), 08/10/26 (69%). OR 3: 08/03/26 (62%), 08/05/26 (65%), 08/07/26 (63%). OR 4: 08/03/26 (63%), 08/04/26 (61%), 08/05/26 (62%), 08/06/26 (72%), 08/07/26 (69%), 080/9/26 (73%), 08/10/26 (69%). OR 5: 08/03/26 (64%), 08/06/26 (64%), 08/07/26 (66%). OR 6: 08/03/26 (63%), 08/05/26 (61%), 08/06/26 (61%), 08/07/26 (68%), 08/10/26 (61%). OR 7: 08/04/26 (63%), 08/05/26 (64%), 08/06/26 (62%), 08/07/26 (67%). OR 8: 08/01/26 (70%), 08/03/26 (64%), 08/05/26 (68%), 08/06/26 (66%), 08/07/26 (68%), 08/10/26 (70%). OR 9: 08/02/26 (63%), 08/03/26 (62%). S1 revealed that the temperature and humidity results are not analyzed monthly and results are not shared with any hospital committees. The Infection Prevention Committee meeting minutes for 2025 and 2026 were requested. S1 provided meeting minutes dated 12/18/25, 05/06/26, and 07/08/26. Review of the meeting minutes provided did not identify documentation of a Plant Operations or Environment of Care report in which analysis and trending of the operating room temperature and humidity would be discussed. At 2:30 PM, S1 confirmed that the facility protocol states that out of range humidity levels are to be reported to the plant operations department, and the OR department did not consistently report the readings. S1 also confirmed that temperature and humidity analysis was not included in the Infection Prevention Committee meeting minutes.”

“INFORMED CONSENT CFR(s): 482.51(b)(2) A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies. This Standard is not met as evidenced by: 49077 Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that informed consent forms are properly executed, in accordance with facility policy. Findings include: Facility policy titled, “Informed Consent Policy,” approved on 06/14/24, stated “... H. Informed consent should never be obtained when a patient has been sedated ... The Consent Form: ... 2. The provider who engages in the informed consent process should be the one who signs the form, along with dating and timing the form ...” On 08/10/26 at 10:11 AM, Staff (S)17 confirmed that only registered nurses are able to sign as a witness to consent and that the signatures must be dated and timed. On 08/11/26 at 1:07 PM, S11 confirmed there was an incident last year where a rep [representative] had given the incorrect device to the nurse to be implanted into Patient (P)1. S11 stated that there was a clicking noise coming from P1’s knee after the surgery and an x-ray revealed that the implant was flipped. S11 stated that P1 was brought back to the OR (Operating Room) to have a revision of the surgery. S11 indicated that someone from P1’s family provided informed consent since P1 would not have been able to after being sedated earlier. Review of P1’s medical record revealed the following: The “Operative Report” entered on 08/15/25 at 3:01 PM by S26 stated, “ ... Upon being transferred to the recovery room I was called aside by the department administrators with the sales rep from the manufactures company and made aware that the implant brought to the table was the right sided femoral prosthesis rather than the left. This was then brought to the attention of the patient who had gone on to wake up in the recovery room and the rationale for making the adjustment today rather than waiting to see how [he/she] progressed made the most sense and I felt was the correct recommendation. They saw the need to proceed and [he/she] was brought to the OR for correction of this implant mismatch ...” The “Informed Consent Form for the Authorization of Treatment (OR Procedure OR Operation)” from 08/15/25 revealed that P1 consented to “Left total knee arthroplasty with quad sparing” [knee replacement] at 7:45 AM. The “Anesthesia Consent Form” from 08/15/25 revealed that P1 consented to anesthesia for the initial procedure at 8:00 AM. The “Surgical” note stated, “ ... Procedure Arthroplasty Total Knee ... Start 08/15/25 8:44 [AM] Stop 08/15/25 10:19 [AM] ...” The “Anesthesia Record” revealed that P1 received Midazolam and Propofol (sedative medications) during the initial knee surgery. Another “Informed Consent Form for the Authorization of Treatment (OR Procedure OR Operation)” from 08/15/25 revealed that P1 consented to the revision surgery at 11:35 AM, one hour and 16 minutes after the initial surgery. A second “Anesthesia Consent Form” revealed there was no time indicating when signatures were obtained. The signatures of P1, a witness, and a provider were written on their respective lines, however, no time was entered, only “08/15/25” was written in the field for “Date/Time.” It was identified that P1 signed the second “Informed Consent Form for the Authorization of Treatment (OR Procedure OR Operation)” after he/she was sedated for the first procedure, which in not in accordance with facility policy. On 08/12/26 at 2:04 PM, above findings confirmed with S1, S2, and S30.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 48414 Based on staff interview, review of facility documents, and review of medical records, it was determined the facility failed to ensure comprehensive pain assessments and reassessments are completed in seven of ten medical records (Patient (P)1, P2, P3, P4, P5, P6, and P8), in accordance with facility policy. Findings include: Reference facility policy titled, “Pain Management”, undated, states, “Guidelines: 1. A comprehensive pain assessment, includes but is not limited to, pain intensity, pain location, and quality, precipitating factors, alleviating factors, responses to treatment. This assessment is documented by the RN [registered nurse]: Med/Surg [medical-surgical] ...: The RN completes the pain assessment on admission, every shift while hospitalized, after interventions, day of discharge or transfer to another level of care, and PRN [as needed]. ...3. After pain management interventions, reassessments of pain will include the intensity level documented in the EMAR [electronic medication administration record]. The pain level will be reassessed within one hour in the EMAR according to the onset of the prescribed medication. 4. A task will generate in the EMAR for pain reassessment as follows: Sublingual- 5 minutes; IV [intravenous] -15 minutes; SQ[subcutaneous] /IM [intramuscular] -30 minutes; PO [by mouth]- one hour ...” On 4/11/24 at 11:50 AM, medical record review was conducted with S1, Director of Risk Prevention, and S11, Clinical Informatics. P1 was admitted on 1/1/24 at 11:59 PM, with a reason for visit of Cellulitis. P1 had an order for Hydromorphone 0.5mg IV (Intravenous) every 4 hours, PRN (as needed), Severe Pain (Pain Score 7-10). Medical Record (MR)1 lacked a comprehensive pain assessment prior to administration of Hydromorphone 0.5mg IV on: 1/2/24 at 8:56 PM, 1/3/24 at 2:00 AM, 1/3/24 at 6:09 AM, and 1/3/24 at 10:33 AM. P2 was admitted on 12/25/23 at 8:16 PM, with a reason for visit of Acute Asthma. P2 had an order for Tramadol 50mg, PO, every 6 hours, PRN, Moderate Pain (Pain Score 4-6). MR2 lacked a comprehensive pain assessment prior to administration of Tramadol 50mg PO on: 1/6/24 at 2:08 PM, and 1/7/24 at 9:30 AM. P2 had an order for Tylenol 650mg, PO, every 6 hours, PRN, Mild Pain (Pain Score 1-3). MR2 lacked a comprehensive pain assessment prior to administration of Tylenol 650mg PO on: 1/1/24 at 6:34 PM, 1/2/24 at 12:50 AM, 1/3/24 at 2:07 PM and 1/3/24 at 3:33 PM. P4 was admitted on 12/4/23 at 8:36 PM, with a reason for visit of Pneumonia. P4 had an order for Oxycodone 10mg, PO, every 4 hours, PRN, Severe Pain (Pain Scale 7-10). MR4 lacked a comprehensive pain assessment prior to the administration of Oxycodone 10mg PO on: 12/7/23 at 2:35 PM and 12/7/23 at 6:20 PM. MR4 lacked a pain reassessment following the administration of Oxycodone 10mg PO on: 12/7/23 at 2:35 PM and 12/7/23 at 6:20 PM. On 4/11/24 at 1:11 PM, S1 stated, “...A complete pain assessment should be completed when administering pain medications.” S1 confirmed a pain reassessment should be documented with a pain intensity level following the administration of a pain medication. S1 and S11 confirmed the findings above on 4/11/24 as they were identified. On 4/12/24 at 11:22 AM, medical record review was conducted with S1 and S13, Clinical educator. P3 was admitted on 1/21/24 at 2:19 PM, with a reason for visit of Abdominal Pain. MR3 lacked documentation of a comprehensive pain assessment upon admission. P3 had an order for Oxycodone 15mg, PO, every 4 hours, PRN, Severe Pain (Pain Scale 7-10). MR3 lacked a comprehensive pain assessment prior to the administration of Oxycodone 15mg PO on: 1/30/24 at 7:05 AM, and 1/30/24 at 12:41 PM. P5 was admitted on 12/11/23 at 10:42 PM, with a reason for visit of Neck Fracture. MR5 lacked documentation of a comprehensive pain assessment upon admission. P5 had an order for Morphine 2mg IV, every 4 hours, PRN, Moderate Pain (Pain Scale 4-6). MR5 lacked a comprehensive pain assessment prior to the administration of Morphine 2mg IV on: 12/13/23 at 8:28 AM. MR5 lacked a pain reassessment following the administration of Morphine 2mg IV on: 12/13/23 at 8:28 AM. P6 was admitted on 1/11/24 at 6:21 PM, with a reason for visit of Partial Intestinal Obstruction. P6 had an order for Hydromorphone 0.5mg IV, every 2 hours, PRN, Mild Pain (Pain Scale 1-3). MR6 lacked a comprehensive pain assessment prior to the administration of Hydromorphone 0.5mg IV on: 1/15/24 at 12:10 PM. P8 was admitted on 12/21/23 at 7:19 AM, with a reason for visit of unilateral primary osteoarthritis of left knee. P8 had an order for Acetaminophen-Oxycodone 325mg-5mg 2 tablets, PO, every 4 hours, PRN, Severe Pain (Pain Scale 7-10). MR8 lacked a comprehensive pain assessment prior to the administration of Acetaminophen-Oxycodone 325mg-5mg PO on: 12/22/23 at 5:17 AM and 12/22/23 at 9:23 AM. MR8 lacked a pain reassessment following the administration of Acetaminophen-Oxycodone 325mg-5mg PO on: 12/22/23 at 5:17 AM. On 4/12/24 the above findings were confirmed with S1 and S13 as they were identified.”

“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: 39724 Based on medical record review, facility document review, and staff interview, it was determined the facility failed to ensure that 1. policies and procedures that address the accountability of Controlled Dangerous Substances (CDS) are developed and implemented; and 2. prescription medication brought to the facility from the patient’s home is returned to the patient upon discharge, in one of two medical records (MR), MR7, reviewed, in accordance with facility policy. Findings include: During the entrance conference on 4/11/24 at 10:00 AM with Staff #1 (S1), Director of Risk Prevention, S2, Chief Nursing Officer, and S3, Administrative Director of Quality and Regulatory, it was confirmed the facility identified an incidence of potential CDS diversion by S14, an agency Registered Nurse (RN). S14 was employed at the facility from 9/11/23 until 3/25/24. The facility’s diversion investigation was reviewed, and indicated the facility’s review of CDS usage was retrospective starting from 1/1/2024. On 4/11/24 at 10:20 AM, S5, the Informatics Pharmacist, stated the investigation did not include S14’s CDS utilization from 9//11/23 through 12/31/23 due to a change in the facility’s CDS monitoring process. During an interview on 4/11/24 at 10:25 AM, S5, the Informatics Pharmacist, stated the facility currently uses a drug diversion monitoring software called “Blue Sight” to monitor staff administration and waste of CDS. S5 stated this program was fully implemented in March of 2024. This system sends CDS utilization data reports to the nurse managers for review, and has an embedded method to electronically track if the potential CDS discrepancy has been addressed. This software identified the CDS discrepancy that triggered the facility investigation into S14’s CDS utilization on 3/25/24. On 4/11/24 at 10:30 AM, S5 stated that prior to the use of “Blue Sight,” CDS utilization and accountability was reviewed by manually reviewing CDS utilization reports and compiling the data on an Excel sheet. These data sheets were then shared with nurse managers for review. This system did not have a method in place to monitor if the nurse managers reviewed the CDS discrepancy data and completed the necessary follow up. On 4/11/24 at 1:30 PM, the facility documentation that CDS utilization review was completed from 11/2023 through 12/2023, prior to the use of the “Blue Sight” software, was requested. The facility failed to provide documentation that CDS monitoring was completed prior to the institution of “Blue Sight.” It could not be determined if the facility had a process in place to ensure the accountability of CDS prior to 1/1/ 2024. On 4/11/24 the facility policy and procedure, that addresses the use of “Blue Sight” for monitoring of CDS accountability, was requested. On 4/11/24 at 10:45 AM, S5 stated he/she was not aware of a policy that addressed these processes. On 4/11/24, the facility failed to provide a policy and procedure that addressed the use of “Blue Sight” to ensure the accountability of CDS upon request. However, on 4/12/24 at 10:45 AM, the facility provided a document titled “Drug Diversion Prevention and Detection Policy” that was undated and stated “draft.” The facility provided a new draft policy that addressed drug diversion processes in response to the surveyors’ request on 4/11/24. During an interview on 4/11/24 at 1:45 PM, S5 stated that patients are not profiled by the pharmacy department in the procedural areas of the facility, such as the operating rooms, the procedure rooms, and the cardiovascular institute (CVI) which includes the cardiac catheterization procedure room and the interventional radiology procedure room. S5 provided documentation that CDS accountability was monitored for anesthesia providers in the operating rooms and procedure rooms, however S5 stated the facility did not have a process in place to monitor CDS accountability in the CVI, as that area used an electronic medical record called IVIEW, that did not interface with Blue Sight, the drug diversion software. S5 confirmed the facility did not monitor CDS accountability in the CVI units. Medical record review conducted on 4/12/14 identified the following discrepancy: On 4/12/24 at 1:47 PM, one of 10 Medical Records (MR), MR18, reviewed with S10, the Assistant Director of Pharmacy, and S15, a Registered Nurse (RN), revealed a discrepancy when compared with Omnicell medication CDS waste reports. Patient (P)18 was treated in the Cardiac Catheterization Unit on 3/14/24. MR 18 was documented in the electronic medical record called “IVIEW.” The medication administration documentation dated 3/14/24 was compared with the report obtained by the facility’s drug diversion software, BlueSight, and the Omnicell Waste Transaction Report. The Bluesight report revealed one 2 ml vial of Midazolam 1 mg (milligrams)/ml (milliliter) (a CDS) was removed from the Omnicell on 3/14/24 at 10:14 AM. MR18 lacks documentation that the Midazolam was administered to P18 on 3/14/24. The BlueSight Report and the Omnicell Transaction Report lack documentation that the Midazolam, removed for P18, was discarded as waste. The facility could not ensure the accountability of the Midazolam removed for P18. This finding was confirmed with S10 and S15 on 4/12/24 at 1:50 PM. On 4/12/24 at 10:45 AM, the facility provided a document titled “CVI/Cardiac Cath [Catheterization] Controlled Med [Medication] Verification Process,” undated. S12, the Director of Pharmacy, confirmed this document was a draft created on 4/12/24 at 11am, in response to the surveyors’ requests made on 4/11/24. This document states, “...Nurse managers will do a random spot check (5 cases a day 2 days a week) that meds [medications] are correctly documented as given...” This monitoring process was not in place prior to 4/11/24. 48414 Policy titled “Medications Patient Brought From Home”, undated, states, “Definitions: Patient’s own medication- A prescription medication that a patient brings in from home during an inpatient or outpatient visit. ...19. At discharge nursing will return the patient’s own supply of medication to the patient. ...”. On 4/12/24 at 11:22 AM, medical record review was conducted with S1, Director of Risk Prevention, and S13, Clinical Educator. MR7 contained a “Medication Order” dated 1/18/24 at 1:37 PM, for “Patient Own (Lomotil (Diphenox/atrop) 2.5/0.025 mg (id’d) POM [Patient Own Medication] ... Order comment: ** this is a narcotic ...stored in Omnicell as patient’s own med ** patient initial count in RX vial = 30 tablets ...”. S10 (Assistant Director of Pharmacy) provided P7’s “Patient Profile” that stated, “ ...Med Location ...For Patient Own Use In Hospital ...Medication Description Lomotil 2.5mg #30 tabs **sent to the floor for patient use.**” P7’s MAR lacked documented administrations of this medication. MR7 lacked nursing documentation the medication was returned to the patient upon discharge. It could not be determined what happened to the medication P7 brought from home. The facility failed to ensure the accountability of a patient’s own controlled medication from home. On 4/12/24 at 11:30AM. These findings were confirmed with S1.”

“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: 37432 Based on staff interview, review of two of 10 medical records (#1, #8), and review of facility documents, it was determined the facility failed to ensure that pain assessments for patient’s on End of Life Care, is performed in accordance with facility policy. Findings include: Reference: Facility Policy titled, “End of Life Care (Comfort Care)” (approved 6/5/23) states, “... FLACC- a behavior pain assessment scale for use in non-verbal patients unable to provide reports of pain. A behavior scale for scoring pain in no-communication patients which includes (F) facial expression, (L) leg movement, (A) activity level, (C) crying, and (C) consolability scored from 0 to 2 resulting in a total score of 0 to 10 ... Procedure: ... 1. The patient’s symptoms will be assessed based on the FLACC scale for pain ... and the drip titrated appropriately.” On 12/28/23 at 1:00 PM, a review of Patient (P)1’s medical record was conducted with Staff (S)4 (Clinical Informatics). P1 presented to the facility on 12/01/23 for inpatient hospice care and had a history of metastatic pancreatic cancer. P1 expired at the facility on 12/15/23 at 12:26 PM. The physician order for Hydromorphone IV (Intravenous) infusion dated 12/10/23 at 17:28 [5:28 PM] was reviewed and indicated that the Hydromorphone IV drip should be titrated for P1’s comfort. All nursing assessments dated 12/01/23 to 12/15/23 were reviewed and indicated the facility performed verbal pain assessments on 12/1/23, 12/2/23, and 12/3/23 when the patient was alert and oriented. However, there was no evidence the FLACC Scale was used for pain assessments from 12/4/23 to 12/13/23 when the patient was non-verbal and unable to provide a verbal pain score. On 12/28/23 at 2:00 PM, P8’s medical record was reviewed with S4. The medical record indicated P8 was placed on hospice care on 4/1/23 and expired on 4/7/23. Review of P8’s medical record revealed the following: The following physician’s orders were entered for P8: On 4/1/23 at 11:07 AM, Morphine drip 100 mg (milligrams) in Sodium Chloride 100 mL (milliliters) at a rate of 0.5 mL/hr (hour): Titrate to Air Hunger, Dyspnea, Comfort. On 4/4/23 at 10:15 AM, Lorazepam (Ativan Injection) 2 mg/mL IV (intravenous) Push every two hours PRN (as necessary), for agitation for seven days. On 4/4/23 at 10:16 AM, Morphine 2 mg/mL IV push every hour, PRN for Air Hunger. The Medication Administration Record (MAR) was reviewed and revealed that the morphine, starting on 4/1/23, was titrated over five days from 0.5 mg/hr up to 18 mg/hr on 4/6/23. The MAR lacked documented evidence of a nursing assessment and reassessment when the morphine infusion rate was increased on the following dates: 4/1/23 11:10 PM - the morphine drip was increased from 0.5 mg/hr to 1 mg/hr (milligram/hour) 4/2/23 at 11:37 AM - the morphine drip was increased to 2 mg/hr from 1 mg/hr 4/2/23 at 10:06 PM - the morphine drip was increased to 3 mg/hr from 2 mg/hr 4/3/23 at 1:57 AM - the morphine drip was increased to 4 mg/hr from 2 mg/hr 4/3/23 at 8:45 AM - the morphine drip was increased to 5 mg/hr from 4 mg/hr 4/3/23 at 7:00 PM - the morphine drip was increased to 6 mg/hr from 5 mg/hr 4/4/23 3:32 AM - the morphine drip was increased to 10 mg/hr from 9 mg/hr 4/4/23 9:30 AM - the morphine drip was increased to 11 mg/hr from 10 mg/hr 4/5/23 5:49 AM - the morphine drip was increased to 12 mg/hr 11 mg/hr 4/5/23 10:14 PM - the morphine drip was increased to 16 mg/hr from 12 mg/hr 4/6/23 5:19 AM - the morphine drip was increased to 17 mg/hr from 16 mg/hr 4/6/23 9:50 PM - the morphine drip was increased to 18 mg/hr from 17 mg/hr The rate of the morphine drip remained at 18 mg/hr until P8 expired on 4/7/23 at 3:51 AM. A review of P8’s medical record lacked documentation of a pain assessment using the FLACC pain scale prior to increasing the morphine drip rates in the above dates. S4 confirmed the above findings at the time of discovery.”