Rome Memorial Hospital, Inc.

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46619 Based on document review, medical record (MR) review, and interview, the facility did not ensure that nursing staff maintained suction equipment for immediate use for a patient (Patient #1) who was on aspiration precautions. Findings include: -- Review of the facility policy and procedure (P&P) titled “Aspiration Precautions,” reviewed 7/2024, indicated “Initial aspiration precautions require the following ... Suction set up with Yankauer (device used to suction the mouth) at the bedside.” -- Per MR review Patient #1 was admitted to the Rome Memorial Hospital on 4/7/2026 in anticipation of a colonoscopy scheduled for 4/8/2026. The patient had an extensive medical history e.g., severe cognitive impairment, high blood pressure, cerebral palsy (group of permanent neurological disorders of movement, muscle tone, and posture), gastroesophageal reflux disease (heartburn), hiatal hernia (condition where upper part of the stomach pushes through the diaphragm into the chest cavity), and osteogenesis imperfecta (brittle bones), Patient had a history of dysphasia (difficulty swallowing) and was on pudding thickened liquids. The admitting physician noted patient’s history of dysphagia and ordered that they have nothing by mouth except for medications. Aspiration precautions were ordered. Medications were ordered including bowel preparation for colonoscopy. -- On 4/7/2026 a registered nurse (RN) documented that they were continuing to offer pudding thick bowel preparation though the patient was only taking small bites. A nasogastric tube was ordered and placed. The nasogastric tube placement was unable to be verified by x-ray, so the tube was removed and not used. Staff continued to provide bowel preparation by mouth. -- On 4/8/2026 at 5:44 am a rapid response was called. At 5:45 am the patient had no pulse, so a code blue was called and cardiopulmonary resuscitation (CPR) started and other interventions were carried out. Patient #1 was resuscitated and transferred to the intensive care unit (ICU) but suffered additional cardiac events and expired. -- Per interview of Staff A, Clinical Staff, on 4/20/2026 at 3:15 pm, they stated that they were in a different room, when it was reported to them by another RN, that Patient #1 brought up some of the thickened prep that had been administered to them. Staff B, the RN who had been feeding them the preparation, was in the room with Patient #1 when this occurred and yelled out for help. Staff A responded with other clinical staff to assist. Staff A indicated they know the hospital is trying to get a wall-mounted suction outlet for each patient room. Currently the rooms do not all have wall suction and they had to leave the patient’s room to get a suction set up during this event. This patient had aspiration precautions ordered by the provider. -- Per interview of Staff B, Clinical Staff, on 4/21/2026 at 12:00 pm, Staff B thickened the colonoscopy preparation and administered it by mouth to Patient #1, when the patient “spit out a glob of the preparation” Staff B ran to find help. They also needed a suction setup as there was none in the room. When they returned the patient was gray in color; a rapid response was first called. A code blue followed when the patient had no pulse. Staff were able to achieve return of spontaneous circulation (ROSC) and the patient was transferred to the ICU. -- Per interview of Staff C, Clinical Staff, on 4/21/2026 at 12:45 pm, Patient #1’s case was reviewed after the incident. As part of their action plan the facility has ordered suction equipment to ensure that suction equipment is present in each room. This equipment had not arrived at the time of the survey. Staff C acknowledged these findings at the time of interview.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 49512 Based on medical record (MR) review, interview, and document review, an ambulatory surgical patient (Patient #2) required an unplanned overnight hospital stay due to not meeting discharge criteria. The operating surgeon was not aware that Patient #2 did not meet discharge criteria and was staying overnight; therefore no physician orders were written. Additionally, the MR lacked documentation that nursing staff monitored the patient overnight. Findings include: -- Per MR review, on 10/30/2024, Patient #2 presented to the ambulatory surgical unit (ASU) for a scheduled same-day surgery. Following surgery, Patient #2 experienced low oxygen saturations and did not meet discharge criteria. Patient #2 was transferred from the ASU to a medical surgical floor at 8:22 pm to spend the night for further monitoring and observation. The MR lacked a physician order for Patient #2’s inpatient stay and orders for medical care. The MR also lacked documentation of monitoring of Patient #2’s oxygen saturation and oxygen use from 12:44 am to 8:40 am (on 10/31/2024). On 10/31/2024 at 8:41 am, physician orders were written for Patient #2’s inpatient stay and medical care. -- Per interview of Staff A, Registered Nurse (RN) on 1/28/2025 at 12:05 pm, they called the Post-Anesthesia Care Unit asking to speak with the surgeon for Patient #2 as they were experiencing low oxygen saturations and not meeting discharge criteria. Staff A was told that the surgeon was busy, in surgery, and could not come to the phone. Staff A then notified the nursing supervisor of not being able to speak directly with the surgeon. The nursing supervisor instructed Staff A to transfer Patient #2 to the floor for inpatient admission. Staff A transferred Patient #2 to the floor as instructed by the nursing supervisor. -- Per interview of Staff B, Nursing Supervisor on 1/28/2025 at 10:25 am, they confirmed that they were contacted by Staff A and directed them to transfer Patient #2 to the medical surgical floor for inpatient admission. Staff B stated the surgeon should have been contacted, and this was a “hiccup” in the process. Staff B stated they called the surgeon the following morning as soon as the lack of notification was identified. -- Per interview of Staff C, Surgeon on 1/28/2025 at 9:00 am, they indicated they were never contacted and made aware that Patient #2 had not met discharge criteria and needed to spend the night. Staff C confirmed that they were notified the following morning and issued orders at that time. -- Review of the facility’s policy and procedure titled “Transfer or Admission to Acute Care,” (revised 8/2024) indicated the ASU RN “must be informed by the operating practitioner and/or anesthesiologist of the need for the patient’s admission as an inpatient or observation status. ... A physician order indicating said change will be issued to Patient Registration in order to process the requested change. ... Orders will be obtained from the operating practitioner.” -- Review of the facility’s policy and procedure titled “Nursing Assessment,” (revised 2/2023) indicated “ ... assessment will allow for ongoing monitoring during hospitalization as well as identify changes that may indicate a change in the patient’s condition. ... A focused re-assessment specific to patient condition will be conducted as needed/indicated per nursing judgment, protocol, or physician order.” -- During interview of Staff D, Chief Quality Officer on 1/28/2025 at 9:45 am and Staff B on 1/28/2025 at 10:25 am, they confirmed the above findings.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 49512 Based on findings from interview and document review, 1 of 1 personnel files reviewed (Staff A, Manager of Security) lacked evidence of training in first aid and certification in the use of cardiopulmonary resuscitation (CPR). This could place patients at risk for potential harm. Findings include: -- Per interview of Staff A on 7/9/2024 at 9:00 am, he/she/they does monitor patients in restraints. Staff A confirmed that he/she/they does not have first aid or cardiopulmonary resuscitation training. Staff A also confirmed that security staff are not required to have training in first aid or cardiopulmonary resuscitation. -- Per review of Staff A’s personnel file, it lacked evidence of first aid training and cardiopulmonary resuscitation training. -- Per review of facility’s policy and procedure titled “RBHU Seclusion and Restraints” last reviewed 10/2023, it indicated training for staff that participate in seclusion and restraint must also include the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. -- During interview of Staff B, Chief Quality Officer on 7/9/2024 at 12:00 pm, he/she/they acknowledged the above findings and confirmed that security officers do not have training in either cardiopulmonary resuscitation or first aid.”

“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: 46619 Based on medical record (MR) review, document review and interview the hospital did not comply with the requirements at 489.24 and 489.20. Three of 3 (Patient #2, Patient #3 and Patient #4) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the risks of transfer specific to the patient’s medical condition. This could lead to patients not being informed of potential risks related the transfer and untoward patient outcomes. Please reference specific findings within Tag 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: 46619 Based on medical record review, document review and interview, in 3 of 3 (Patient #2, Patient #3 and Patient #4) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the risks of transfer specific to the patient’s medical condition. This could lead to patients not being informed of potential risks related the transfer. Findings include: -- Per review of Patient #2’s medical record, she was a 2-year-old who presented to the emergency department on 12/31/2023 at 10:38 pm via ambulance after having seizures and vomiting at home. Patient arrived with continued seizure activity and reduced responsiveness. An intravenous line was started and Ativan (treat seizures) was given on 12/31/2023 at 10:53 pm and repeated on 1/1/2024 at 12:10 am to treat the seizure activity. On 1/1/2024 at 1:20 am the patient received Keppra (anti-seizure medication) 800 milligrams intravenously as additional treatment for the seizures. Physician documentation indicated that the patient appeared to be in moderate distress, was somewhat obtunded, and noted crying and abnormal consolability. The physician documented “Patient has now had five seizures with very little to no post-ictal (post seizure when patient returns to baseline) period. Will give bolus of intravenous Keppra and transfer for more inpatient care.” -- Per review of the form labeled “Physician Assessment and Certification- Patient Transfer Request,” which was signed by the physician on 1/1/2024 at 12:41 am, there is a preprinted statement: “All transfers have the inherent risk of traffic delays, accidents during transport, inclement weather, rough terrain, or turbulence, and the limitations of equipment and personnel present in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” Under the section titled “risks” Motor Vehicle Accident, Death, and Disability were indicated. There was no reference made to risks that were specific to this patient’s condition. -- Per review of Patient #3’s medical record, she was a 20-year-old who presented to the emergency department on 3/10/2024 at 11:47 am. The patient reported that one month ago she was assaulted and sustained a blow to the face. Over the past week the patient has had chills, noticed a red bump under her chin, and then had purulent drainage come out near her teeth. One of these teeth was loose. Imaging was done and revealed a fractured mandible (jaw) in the vicinity of two lower teeth and a presumed abscess adjacent to the fracture. -- Per review of the form labeled “Physician Assessment and Certification- Patient Transfer Request,” which was signed by the physician on 3/9/2024 at 2:30 pm, there is a preprinted statement: All transfers have the inherent risk of traffic delays, accidents during transport, inclement weather, rough terrain, or turbulence, and the limitations of equipment and personnel present in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” Under the section titled “risks” Motor Vehicle Accident, Death, and Disability were indicated. There was no reference made to risks that were specific to this patient’s condition. -- Per review of Patient #4’s medical record, she was a 21-year-old who presented to the emergency department reporting a two day history of jaw pain and swelling. The patient reported she had teeth pulled the prior week and noticed two days ago that her face was starting to swell, today it has moved to her neck and she reported she is having a hard time swallowing. The physician documented swelling to the submental space (area under chin). A computed tomography was ordered and did not reveal any focal collection. It did show the patient had multiple dental caries which needed to be addressed through a dental consult. Treatment was started with intravenous Clindamycin (antibiotic). Patient complained of a headache and was given Tylenol with improvement noted. At 7:47 pm the patient reported tongue swelling, the doctor was notified, and she received Decadron (steroid), Benadryl (antihistamine), and famotidine (decreases stomach acid) intravenously. On 2/1/2024 at 12:17 am Racemic Epinephrine (for relief of symptoms associated with bronchial asthma and shortness of breath) was given via nebulizer and at 12:33 am the nurse gave a second dose of Decadron intravenously. The transfer orders indicated the diagnosis of Ludwig’s Angina (life-threatening cellulitis of the soft tissue involving the floor of the mouth and neck). -- Per review of the form labeled “Physician Assessment and Certification- Patient Transfer Request,” which was signed by the physician on 2/1/2024. No time was indicated. The form includes a preprinted statement: “All transfers have the inherent risk of traffic delays, accidents during transport, inclement weather, rough terrain, or turbulence, and the limitations of equipment and personnel present in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient.” Under the section titled “risks” Motor Vehicle Accident, Death, and Disability were indicated. There was no reference made to risks that were specific to this patient’s condition. -- Per review of facility’s policy and procedure, “Transfer of Patient to Another Facility,” last reviewed 12/2023, “The physician certifies in writing on Form Physician Assessment and Certification - Patient Transfer Request, a summary of the risks and benefits upon which the certification is based.” -- During interview of Staff D, Emergency Department Director, on 3/12/2024 at 3:30 pm, he/she/they acknowledged the above findings.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 49512 Based on document review, medical record review and interview, in 5 of 10 medical records (Patient’s #2, #3, #4, #5, #6) reviewed, nursing staff initiated patient care plans on admission, however, there was no documentation that care plans were reviewed and updated. This could cause untoward patient outcomes. Findings include: -- Review of the facility’s policy and procedure titled “Patient Care Plans,” reviewed 2/2023, indicated all problem lists (patient care plans) must be reviewed and updated every 24 hours and as needed. -- Review of Patient #2’s medical record revealed Patient #2 was admitted on 12/6/2023 at 11:50 am with a diagnosis of change in mental status, hypothermia and hypotension. The care plan was initiated on admission, there was no documentation that the care plan had been reviewed/updated as of 12/13/2023 (7 days later). -- Review of Patient # 3’s medical record revealed Patient #3 was admitted on 12/8/2023 at 4:23 pm with a diagnosis of altered mental status, cystitis, and sepsis. The care plan was initiated on admission, there was no documentation that the care plan had been reviewed/updated as of 12/13/2023 (5 days later). -- Review of Patient # 4’s medical record revealed Patient #4 was admitted on 12/7/2023 at 2:50 pm with a diagnosis of hip fracture. The care plan was initiated on admission, there was no documentation that the care plan had been reviewed/updated as of 12/13/2023 (6 days later). The same lack of care plan review/update documentation was noted for Patient #5 and Patient #6. -- During interview of Staff A, Peer Review Coordinator, on 12/14/2023 at 1:20 pm, he/she/they acknowledged the above findings.”

“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: 49512 Based on document review, medical record review and interview, (1) in 1 of 10 medical records (Patient #1) nursing staff did not administer medications as ordered by a provider. (2) In 5 of 7 medical records (Patient’s #2, #4, #7, #6, #8) in patients who received pain medication, nursing staff did not document pain reassessment after pain medication was provided. This could lead to untoward patient outcomes and cause patients pain to not be controlled sufficiently. Findings related to (1) include: -- Review of the hospital’s policy and procedure titled “Medication Administration Overview,” reviewed 4/2023, indicated to bring the eMAR (electronic Medication Administration Record) via computer workstation and the medications to the bedside. Follow the rules of the 6 rights: Right Drug, Right Dose, Right Dosage Form, Right Patient, Right Time and Right Route. Before administration, check the medication label three times and check the eMAR three times. Prior to administration, scan all required medications and visually confirm that the correct dose, correct medication, and correct patient ID (identification) are displayed on the eMAR screen. -- Review of Patient #1’s medical record revealed on 11/16/2023 at 9:00 pm a medication order for Olanzapine 10 milligrams (Zyprexa). Give 2.5 milligrams every 12 hours intramuscular. Comments: Dose 2.5 milligrams = 0.5 milliliters. Reconstitute with 2.1 milliliters sterile water injection - Final concentration is 5 milligrams/milliliter. (This is the same medication order for administration on 11/28/2023 at 9:00 pm.) -- Review of Patient #1’s medical record revealed on 11/16/2023 at 9:00 pm a medication order for Lorazepam (Ativan) 2 milligrams/1 milliliter. Dose 1 milligram/0.5 milliliters intravenously twice a day. Comments: look-alike, sound-alike drug please verify high risk medication please verify caution medication may cause cognitive impairment, delirium, falls, and fractures in elderly population. (This is the same medication order for administration on 11/28/2023 at 9:00 pm.) -- A patient safety event (concerning Patient #1) dated 11/28/2023 at 2:37 am documented a medication occurrence for Olanzapine (Zyprexa) 2.5 milligrams ordered to be administered intramuscular was administered intravenously. Contributing factors: Nurse administered 2.5 milligrams of Zyprexa intravenous instead of ordered intramuscular route. This was the wrong route of administration. -- A patient safety event (concerning Patient #1) dated 11/28/2023 at 2:40 am documented a medication occurrence for Lorazepam (Ativan) 1.0 milligrams ordered intravenously, 2.0 milligrams was administered intravenously. Contributing factors: Failure to follow policy, procedure, or protocol. This was the wrong dose of administration. -- Per interview of Staff B, Registered Nurse, Nurse Educator on 12/13/2023 at 11:20 am, there is a yearly medication recredentialing for staff which was started the second week of November (prior to the medication errors). Staff B has a spreadsheet to track who has been recredentialed and uses a competency to clinically evaluate a staff member being signed off. For example, the competency includes observations of intravenous medications drawn at a patient’s bedside so the patient knows what they are being given, that secondary intravenous lines are dated, medication is administered properly with a pump, and proper disposal of sharps. Staff B will be recredentialing the traveling nurses and coming in at night to meet with the night staff. At the time of the survey, not all nursing staff and traveling nurses had received the yearly medication recredentialing. -- During interview of Staff C, Nurse Manager, on 12/13/2023 at 9:10 am, he/she/they stated morning huddles starting 11/29/2023 included education on the administration of Zyprexa and its reconstitution, dosing, and intramuscular. Staff C acknowledged the above findings. Findings related to (2) include: -- Review of hospital’s policy and procedures titled “Acute Pain Assessment and Pain Control,” reviewed 7/2022, indicated reassessment and documentation to evaluate the effectiveness of pain intervention should occur within one hour after the intervention and should include the pain score when the patient is awake. -- Review of the hospital’s policy and procedure titled “Medication Administration Overview,” reviewed 4/2023, indicated to monitor the patient and document the response to any medication given for pain or to accomplish immediate effect. -- Review of Patient # 2’s medical record revealed on 12/6/2023 at 8:46 pm, Patient #2 complained of pain of a level 4 (on a scale of 0 to 10, 0 indicating no pain and 10 indicating severe pain). Tylenol 650 milligrams was administered, there was no documentation of a pain reassessment. -- Review of Patient #4’s medical record revealed on 12/12/2023 at 6:30 am, Patient #4 complained of pain of a level 8. Morphine 2 milligrams intravenously was administered, there was no documentation of a pain reassessment. On 12/12/2023 at 10:37 am Patient #4 complained of pain of a level 10. Morphine 2 milligrams intravenously was administered, there was no documentation of a pain reassessment. -- Review of Patient #7’s medical record revealed on 12/14/2023 at 8:47 am, Patient #7 complained of pain of a level 8. Hydrocodone 5 milligrams and Acetaminophen 325 milligrams was administered, there was no documentation of a pain reassessment. The same lack of documentation of pain reassessment was noted for Patient #6 (pain level 4) and Patient #8 (pain level 10). -- During interview of Staff A, Peer Review Coordinator, on 12/14/2023 at 1:20 pm, he/she/they acknowledged the above findings.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 49512 Based on document review and interview, the hospital did not ensure emergency equipment was maintained and readily available for treatment of emergency cases. Specifically, the adult crash carts on both medical/surgical units lacked documentation of routine checks. This could cause the hospital to not be prepared for an emergency situation and could cause untoward patient outcomes. Findings include: -- Review of the hospital’s policy and procedure titled “Cardio-Pulmonary Crisis Response Codes and Equipment,” reviewed 12/2021, indicated a nurse is assigned to check the contents of each crash cart for completeness and intubation equipment for proper function. Checks are performed daily and documented in the record provided for this purpose. All defibrillators are tested daily as per manufacturer guidelines. -- Review of the forms titled “Crash Cart Checklist”, dated 1/2023 - 12/2023 on unit 2 East revealed multiple days lacked documentation that the crash cart checklist was completed. For example from 12/1/2023 - 12/13/2023, 5 days lacked documentation that the crash cart was checked. -- Review of the forms titled: “Crash Cart Checklist”, dated 5/2023 - 12/2023 on unit 2 North revealed multiple days lacked documentation that the crash cart checklist was completed. For example from 11/1/2023 - 11/30/2023, twenty days lacked documentation that the crash cart was checked. -- During interview of Staff C, Nurse Manager, on 12/13/2023 at 11:25 am, he/she/they acknowledged the above findings.”