Lovelace Medical Center

“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: 47302 Based on record review and interview the facility failed to ensure that patient grievances were promptly resolved for 3 (P[patient]1, P3, and P8) out of 3 (P1, P3, and P8) patients reviewed for filing a grievance. This deficient practice could lead to unresolved issues that could negatively impact patient safety, quality of care, and trust in the hospital. The findings are: A. Record review of facility’s policy titled, “Risk Management - Grievance Procedure” dated 12/27/2022 under “Procedure” it is stated, “11) The grievance is considered resolved when the patient or his/her representative is satisfied with the actions taken on their behalf.” B. Record review of the facility’s complaint log from 12/2023 through 12/2025 revealed a grievance on 03/15/2024 with a resolution date of 04/12/2024. The grievance was filed by P3’s representative. 1. Review of a letter from the facility dated 04/12/2024 regarding the grievance identified above revealed that the letter was addressed to P3 and stated, “[Name of Facility] prides itself in customer service and we sincerely apologize that we did not meet your expectations. This matter is considered closed as of 4/12/24.” There is no evidence that P3 or P3’s representative was satisfied with the actions of the facility. There is no evidence that P3 or P3’s representative did in fact receive this letter. C. Record review of the facility’s complaint log from 12/2023 through 12/2025 revealed a grievance on 07/20/2025 with a resolution date of 08/20/2025. The grievance was filed by P1’s representative. 1. Review of a letter from the facility dated 08/20/2025 regarding the grievance identified above revealed that the letter was addressed to P1 and stated, “After review and investigation of your concerns this matter is considered closed as of 8/20/25.” There is no evidence that P1 or P1’s representative was satisfied with the actions of the facility. There is no evidence that P1 or P1’s representative did in fact receive this letter. D. Record review of the facility’s complaint log from 12/2023 through 12/2025 revealed a grievance on 05/05/2025 with a resolution date of 06/03/2025. The grievance was filed by P8’s representative. 1. Review of a letter from the facility dated 06/03/2025 regarding the grievance identified above revealed that the letter was addressed to P8 and stated, “I sincerely want to thank you for the opportunity to review your concerns and improve our processes, when indicated. I will consider my investigation closed as of 6/3/25.” There is no evidence that P8 or P8’s representative was satisfied with the actions of the facility. There is no evidence that P8 or P8’s representative did in fact receive this letter. E. During an interview on 12/17/2025 at 8:15 am with P8’s representative it was confirmed that P8 was in the hospital on 06/03/2025, the letter was delivered to P8’s house. As of the interview on 12/16/2025 P8’s representatives felt their grievance was not resolved. F. During an interview on 12/18/2025 at 12:04 pm with S(staff)13, clinical, the process for resolving grievances was reviewed and it was explained that all grievances are closed by the facility once the facility has completed its investigations. There is no communication with the patient or the patient’s representative prior to the grievance being closed. The grievance is not reopened unless there is a new complaint. Patient’s representatives do not receive the final letter regarding the grievance investigation results or resolution.”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 47302 Based on record review and interview, the facility failed to ensure that the process for resolving patient grievances followed the established grievance time frames for 3 (P[patient]1, P3, and P8) out of 3 (P1, P3, and P8) patients reviewed for filing a grievance. This deficient practice could delay grievance resolution and lead to unresolved issues that could negatively impact patient safety, quality of care, and trust in the hospital. The findings are: A. Record review of facility’s policy titled, “Risk Management - Grievance Procedure” dated 12/27/2022 under “Procedure” it is stated, “9) All grievances will be investigated in tandem with Unit Managers/Directors, medical staff leaders, and staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the patient’s grievance within 7 days. 10) If, within seven (7) business days, the grievance is not resolved, an acknowledgement letter will be sent to the patient or his/her representative. Completion of the investigation will occur within 30 days, unless otherwise specified in the letter.” B. Record review of the facility’s complaint log from 12/2023 through 12/2025 revealed a grievance on 03/15/2024 with a resolution date of 04/12/2024. 1. Review of a letter from the facility dated 03/19/2024 regarding the grievance above stated, “We are reviewing your concerns and issues with the staff and leadership involved. The investigation will take some time, possibly up to 30 days. Your patience is greatly appreciated.” 2. Review of a letter from the facility dated 04/12/2024 regarding the grievance above revealed that the letter was addressed to P3 and stated, “This matter is considered closed as of 4/12/24.” C. During an interview on 12/18/2025 at 12:04 pm with S(staff)13, clinical, it was confirmed that the letter dated 03/19/2024 is a letter sent acknowledging receipt of a grievance. The letter is based on a template that is used for every grievance. The timeframe provided is always 30 days. D. Record review of the facility’s complaint log from 12/2023 through 12/2025 revealed a grievance on 07/20/2025 with a resolution date of 08/20/2025. 1. Review of a letter from the facility dated 08/20/2025 regarding the grievance identified above revealed that the letter was addressed to P1 and stated, “After review and investigation of your concerns this matter is considered closed as of 8/20/25.” E. Record review of the facility’s complaint log from 12/2023 through 12/2025 revealed a grievance on 05/05/2025 with a resolution date of 06/03/2025. 1. Review of a letter from the facility dated 06/03/2025 regarding the grievance identified above revealed that the letter was addressed to P8 and stated, “I will consider my investigation closed as of 6/3/25.” F. During an interview on 12/18/2025 at 12:04 pm with S13, clinical, it was explained that the acknowledgement letter for P1 and P8 were not saved.”

“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: 47302 Based on record review and interview the facility failed to provide medical information to the receiving facility for 1 (P[patient]1) out of 3 (P1-P3) patients reviewed for discharge planning. The deficient practice could possibly lead to patients not receiving the appropriate care after discharge from the hospital and contribute to patients being readmitted. The findings are: A. Record review of P1’s medical chart for visit dated 10/19/2024 at 12:56 PM revealed P1 was brought to the hospital via ambulance from a nursing home after a fall. 1. Under “Flowsheets - Care Handoff” a note dated 10/20/2024 at 3:19 AM “Report given to [Name of ambulance company] ambulance.” Records indicated that report was provided to the transporting ambulance, but a report was not given to the nursing facility that was going to be providing care to the patient. 2. There was no evidence in the medical chart that the facility provided medical information or verified with the nursing home that the patient was being discharged from the hospital and was able to return to her previous arrangement. There was no evidence that the facility provided medical information to the nursing home regarding P1’s visit to the hospital. B. Record review of P1’s medical chart for visit dated 10/20/2024 at 4:19 AM, the provider note stated, “[Patient] came to the emergency department yesterday for fracture dislocation right shoulder and acromion [part of the shoulder blade], who was discharged and taken back to her nursing home where it turned out the nursing home had given away her bed, so she did not have a place to return. The ambulance brought her back. We will now need to have case management find a place for her to live. No new symptoms.” C. During an interview on 04/01/2025 at 9:30 AM with S(staff)5, clinical it was explained that if a patient comes from a nursing home, nursing staff would provide report to the nursing facility when patient is getting discharged.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to document a complete medical record for 1 (P [patient] 7) out of 10 (P1-P10) patients reviewed for medical screening examinations. This deficient practice could possibly lead to incomplete records that do not adequately support the patient’s diagnoses and condition. The findings are: A. Record review of P7’s medical record revealed the following: a. The face sheet revealed P7 presented to the emergency department on 10/15/24 for Hematemesis (Vomiting blood) b. Provider’s note revealed a physical examination was not documented. The note did not contain any review of systems (ROS, method of collecting history and full assessment from patients) for P7. Under “Physical Exam” there were only vital signs charted, no further documentation of an assessment was documented. c. Section “ED [Emergency Department] course and impression [explanate of care that was provided in the ED]” stated “He [name of P7] was discharged home with a prescription for Zofran [medication for nausea] as well as Carafate [medication for stomach ulcers]. Referral to GI [gastroenterology] made.” C. During an interview on 11/12/24 at 2:00 PM with S2, Clinical staff member, S2 confirmed that there was nothing documented under “Review of Systems” (ROS) and there was no further assessment documented. D. During an interview on 11/13/24 at 8:55 AM, with S (staff) 5, clinical staff member, S5 confirmed that a physical examination was not documented. S5 also confirmed that a physical examination should be documented on all patients.”

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 47480 Based on record review, observation and interview the facility failed to meet the Condition of Participation by not maintaining machines used to clean surgical instruments according to the manufacturer’s recommendations and instructions for use, The facility failed to ensure the sterility of surgical instruments. The facility failed to establish policies and procedures for expiration dates for sterile surgical instruments and sterile instrument trays; and failed to maintain a complete and accurate operating room register. These deficient practices could lead to surgical complications, infections, delays in treatment, or death for all patients receiving surgical services at this facility. The findings are: Refer to Tag A-0951 and A-0958.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 47480 Based on observation, record review and interview, the facility failed to ensure that the Washer, Decontamination System (a medical machine using sterile and purified water, detergents, steam and heat to clean and disinfect (but not sterilize) dirty contaminated surgical instruments), or washer/disinfector, used for washing and disinfecting (clean by destroying bacteria, viruses and fungi that may cause infections) surgical instruments and tools were maintained according to the manufacturer’s Instructions For Use (IFU); the facility failed to ensure that the sterilized (make free of bacteria and other microorganisms) instruments were packaged, handled, and stored in a manner to ensure sterility; and failed to institute policies and procedures establishing expiration dates for sterilized instruments. These deficient practices are likely to lead to surgical site infections, injury or death for all patients undergoing surgical procedures at this facility. The findings are: A. Record review of a facility provided document listing Sterile Processing Department (SPD) equipment revealed that the facility maintains the following washer/disinfectors (a medical machine using sterile and purified water, detergents, steam and heat to clean and disinfect (but not sterilize) dirty contaminated surgical instruments): 1. AMSCO 5052 Washer, Decontamination System Serial Number 3618814006, located on the 1st Floor, SPD 2. AMSCO 5052 Washer, Decontamination System Serial Number 3613721006, located on the 1st Floor, SPD 3. AMSCO 5052 Washer, Decontamination System Serial Number 3610921007, located on the 6th Floor, SPD 4. AMSCO 5052 Washer, Decontamination System Serial Number 3610921006, located on the 6th Floor, SPD B. Record review of the facility’s policy “OR/PACU [Operating Room-a room where surgeries are performed/Post-Anesthesia Care Unit-an area where patients are taken to recover immediately after a surgical procedure]-Cleaning and Care of Surgical Instruments and Powered Equipment” “Effective Date: 04/04/2018”, stated: “h) (i) Automated washer decontaminators or disinfectors and washer sterilizers should be used according to the manufacturer’s written instructions.” C. Record review of IFU (Instructions For Use-which are manufacturer’s instructions) for the “Verify All Clean Test, Washer Indicator Test” “For Monitoring Cleaning Processes”, revealed an indicator test strip (formulated to mimic typical soiling of instruments during normal use that would include blood and other body fluids, body tissue, and other materials encountered during surgeries), used daily, prior to the first washing and disinfecting of instruments for that day. Per the IFU, the test strip, which is initially 2 squares of pink coloring, must be completely clear to indicate the washer/disinfector has passed the test and is ready for use. According to the test strip IFU, “Inspect (the indicator test strip) by placing the plastic film against a white background .... If the color remains visible, the result is a fail.” D. A review of a random sample of 60 Verify All Clean Test strip results that were performed on the washers/disinfectors prior to use, from November 1, 2023, through March 18, 2024, found 44 of 60 test strips had residual pink coloring that indicated a failed test. The facility had the tests marked as “Passed” and proceeded to use the machines without performing corrective actions. E. During an interview on 03/20/2024 at 10:00 am, with Staff (S)9 Sterile Processing Technician, S9 was asked to review a test strip with some residual pink coloring. S9 indicated it was a “pass”, in other words, the machine was ready for use. S9 was asked to review a test strip with part of a pink grid remaining on the strip. S9 indicated it was a “pass”. S9 stated the test is a “pass” if most of the color is gone or faded. S9 provided a copy of a poster from the office that showed pictures of failed and passed test strip results. The poster clearly showed 2 test strips with residual pink coloring as failed results, and a single test strip that is completely clear as the passed result. F. During an interview on 03/21/2024, at 1:45 pm, with S11 STERIS Product Representative (the washer/disinfectors and test strips are all STERIS products), S11 confirmed that “any pink left on the strip is a fail.” S11 confirmed that when any part of the washer/disinfector does not pass the strip test, the facility should stop using the machine, determine and correct the cause of the failure prior to use. G. During an observation on 03/18/2024, at 1:55 pm, with S5 Emergency Department (ED) Director and S4 Assistant Chief Nursing Officer, of ED Room A1, the following surgical instrument trays and box were found without the outer plastic covering and in an uncontrolled area (an area that is readily accessible by individuals not authorized to use or handle sterile instruments such as patients or visitors). In other words, there was no way to verify that the trays and box of instruments were sterile. 1. Tracheotomy (making an incision in the windpipe to relieve a blockage to breathing) Tray (this is a tray of sterile instruments used to perform tracheotomies) revealed the tray wrapped as a sterile tray in blue paper, no outer plastic covering, found laying on counter in an uncontrolled area. 2. Finochietto Retractor (a type of retractor specifically designed to separate ribs in thoracic surgery) revealed the tray wrapped as a sterile tray in blue paper, no outer plastic cover, found laying on cabinet shelf in an uncontrolled area. 3. Finochietto Retractor (Small) revealed the tray wrapped as a sterile tray in blue paper, no outer plastic cover, found laying on cabinet shelf in an uncontrolled area. 4. Orange Metal Box labeled “Oral Surgery Set” revealed a red tag that slips through the lock on the box and, when engaged, indicates that the box is sealed until tag is broken. This tag was not engaged and is open, the tag is undamaged and slipped through the lock slot, i.e. the box seal is broken. There was no way to verify that the surgical instruments within the box were sterile. The box was found on a cabinet shelf in an uncontrolled area. H. During an interview on 03/18/2024 at 1:58 pm, with S4, regarding the wrapped sterile trays, when asked if the trays should be sealed in clear plastic covering, S4 stated “Yes ...” Referring to the orange metal box, S4 was asked if the red tag should be “locked”, and S4 confirmed it should be locked. When asked if the contents were sterile, S4 indicated “I don’t know.” S4 confirmed that the ED room was not a controlled area. I. During an interview on 03/18/2024 at 3:10 pm, with S7 Administrative Director of Surgical Services, S7 confirmed that sterile instrument trays sent to the ED should be sealed in plastic wrapping unless they are going to a sterile controlled area (a locked room, cabinet or drawer that is only accessible by staff authorized to handle and use sterile surgical instruments) S7 confirmed that the orange metal instrument box is not sterile if the tag is not locked and if it is not there or is broken, the item should be reprocessed. When asked if an SPD technician would ever place a red tag on the box without locking it, he confirmed “No”. J. During an observation on 03/19/2024, at 2:55 pm, of the SPD Sub-Sterile Storage Room 6th Floor, a random spot check of shelves of sterilized instrument trays, instrument boxes, and surgical instruments (for example forceps or scissors) in plastic outer coverings found the following: 1. A right-angle forceps (an instrument that looks like large spoons or tongs) with punctured packaging-causing the contents to lose sterility 2. A second right-angle forceps with punctured packaging-causing the contents to lose sterility 3. A third right-angle forceps with cracked and chipped paint on the finger loop 4. A fourth right-angle forceps with a rubber tip protector K. During an interview on 03/19/2024, at 2:55 pm, with S7 Administrative Director of Surgical Services, S7 confirmed that the forceps with the punctured packaging were not sterile and removed the instruments. When asked if the cracked and chipped paint on the finger loop of the third forceps could be adequately sterilized, S9 Sterile Processing Technician, who was present at the time, stated that they do take these types of instruments out of use due to concerns about sterilization. When asked if the fourth forceps was sterilized with the rubber tip protector on, S7 stated “No” it was probably placed after sterilization by a tech. When asked if the rubber tip protectors are sterilized, S7 confirmed that they are not sterilized because they are rubber. When asked if the rubber tip protectors would contaminate the sterile forceps, S7 stated “No” the rubber protectors are “clean.” L. Record review of the facility’s policy “OR/PACU-Cleaning and Care of Surgical Instruments and Powered Equipment” “Effective Date: 04/04/2018”, revealed: “(h) (a) surgical instruments should be inspected for cleanliness and proper working order after decontamination ...corrosion, pitting, burrs, nicks and cracks”; (9) (v) Instruments in disrepair should be tagged or labeled and removed from service until repaired.” M. Record review of the Centers for Disease Control and Prevention (CDC) “Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)”, content source: Centers for Disease Control and Prevention for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP); revealed that “cleaning” refers to “the removal of foreign material...the effectiveness of ...sterilization mandates effective cleaning”. However, “sterilization destroys all microorganisms on the surface of an article”. In other words, the clean rubber tip protector can contaminate the sterile forceps. N. During an observation on 03/18/2024 at 1:55 pm of the Emergency Department room A1, revealed a Finochietto Retractor sterilization date “7/31/18”, and a Finochietto Retractor Small sterilization date “7/31/18”. During an observation on 03/19/2024 at 2:55 pm of the SPD Sub-Sterile Storage Room 6th floor, revealed 3 sterile trays with faded indicator tape (tape that turns black when item is sterilized) dated “2018”. O. During an interview with S7 Administrative Director of Surgical Services, S7 stated that if the outer covering of a sterile package is intact and the tray is not wet, then the tray stays sterile “forever.” When asked if there is a policy regarding expiration dates and storage of sterile supplies, S7 indicated “no”. Facilities are required to have policies for expiration dates of sterilized materials.”

“OPERATING ROOM REGISTER CFR(s): 482.51(b)(5) The operating room register must be complete and up to date. This Standard is not met as evidenced by: 47480 Based on record review and interview the facility failed to maintain a complete operating room register with all of the following required information: patient’s name; patient’s hospital identification number; date of operation; inclusive or total time of the operation; name of the surgeon and any assistant(s); name of nursing personnel (scrub and circulating); type of anesthesia used and name of person administering it; operation performed; pre and post-op diagnosis; and age of patient. The operating room register maintained by the facility is incomplete. This deficient practice could lead to misidentification of patients and procedures, insufficient patient monitoring, and delays in treatment for all patients undergoing surgical procedures at this facility. The findings are: A. Record review of the Operating Room Register revealed that it did not contain the following required information: inclusive or total time of the operation; any assistant(s) to the surgeon; name of nursing personnel; type of anesthesia used; and post-op diagnosis. B. During interview on 03/20/2024, at 8:00 am with Staff (S)7 Administrative Director of Surgical Services, confirmed the Operating Room Register provided to surveyor was the actual document in use.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 46375 Based on record review, observations and interviews, the facility failed to maintain patients’ Protected Health Information (PHI) for 2 (P (Patient) 27 and P28) of 2 (P27 and P28) patients. This failed practice can lead to direct inappropriate disclosure and an increased risk of misuse and breach of PHI. The findings are: A. Record review of facility’s policy titled, “HIPAA37 [Health Insurance Portability and Accountability Act] Safeguards” dated 09/11/2021, stated “Policy: 1) [facility name] will maintain appropriate administrative, technical and physical safeguards to protect the confidentiality, integrity and accessibility of Protected Health Information, consistent with the requirements of these Policies and Procedures. 2) [facility name] must safeguard Protected Health Information form an intentional and unintentional use or disclosure that is in violation of these Policies and Procedures ... Procedure: 3) [facility name] workforce will take reasonable measures so that Protected Health Information on computer screens is not visible or accessible to unauthorized persons.” B. During an observation on 12/19/2023, at 7:54 am, of the emergency department, nursing area and triage, (the preliminary assessment of patients in order to determine the urgency of their need for treatment) the following PHI patient’s information was revealed: 1) An unattended computer screen had P27’s name, date of birth (DOB), age, gender, vaccines, allergies, room number, sepsis score, vitals, pain assessment, neurological (nervous system) assessment, respiratory assessment (appraisal of the patients respiratory system by a health care provider), and PRN (as needed) medication. 2) In an empty triage room, the following was revealed on a patient sticker sheet for P28: patient name, sex, DOB, medical record number, age, financial number and admission date and time. C. During an interview on 12/19/2023, at 3:56 pm, with Staff (S) 13, Interim Nurse Manager, when asked if computers should be left on and unattended with patient information showing, S13 answered, “No, we are supposed to close or lock the computer as soon as we get up.” D. During an interview on 12/20/2023, at 8:15 am, with S3, Risk Manager, when asked what the policy is on securing electronic patient information, S3 answered, “If you are going to step away, you are supposed to lock your computer. We don’t want any open computers with patient information.” E. During an interview on 12/19/2023, at 7:58 am, with S17, Registered Nurse (RN) when asked if patient stickers should remain in a triage room after the patient has been moved, S17 stated the patient stickers should be secured behind the nursing station when the patient has left the triage room. 49844”

“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: 47302 Based on record review and interview the facility failed to ensure that policies were being followed that related to pain management for 1 (P[patient] 24) of 3 (P24, P25, and P26) patients reviewed for pain assessments. This deficient practice could lead to patients pain not being addressed properly and care plans not being adjusted for pain. The findings are: A. Record review of facility’s policy titled, “Pain Management” dated 12/27/2022 stated, “Purpose: To provide clinical guidance in facilitating the effective pain management of patients thereby enhancing their comfort, function, outcomes, and personal/family satisfaction. Pain management is an organizational priority. Policy:1) [Name of facility] recognizes the patient’s right to the appropriate assessment, management and reassessment of pain. Caregivers from all disciplines will acknowledge, assess, and document, as appropriate, throughout the continuum of care the patient’s self-report of pain or observable responses to pain utilizing cognitively and age appropriate pain scales. Patient descriptors of pain may include existence, nature, location, intensity, aggravators, and relievers [meaning patient’s pain should be evaluated regularly while receiving care based on patients level of understanding and should be a detailed evaluation of the pain]. Pain is to be recognized as the 5th vial [sic] sign [in addition to blood pressure, temperature, pulse, and oxygen] and will be documented before and after pain medication and as indicated by the patient’s care, treatment, and services. . . .” B. Record review of P24’s pain assessment and pain medication administration revealed: 1. Physician orders for: morphine (medication given for pain) 1 mg (milligram) every 2 hours as needed ordered 02/22/2022, at 9:34 AM, and oxycodone-acetaminophen (Percocet, medication given for pain) 5-325 mg every 4 hours as needed ordered 02/24/2022, at 7:52 AM. 2. On 02/23/2022, at 11:59 AM, P24 was given morphine 1 mg intravenously (through a catheter in the vein). The record did not contain any evidence P24’s pain assessment at this time. 3. On 02/23/2022, at 12:29 PM, P24’s pain level was reported (using a numeric rating on a scale of 1-10) at a level of 3 (mild pain) in the abdomen (stomach). No medication was administered at this time. 4. On 02/24/2022, at 2:52 AM, P24 was given morphine 1 mg intravenously. The record did not contain any evidence P24’s pain assessment at this time. 5. On 02/24/2022, at 8:09 AM, P24’s pain level was reported at a level 10 (severe pain). P24 was given oxycodone-acetaminophen 5-325 mg by mouth. The record did not contain any evidence P24’s pain assessment, to include location and description of pain, at this time. 6. On 02/24/2022, at 11:36 AM, P24’s pain level was reported at a level 10. P24 was given morphine 1 mg intravenously. The record did not contain any evidence P24’s pain assessment, to include location and description of pain, at this time. 7. On 02/24/2022, at 3:35 PM, P24’s was given oxycodone-acetaminophen 5-325 mg by mouth. The record did not contain any evidence P24’s pain assessment at this time. 8. On 02/25/2022, 7:55 AM, P24’s pain level was reported at a level 6 (moderate pain). P24 was given oxycodone-acetaminophen 5-325 mg by mouth. The location of pain was documented as left arm. The record did not contain any documentation of P24’s description of pain at this time. C. During an interview on 12/20/2023, at 2:15 PM, with S (Staff) 21, intensive care unit supervisor, confirmed staff should be documenting a pain assessment when administering pain medications.”

“IC PROFESSIONAL DOCUMENTATION CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 46375 49844 Based on record review, observations and interviews the facility failed to perform accurate and daily checks of the crash cart (cart stocked with emergency medical supplies and medications) and defibrillator (device that applies an electric current to the heart) to ensure the supplies are not expired, damaged or unsafe. This deficient practice is likely to lead to infections, harm or death of all patients. The findings are: A. Record review of facility’s policy titled “Patient Care - Crash Cart Maintenance,” dated 10/28/22 stated, “Procedure: 1) Daily Crash Checks are to be completed on every workday and documented on the CRITICAL CARE - Crash Cart/Defibrillator - Daily Checklist [capitalized and underlined in policy] by the Charge Nurse or as designated by the unit.... c) Verify the following items are on the top or side of the crash cart: i) Checklists and forms, g) Verify that there are no expired items in or on cart.” B. During an observation and record review of the crash cart on 12/12/2023, at 10:40 am, of the [facility name] clinic revealed the following: 1) The cardiac unit crash cart “Crash Cart/Defibrillator Daily Checklist” was checked off on Tuesday 12/12/2023 for the following days 12/13/23, 12/14/23 and 12/15/23. 2) The “Crash Cart/Defibrillator Daily Checklist” showed the crash chart daily checks category: Checked by Initials: of S25, Tech, for the entire month of December 2023. This was front dated (days that have not yet happened) and days 12/12/2023 (S25 called off sick) and 12/13/2023 that S25 was not working (this is a normal day off). 3) One packet of Electrodes (carries electricity form an instrument to a patient for treatment) with an expiration date of 06/01/2023. 4) One packet defibrillation pads (an essential part of an automated external defibrillator to treat a sudden cardiac arrest emergency) with an expiration date of 11/11/2023 C. During an interview on 12/12/23, at 10:43 am, with S10, Imaging Manager, when asked who was responsible for performing daily crash cart. S10 stated it is alternated between two techs (S11 and S25). When asked about who had performed the daily crash cart checks this week (12/12/23), S10 stated, S25 had been out all week and S25 had completed the daily crash cart checks. D. During an interview on 12/12/23, at 10:47 am, with S11, Tech, when asked who filled out the checklist on 12/12/2023, S11 answered, “S25.” When asked how S25 could have filled it out when she is out sick, S11 replied “Not sure. I didn’t check it today.” When asked if the checklist had been done by S11 or double checked by S11 this month, S11 confirmed that she had not looked at the crash cart in the month of December. E. During an observation on 12/19/23, at 7:50 am, of the Emergency Department Triage Room, it revealed three Intravenous (IV) Catheters (give medication or fluids straight into the bloodstream) with an expiration date of 11/27/23. F. During an interview on 12/19/23, at 7:58 am with S17, Registered Nurse (RN), it was confirmed that the IV Catheters had expired.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to re-assess patient’s discharge based on changes in the patient’s condition for 1 (P[patient]24) of 3 (P24, P25, and P26) patients reviewed for discharge planning. This deficient practice led to the patient being improperly discharged and patient being admitted to another hospital in less than 24 hours. The findings are: A. Record review of facility’s policy titled, “Discharge Planning Policy” dated 04/24/2023 stated, “Purpose: To provide an effective hospital-wide discharge planning process that focuses on the patient’s goals and treatment preferences; includes the patient and his or her caregivers/support persons as active partners in the discharge planning for post-hospital care and reduces factors that may lead to an avoidable readmission. 1) Discharge planning is a responsibility for all hospital staff within each department. . .” Page 4 stated, “c) As part of the registered nurse’s process to reassess patients, if the following circumstances occur, a case management consult will need to be completed to reassess the discharge plan.... i) Upon request of any individual for any reason ii) A change in the patient’s medical stability. iii) A change in the patient’s functional ability. iv) A change in social or financial status becomes apparent. v) A change in the ability of the caregiver to resume the previous level of care prior to admission. vi) A patient and/or the patient’s representative changes their goals and/or treatment preferences. vii) A patient and/or the patient’s representative changes the discharge plan. In response to the Case Management consult, the patient will be reevaluated within one business day of the consult with all pertinent documentation of the reassessment entered in the medical record.” B. Record review of facility’s incident log revealed a fall was reported for P24 on 02/23/2022 at 3:36 PM. The description of the incident stated, “Patient has history of dementia [group of symptoms that affect memory and thinking] and is alert and oriented to name and date of birth only. Patient [P24] was placed in chair by physical therapy after working with them with call light in reach. Nurse went into room to round on patient and patient was found in [sic] the floor with complaints of pain to left arm. New skin tears to bilateral [both] arms. IV [intravenous catheter] had been pulled out. Nurse and PCT [patient care tech] helped patient out of [sic] floor and placed patient back into bed. . .” C. Record review of P24’s electronic health record revealed the following: 1. Review of physical therapy notes revealed P24 was seen by physical therapy on 02/23/2022 at 1:38 PM. Discharge recommendations at this visit stated, “Home with family, Home - community based therapy.” Under “Fall History” it is stated, “None, Last 90 days” and under “Ambulation” it is stated that the patient walked 25 feet with a walker. 2. Review of X-ray results dated 02/23/2022, at 9:43 PM, revealed, “There is a mildly comminuted [broken in at least two places] and displaced [not aligning] fracture involving the left humeral neck [upper arm near shoulder joint]. No other convincing displaced fracture is identified. Glenohumeral [shoulder joint] alignment appears grossly intact, though dedicated shoulder radiographs may be beneficial in further evaluation.” 3. Provider progress note dated 02/24/2022, at 7:46 AM, under “Assessment and Plan” stated “Left humeral fracture. Had a fall, from a sitting position, when she was pushing the table away from the bed and it skidded a little too much causing her to lose her anchor point on the table. Fell on her left side. Did not hit head, or lose consciousness, On my exam post fall, she was at her baseline mental status LUE (left upper extremity) sling [sic]” 4. Facility order for “OT [occupational therapy] eval [evaluation] and treat (evaluation and treatment)” dated 02/24/2022, at 7:50 AM. The order stated “Reason for Consult? New left humeral fracture that [patient] sustained on the afternoon of 2/23. Please evaluate” 5. Discharge summary dated 02/25/2022, at 12:34 PM, under “Brief History and Hospital Course by problem” stated, “On 2/23, [patient] had a fall, from a sitting position, when [patient] was pushing the table away from the bed and it skidded a little too much causing [patient] to lose [patients] anchor point on the table. Fell on [patients] left side. Did not hit head, or lose consciousness. And x-ray showed a left humeral fracture. Left upper extremity placed in sling [sic]. . . “Seen by physical therapy, recommended discharge home with home health care. . . Stable for discharge home” 6. Document titled, “Occupational Therapy Treatment Deferral Note dated 02/25/2022, at 12:50 PM, stated, “Reason for Treatment Deferral: Other (comment) (pt (patient) discharged from facility)” 7. Review of case management notes from 02/23/2022 to 02/25/2022 dated did not mention fall from 02/23/2022 and did not reveal any discussion on whether the discharge plan needed to be re-assessed. D. Record review of P24’s records from an outside hospital revealed “ED [emergency department] Provider Note” dated 02/26/2022 at 11:08 AM under the history stated, “[Patient] brought from home where [patient] lives w/ [with] [daughter]. Hx [history] obtained from daughter as patient doesn’t know why [patient] is here. Was discharged from [facility name] yesterday after hospitalization for acute chole [inflammation of the gallbladder] and placement of GB [gastro-biliary] drain [remove bile from stomach], complicated by a fall and resulting humerus fx [fracture] and compression fx of L1 [lumbar spine 1]. They [family] are unable to provide the level of care [patient] needs, as [patient] can’t walk or toilet.” Under medical decision making it stated, “Diagnosis management comments: Unsuccessful discharge, needs higher level of care per family. Will admit for SNF [skilled nursing facility] placement.” E. During an interview on 12/20/2023, at 2:30 PM, with S(staff)22, Case Management it was asked if physical therapy and occupational therapy consults are normally completed before discharge planning is completed. S22 confirmed the consults would be done prior to discharge. F. During an interview on 12/20/2023 at 2:40 PM with S24, Occupational Therapist, it was confirmed that an order for occupational therapy would be completed prior to discharge because discharge recommendations are provided by the service. It was asked if re-assessment would be completed if a patient falls. S24 stated, “Yes, any change in status like a fall or surgery would require a new order and a re-assessment.””

“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: 49844 Based on observation, record review and interview, the facility failed to meet the Condition of Participation to ensure a transfer consent was obtained and failed to arrange for appropriate transportation that presented to the Emergency Department. This failed practice can lead to poor outcomes related to patients not being evaluated when seeking medical care. The findings are: A. The facility failed to obtain transfer consents and failed to arrange for appropriate transportation. Refer to tag A-2409.”

“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: 49835 49844 Based on record review, and interview the facility failed to appropriate transfer patients for 2 (P [patient] 16, 18) of 22 (P1-P22) patients reviewed for appropriate transfers by: 1. Failing to provide a summary the risks of transfer for P16. 2. Failing to provide appropriate transfer for P16 2. Failing to obtain a transfer consent for P18. These deficient practices are likely to lead to physical, mental, and psychological harm to all patients. The findings are: Failed to provide appropriate transport: A. Record review of policy titled “EMERGENCY DEPARTMENT - EMTALA (Emergency Medical Treatment and Active Labor Act) - Corp - ED” dated 03/19/2019 revealed Section 4.8. “Order the transfer through the use of appropriate personnel, supplies, and equipment” and 4.8.1. “The patient will not be transferred to another hospital by private automobile.” B. Record review of P16’s medical record revealed P16 was transferred to an outside hospital. An untitled transfer form dated 07/09/23, at 11:52 PM under “section A” ‘Transport Mode’ is ‘POV (Patients Own Vehicle).’ Under “Transport service” it stated “None.” The record did not contain any documented risks given to the patient/family regarding transferring the patient in their own vehicle. No evidence of an AMA (Against Medical Advice) form was found. C. During an interview on 12/20/2023 at 11:58 AM, with S1, Quality Manager, confirmed there was not consent for transferring a patient in their own vehicle. D. During an interview on 12/20/2023 at 11:58 AM, with S1, when asked for a policy regarding patients being transferred in their own vehicle, S1 stated “there is no policy”. E. During an interview on 12/20/2023 at 2:59 PM, with S22, Emergency Department Charge Nurse, stated that patients transferred to other hospitals in a private vehicle would have to sign out AMA. Failure to obtain consent: F. Record review of policy titled “EMERGENCY DEPARTMENT-EMTALA (Emergency Medical Treatment and Active Labor Act)- Corp - ED” dated 03/19/2019 Sections 4.9. “A transfer form must be completed at time of transfer” and 4.9.2 “Complete all sections of the form.” G. Record review of P18’s medical record revealed P18 signed a form titled “CONSENT AND ASSESSMENT FOR TRANSFER” Signed on 07/14/2023 at 5:26 AM, failed to specify what the patient was consenting to. 1. Box 1 stated “CONSENT TO TRANSFER: I agree and consent to be transferred” 2. Box 2 stated “REFUSE TREATMENT / REQUEST TRANSFER: I refuse to consent to further medical examination and treatment offered to me and request to transfer.” 3. Box 3 stated “REFUSAL TO TRANSFER I understand the physician believes it is in my best interest to be transferred however I refuse to be transferred. I request to continue receiving treatment at ______.” 4. All three boxes remain unmarked. H. During an interview on 12/20/2023 at 10:40 AM with S4 Assistant Chief Nursing Officer, confirmed “It’s not clear what this patient consented to because it is not marked.””

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47480 Based on record review, observation and interview, the facility failed to meet the Condition of Participation for the prevention and control of HAIs (Hospital Acquired Infections) and other infectious diseases for all patients. This failed practice is likely to lead to infections, poor outcomes, and death for all patients of this facility. The findings are: A. The facility failed to ensure that all staff members and contract employees adhere to proper hand hygiene practices during patient care. Refer to Tag A-0749.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47480 Based on record review, observation, and interview, the facility failed to prevent unauthorized disclosure of patients’ name, age, and other protected health information for 3 (P (patient)11, P12, and P13) of 13 (P1-P13) patients. This failed practice would likely lead to unauthorized disclosure of all patients’ name, age, and other protected health information in this facility. The findings are: A. Record review of the facility’s policy “RISK MANAGEMENT-Patient Rights & Responsibilities” “Effective Date: 08/10/2015”: 1. “2.8 The organization respects the needs of patients for confidentiality, privacy and security.” 2. “AS A PATIENT YOU HAVE THE RIGHT TO: ...The following in regards to your medical records and health information.” “The right to confidentiality ...” B. During observation on 11/16/23 at 4:09 am of 5th Floor Unit, a portable computer workstation was unlocked and open to P11’s medical chart. There was no staff present. P11’s name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible. C. During interview on 11/16/23 at 4:12 am with Staff (S)14, Registered Nurse (RN), was asked what is the expectation for the nurses if they need to leave the workstation when patient information is on the screen? RN stated, “We’re supposed to lock the computers [block access to the computer desktop and any patient information until a security measure has been completed to gain access], when we get up and leave them...” D. During observation on 11/16/23 at 4:20 am of 4th Floor Unit, a portable computer workstation was in hall unlocked and open to P12’s medical chart. There was no staff present. P12’s name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible. At 4:28 am, a portable computer workstation was in hall unlocked and open to P13’s medical chart. There was no staff present. P13’s name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible. E. During observation on 11/16/23 at 4:28 am, a portable computer workstation was in hall unlocked and open to P13’s medical chart. There was no staff present. P13’s name, age, medical record number, diagnoses, medical orders, and nursing flow sheets were visible. F. During interview on 11/16/23 at 2:37 pm with S8 Assistant Chief Nursing Officer, was asked “What should staff do when leaving a workstation that has patient information on the screen?” S8 responded “Staff are trained not to leave workstations without badging out [blocks access to the computer desktop and any patient information until a security measure has been completed to gain access].””

“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: 47480 Based on record review, observation, and interview, the facility failed to ensure all staff members and contract employees adhere to proper hand hygiene practices. This failed practice is likely to lead to infections, poor outcomes, and death for all patients of this facility. The findings are: A. Record review of the facility’s policy “IC [infection control] Hand Hygiene-IC-Corp” “Effective Date: 08/11/2017”: 1. “Policy: 4) Definitions: a) Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, antiseptic hand rub [or hand sanitizer], or surgical hand asepsis [removal of all microorganisms]” 2. “Procedure: 1) Indications for hand hygiene include inpatient ... settings: a) Before contact with patient or items in the immediate vicinity ...d) When leaving a patient’s room or at the end of caring for a patient-gel in and gel out [to use hand sanitizing gel before going into a patient room and to use hand sanitizing gel on leaving a patient room] ...f) Before donning [putting on] gloves and after removing gloves. Always.” B. During observation on 11/16/23 at 3:45 am on 5th Floor Unit an unidentified contract Phlebotomist (blood drawer) Staff (S)17, put on gloves without performing hand hygiene, entered room, exited room with gloves on, took gloves off, did not perform hand hygiene, and handled items on the cart. C. During observation on 11/16/23 at 4:09 am on 5th Floor Unit, an unidentified contract Phlebotomist S18 put on gloves and entered patient room without performing hand hygiene. D. During interview on 11/16/23 at 4:12 am with 5th Floor S14 Charge RN, it was asked, “When do you perform hand hygiene?” S14 stated “When we go into a room ...we always use gel [hand sanitizer] before we put on gloves and after we take them off and when we are done with the room.” E. During observation on 11/16/23 at 4:25 am on 4th Floor Unit, S21 Registered Nurse (RN) exited a patient room without performing hand hygiene. F. During observation on 11/16/23 at 10:04 am on 9th Floor Unit S15 RN exited a patient room with gloves on, did not remove gloves or perform hand hygiene, retrieved supplies, re-entered patient room with same gloves on and did not perform hand hygiene. G. During interview on 11/16/23 at 10:12 am with S9 Director for the 7th and 9th Floors, S9 confirmed all staff has training on hand hygiene every year. It was asked “What is the process for performing hand hygiene?” S9 stated ...”we gel in [use hand sanitizer], put on gloves, after we’re done with a room we take off gloves and gel out.” H. During interview on 11/16/23 at 2:37 pm with S8 Assistant Chief Nursing Officer, confirmed hand hygiene should be performed before entering a patient’s room, after contact with a patient, on exiting a patient room, before and after patient care. I. During interview on 11/16/23 at 3:45 pm with S22 [Name of Laboratory] Onsite Manager for contract phlebotomists, S22 confirmed that phlebotomists are expected to follow the facility’s protocol for hand hygiene.”