Olympic Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 46745 . Based on interview, document review, and review of hospital policy and procedure, the hospital failed to implement its policies and procedures for seclusion in 1 of 1 patients reviewed (Patient #308). Failure to ensure staff follow approved policies and procedures for restraints and seclusion puts patients and staff at risk of physical and psychological harm, loss of dignity, and violates patients’ rights. Findings included: 1. Document review of the hospital’s policy titled “Seclusion and Restraint,” Revision 9.0, last approved 07/25, showed the following: a. Seclusion: involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. b. At the start of the episode, the nurse documents objective behaviors and alternative interventions attempted. c. The provider orders and completes a 1-hour face-to-face evaluation using the OMC smart phrase. d. Monitoring by trained personnel every 15 minutes for behavior/mental status, physical comfort, signs of injury, continuous observation, and visual monitoring. e. A nursing assessment every 2 hours to assess range of motion, reposition, hydration, nutrition, elimination, and vital signs. f. During the episode, the nurse or physician explains the release criteria to the patient. 2. On 08/06/25 between 9:00 AM and 12:15 PM, Investigator #3 and the Emergency Department (ED) Manager (#302), the Clinical Quality Coordinator (Staff #302) and the Manager of Case Management (Staff #308) conducted a medical record review that showed Patient #308 was seen in the ED for a behavioral health crisis. The review showed the following. a. At 12:11 PM, the nurse’s progress note showed that medications and drinks were offered to the patient, but the patient continued to be agitated and yelling. The provider and hospital security were notified of the patient’s agitation and anxiety. The provider ordered Haldol (an antipsychotic used in emergencies for severe agitation or psychotic episodes) 0.5 milligrams (mg) intramuscular (IM) and Ativan (used to treat anxiety and agitation) 2mg IM one time. b. At 12:26 PM, the provider ordered a physical hold and ordered seclusion for behavior jeopardizing the immediate physical safety of themselves or others, and that the least restrictive alternatives were considered, tried, and failed. At 12:28 PM, the physical hold and seclusion orders were discontinued. The record review showed documentation of the physical hold in the restraint flow sheet and a completed face to face for the physical hold. c. At 12:38 PM, the nurse’s progress note showed that the patient refused medication, was instructed to take the medication, or they would be medicated for safety. A physical hold was used to administer medications. The patient remained in their room with the door shut but not locked. Patient was screaming, cussing at staff, pulling at hair and removing clothing. d. At 1:00 PM, the ED technician documented that the patient was sleeping. e. The Investigator found missing documentation from hospital staff implementing alternate, least restrictive interventions to address the patient’s behavior of yelling, pulling hair, and removing clothes before implementing the seclusion (closed unlocked door). The Investigator found no active order for seclusion after the provider discontinued the initial seclusion order. 3. During the review, Staff #301, Staff #302 and Staff #308 stated they were familiar with the event, and the provider ordered the physical hold and seclusion before the event based on their observations. After administering the medication, the provider discontinued the order once they determined that seclusion was unnecessary and the door was not locked. The patient was yelling and cursing after the event, so the nurse closed the patient’s door to ensure privacy. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 46745 . Based on record review, interviews, and an evaluation of hospital policies and procedures, the hospital did not ensure that staff who order, apply, or monitor patients in restraints or seclusion are trained upon hire in one of the provider’s HealthStream education logs (Provider #301). Failed to ensure staff followed approved policies and procedures for restraints and seclusion puts patients and staff at risk of physical and psychological harm, loss of dignity, and violates patients’ rights. Findings included: 1. Document review of the hospital’s policy and procedure titled “Seclusion and Restraint,” Revision 9.0, last approved on 07/25, showed that all staff with direct patient contact who order, apply, or monitor patients in restraints or seclusion will receive education and training on the correct and safe use of restraints upon hire and annually thereafter. 2. On 08/05/25 between 10:30 AM and 4:30 PM, Investigator #3 and the Clinical Care Coordinator (Staff #302) reviewed the medical records of patients in restraint. The review showed that on 07/21/25, Provider #301 ordered soft, 4- point violent behavior restraints for a pediatric patient with aggressive behavior. 3. At the time of the review, Staff #302 verified that this was an incorrect order. 4. On 08/06/25 between 12:00 PM and 12:15 PM, Investigator #3 and the Director of Education (Staff #304), and the Clinical Care Coordinator (Staff #302) reviewed Provider #301’s HealthStream education log. The review showed that Provider #301’s start date was 07/14/25. A review of the assigned HealthStream restraint modules showed completion on 07/23/25 and 07/24/25. 5. Staff #304 verified that Provider #301’s training was completed after the date of hire. .”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 45663 . Based on document review, the hospital leadership failed to ensure that the appointed nurse executive approved patient care policies, nursing practices, and procedures. Failure to ensure patient care policies, nursing practices, and procedures are reviewed and approved by the appointed nurse executive places patients at risk for unsafe nursing practice due to a lack of nursing oversight. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Policy Management,” no policy number, last approved 02/25, showed that policies are reviewed and updated as needed and at least every 3 years. 2. On 08/11/25, the Investigator noted that the original hypoglycemia algorithm document titled, “Newborn Glucose Management Algorithm - Birth to 4 hours,” no policy number, no policy date, provided at the time of the record review did not have the Olympic Medical Center approval attached. On 08/12/25, the Investigator received a second algorithm document titled, “Newborn Glucose Screening and Hypoglycemia Management, Providence St. Joseph Health”, no policy number, last approved 09/21. 3. On 08/13/25, the Director of Quality (Staff #904) verified that the second algorithm was currently in use and needed to be reapproved. .”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 45663 . Item #1 Blood Product Administration without Orders Based on interview, record review, and document review of the hospital’s policy and procedures, the hospital failed to ensure there were provider orders for blood product administration for 1 of 3 massive transfusion protocol (MTP) records reviewed (Patient #905). Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Massive Transfusion Protocol,” no policy number, last approved 04/25, showed that the Provider or Registered Nurse activates the Massive Transfusion Protocol and enters the order set. 2. On 08/06/25 between 11:00 AM and 3:00 PM, Investigator #9 and the Manager of Clinical Informatics (Staff #901) and the Trauma Program Manager (Staff #902) reviewed the medical records of patients who had an order for an MTP between 07/18/25 and 07/26/25. The review showed the following: a. Patient #905 presented to the Emergency Department with gastrointestinal bleeding. Between 11:57 AM and 1:01 PM, the patient received 4 units of packed red blood cells (PRBC’s), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets (PLT). b. An order was placed by a provider at 12:59 PM to crossmatch and hold 4 units of PRBC’s. c. An order was placed by a provider at 1:26 PM to transfuse MTP product to include FFP, PLT, and cryoprecipitate. There was no order for the PRBC transfusion within the MTP order. d. The Investigator found no order to transfuse the PRBC’s. 3. At the time of the review, Staff #901 and Staff #902 verified there was no order to transfuse the 4 units of PRBC’s administered to the patient. Item #2 Patient Monitoring during Massive Transfusion Protocol Based on interview, record review, and document review of the hospital’s policy and procedures, the hospital failed to ensure that patient temperature was monitored during massive transfusion protocol for 2 of 3 patients reviewed (Patient #905 and #907). Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for unrecognized transfusion reactions and complications. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Massive Transfusion Protocol,” no policy number, last approved 04/18/25, showed the following: a. The Recorder RN captures the vital signs, medications given, staff arrivals and departures, and critical events. b. During the transfusion, monitor and take measures to maintain the patient temperature at 37 degrees Celsius or 98.6 degrees Fahrenheit. c. The Massive Transfusion Protocol showed no frequency for other vital signs assessments (including temperature) or requirements for identifying, treating, or reporting any adverse blood transfusion reactions. 2. On 08/06/25 between 11:00 AM and 3:00 PM, Investigator #9 and the Manager of Clinical Informatics (Staff #901) and the Trauma Program Manager (Staff #902) reviewed the medical records of patients who received blood products during a Massive Transfusion. The review showed the following: a. Patient #905 received 2 units of packed red blood cells (PRBC’s) between 11:57 AM and 12:17 PM and 1 unit of platelets completed at 12:20 PM. The first temperature documented was at 12:19 PM (a period of approximately 22 minutes after initiation and after 2 units of PRBC’s were complete). b. Patient #907 received 3 unit of PRBC’s between 1:34 PM and 2:17 PM. The patient also received 2 units of plasma and 1 unit of platelets between 1:59 PM and 2:24 PM. The first temperature documented after the initiation of the transfusion was at 3:55 PM (a period of approximately 140 minutes after initiation and after the 6 transfusions were complete). 3. At the time of the review, Staff #901 and Staff #903 verified the temperature documentation. The Investigator interviewed Staff #903 regarding vital sign assessment in the policy and Staff #903 verified that the policy did not contain vital sign frequency and it would depend on the patient condition. Item #3 Discontinuation of the Massive Transfusion Protocol Order Based on interview and record review, the hospital failed to ensure there were provider orders to discontinue blood product administration following initiation of the Massive Transfusion Protocol (MTP) order for 3 of 3 MTP records reviewed (Patient #905, #906, and #907). Failure to obtain an order to discontinue Massive Transfusion Protocol blood product administration risks inappropriate and incorrect patient care and puts patients at risk of serious harm. Findings included: 1. On 08/06/25 between 11:00 AM and 3:00 PM, Investigator #9 and the Manager of Clinical Informatics (Staff #901) and the Trauma Program Manager (Staff #902) reviewed the medical records of patients who received blood products under a Massive Transfusion Protocol order. The review showed the following: a. Patient #905 had an MTP transfusion order placed for 4 units of Fresh Frozen Plasma (FFP) 1 unit of platelets and 1 unit of cryoprecipitate. The patient received 2 units of FFP, 1 unit of platelets and no cryoprecipitate. The Investigator found no order to discontinue the MTP prior to the completion of the products ordered. b. Patient #906 had an MTP transfusion order placed for 6 units of PRBC’s, 4 units of FFP, 1 unit of platelets and 1 unit of cryoprecipitate. The patient received 2 units of PRBC’s. The Investigator found no order to discontinue the MTP prior to the completion of the products ordered. c. Patient #907 had an MTP transfusion order placed for 6 units of PRBC’s, 4 units of FFP, 1 unit of platelets and 1 unit of cryoprecipitate. The patient received 3 units of PRBC’s, 2 units of FFP and 1 unit of platelets. 2. At the time of the review, Staff #901 and Staff #903 verified the orders for transfusion, blood products administered to the patient, and that the orders for transfusion were automatically discontinued on discharge of the patient by the computer system. .”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 46745 . Based on interview, document review and review of hospital policy and procedure, the hospital failed to assess and implement elopement prevention in 1 of 1 patient medical records reviewed (Patient #311). Failure to ensure hospital staff follow its policies and procedures places patients at risk for harm, potential sentinel events, and violates patients’ rights. Findings included: 1. Document review of hospital work standard/procedure titled “Decision-Making Capacity Assessment Tool,” revision 4.0, last approved 03/25, showed that only a provider may render a determination of capacity for medical decisions. Document review of hospital work standard/procedure titled “Patient Elopement Prevention and Response,” revision 8.0, last approved 05/15 showed the following: a. Patients in the following circumstances who leave the facility without authorization have eloped: i. The patient lacks a safe discharge and needs a provider to assess capacity and make a determination due to nursing or case management concerns about capacity. Applicable orders: Hold patient, no order needed, document concerns. ii. A provider has determined that a patient lacks capacity and has no safe discharge. Applicable orders: Hold patient, no order needed. Document capacity determination. b. The patient’s nurse should document elopement risk for all patients. c. Security is notified when patient is an elopement risk. d. Increased staff observations based on clinical judgement, the patient’s level of threat to self, others or inability to safely care for themselves if they were to leave. e. Ensure the patient has ID bracelet, remove the patient’s own clothes, and use elopement colored scrubs, place “E” signage on the patient’s room. 2. On 06/11/25 from 9:30 AM to 4:30 PM, Investigator #3 and Emergency Department (ED) Nurse Manager (Staff #301), and Clinical Quality Coordinator (Staff # 302) completed a medical records review of ED patients. The review showed the following: a. On 05/26/25 at 2:56 PM, Patient #311 was seen in the ED for a possible stroke and a history of dementia. During the ED evaluation for stroke, the patient had attempted to leave twice and was assessed by the ED provider, who determined that Patient #311 lacked medical decision-making capacity. At 4:52 PM, the provider ordered a constant observer (bedside sitter) because of the high elopement risk assessment. The constant observer was later discontinued, and the patient was transferred to the inpatient unit at 10:56 PM. At 11:00 PM, the nurse’s documentation showed that Patient #311 was leaving the hospital after initially agreeing to stay. The nurse’s progress note showed that the patient “appeared to have capacity, alert and oriented x4 (person, place, time, and situation), and able to make decisions”. The on-call provider was “informed and aware”. The patient signed the AMA paperwork and was observed by security and nursing personnel as they walked to their vehicle. b. The Investigator found no documentation from the admitting provider addressing the patient’s decision-making capacity. The review showed no documentation from the on-call provider for evaluation of the patient’s decision-making capacity. The Investigator was unable to find documentation of a reassessment of the patient’s capacity by a medical provider. 3. During the review, Staff #301 verified that there was no provider reassessment of the patient’s capacity to sign out AMA. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(B) [A restraint is-] (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. This Standard is not met as evidenced by: 46745 . Based on record review, interview, and review of hospital policy and procedures, the hospital failed to develop and implement policies and procedures to identify and care for patients receiving chemical restraint for 1 of 1 medical records reviewed of patients receiving chemical restraint (Patient #313). Failure to develop and implement policies and procedures for chemical restraint use places patients at risk for physical and psychological harm, loss of dignity, and violates the patients’ rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Restraint and Seclusion,” version 8, last approved 05/25, showed that a restraint is a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. 2. On 06/12/25 from 10:00 AM to 12:30 PM, Investigator #3 and Emergency Department (ED) RN Manager (Staff #301), and Clinical Quality Coordinator (Staff # 302) completed a medical records review of violent restraint use in the ED. The review showed on 06/06/25 at 12:40 PM, Patient #313 arrived at the ED with suicidal ideation and symptoms related to substance use. At 3:10 PM, Patient #313 became agitated, yelling, breaking equipment, and left the ED. At 3:15 PM, hospital security returned the patient to the ED and placed the patient in four-point upper/lower bilateral restraint for violent behavior. At 3:27 PM, the RN administered intramuscular Ativan 2 milligrams (mg), Haldol 5 mg, and Benadryl 50 mg according to the provider’s order. 3. During the review, Staff #301 stated that the hospital does not use chemical restraints. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort) This Standard is not met as evidenced by: 45663 . Based on interview, record review, and review of hospital policies and procedures, the hospital failed to develop and implement policies for initiation and documentation of a physical hold (a type of violent restraint) for 1 of 1 patients reviewed (Patient #301). Failure to develop and implement a policy and procedure for a physical hold risks physical and psychological harm, loss of dignity, and violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled “Seclusion and Restraint,” no policy number, last revised 03/24, showed that the hospital policy did not contain a definition of a physical hold, order requirements for a physical hold, face to face requirements or documentation requirements for the use of a physical hold. 2. On 04/23/25 from 8:20 AM to 11:45 AM, Investigator #3, the Assistant Nurse Manager Emergency Department (ED Staff #301), and Staff #302 completed a medical record review that showed that on 04/18/25 at 4:00 PM, Patient #301 arrived at the ED for mental health evaluation. At 5:45 PM, the patient was kicking, screaming, and trying to bite staff. Documentation showed the patient was held down for medication administration. The Investigator found no order or face-to-face for the physical hold. 3. During the review, Staff #301 and Staff #302 verified that there was no order or face-to-face for the physical hold. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 45663 . Based on record review, interview, and review of hospital policy and procedures, the hospital failed to modify the patient’s plan of care after placing patients in restraints or seclusion for 1 of 1 records reviewed (Patient #310). Failure to modify care plans for patients in restraints or seclusion puts patients at risk of harm by not meeting their physical and emotional needs. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Patient Outcomes Documentation,” no policy number, last approved 07/24, showed the following: a. The patient’s plan of care can be customized to the specific patient’s needs. b. Outcomes are measured on admission, transfer, discharge, and or change in condition. c. A nurse care plan summary is required at the handoff of care to summarize progress towards meeting outcome goals. Document review of the hospital’s policy and procedure titled, “Nursing Standards of Care Inpatient/Adult,” version 2, last reviewed 04/24, showed that care plans specific to the patient’s diagnosis are implemented as appropriate, additional nursing interventions may be added and or resolved as changes in the patient’s condition occur. 2. On 04/22/25 from 3:45 PM to 4:45 PM, Investigator #3 and Staff #302 completed a patient record review of non-violent restraints. The review showed the following: a. On 04/14/25 at 4:55 PM, Patient #310 was admitted to the hospital for altered mental status changes. On 04/15/25 at 4:55 AM, Patient #310 was placed in non-violent soft bilateral wrist restraints. b. At 9:15 AM, the soft bilateral upper restraints were discontinued, and bilateral hand mitts were initiated. c. At 9:29 AM, the bilateral hand mitts were discontinued, and soft bilateral upper limb restraints were initiated. d. At 1:38 PM, the soft bilateral upper limb restraints were discontinued. e. On 04/17/25 at 5:30 AM, Patient #310 was placed in soft bilateral upper extremity restraints. The restraints were discontinued at 8:24 AM. 3. The care plan review showed initiation of nonviolent restraints on 04/15/25 at 4:55 AM and was documented as ongoing progress until discharge on 4/22/25. The review showed no individualization of interventions or daily care plan notes. The care plan was not documented as resolved after the restraints were discontinued on 04/15/25 or 04/17/25. 4. During the review, Staff #302 stated that the completed fields on the care plan were auto populated from the flowsheets and not individualized. Staff #302 verified the Investigator’s findings. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45663 . Based on observation, interview, and document review, the Hospital failed to meet the requirements for the Condition of Participation for Patient Rights. Failure to establish and implement policies and procedures for consent to treat and restraint or seclusion risks physical and psychological harm, loss of dignity, and violation of patient rights which can lead to negative patient outcomes. Findings included: 1. Failure to ensure patient rights, including consent for treatment and the right to refuse treatment, limits the patient’s ability to participate and to make decisions about his or her care. Cross Reference: A 0131 2. Failure to obtain the correct restraint order for the appropriate restraint type puts patients and staff at risk of harm. Cross Reference: A 0168 3. Failure to discontinue restraints at the earliest opportunity risks physical and psychological harm, loss of dignity, and violation of patient rights. Cross Reference: A 0174 4. Failure to monitor patients in restraint at designated intervals as required by hospital policy risks physical and psychological harm, loss of dignity, and violation of patient rights. Cross Reference: A 0175 5. Failure to ensure a licensed practitioner or trained registered nurse conducted a face-to-face evaluation of the patient that included all required elements within 1 hour of restraint initiation risks physical and psychological harm, loss of dignity, and violation of patient rights. Cross Reference: A 0179 Due to the cumulative effect of these findings, the Condition of Participation at 42 CFR 482.13 was NOT MET. .”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45663 . Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that nursing staff members provided nursing care in accordance with orders and the patient’s health care needs. Failure to follow hospital policy and procedure and recognized standards of care for nursing oversight for patient assessments, reassessment, evaluation, treatment, and care puts patients at risk for delayed treatment, inappropriate treatment, poor health care outcomes, and patient harm. Findings included: 1. Failure to ensure staff completed and documented appropriate screenings and assessments risks patient harm due to delayed recognition of condition and inadequate or substandard treatment. Cross Reference: A 0395 2. Failure to ensure staff adhere to the hospital’s policies and procedures risks inappropriate and/or ineffective patient care and poor outcomes. Cross Reference: A 0398 3. Failure to follow the hospital’s medication administration processes places patients at risk for serious medication errors and patient harm. Cross Reference: A 0405 Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.23, Nursing Services was NOT MET. .”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45663 . Item #1 Right to refuse treatment Based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure that patients are allowed to exercise their rights including the right to refuse treatment. Failure to ensure patient rights, including the right to refuse treatment, limits the patient’s ability to participate and to make decisions about his or her care. Findings included: 1. Review of the hospital’s document titled, “Important Patient Notices, Rights and Responsibilities,” last revised 08/24, showed the following patient rights: a. To receive information and make informed decisions regarding your care. b. To request or refuse treatment. c. To be involved and have family or designated surrogate involved in care planning and treatment. Document review of the hospital’s policy and procedure titled, “Adult Behavioral Mental Health Crisis,” no policy number, last revised 07/24, showed the following: a. Concern for a patient’s behavioral health constitutes a crisis when a member of the Olympic Medical Center care team suspects that the patient is or is becoming significantly adversely impacted due to a mental health condition or substance use disorder. b. Per the Involuntary Treatment Act, only people presenting with a likelihood of serious harm due to a behavioral health condition are to be held, detained, or committed for evaluation and treatment. 2. On 02/05/25 between 1:40 PM and 3:30 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Clinical Informaticists (Staff #916 and Staff #917) reviewed the medical record of Patient #911 who was brought to the hospital by Emergency Medical Services after his caregiver was concerned that the patient did not have enough care at home, was unable to care for himself, and had fallen 3 times that day. The review showed the following: a. The ED providers note showed that the patient was alert and oriented x 4. The patient stated that he did not have any acute injuries, and he needed more help at home. The note showed that his mood and behavior were normal. The final impression per the note was frailty, frequent falls, and failure to thrive syndrome and the plan was to admit for further evaluation and treatment. There was no documentation in the ED provider’s note of a “behavioral health crisis.” b. The History and Physical written on 01/05/25 at 12:15 AM, showed that the patient “is very irritable and wants to go home,” “patient tried to leave multiple times, placed on involuntary hold, tele psych consulted.” Documented under the psychiatric portion of the physical exam was “patient is focused on calling his caregiver but is agreeable to being examined. He is currently not agitated.” There was documentation that “he is requesting his cell phone so he can call someone to come and pick him up.” There was no documentation of the patient having a behavioral health crisis or substance use disorder. c. On 01/05/25 at 12:47 AM, the same provider wrote an order for an involuntary 120-hour hold. d. The patient was evaluated by a tele psych provider on 01/05/25 at 6:18 PM (a period of approximately 17 hours after the order for the hold was placed). Review of the provider note showed that the patient does not meet criteria for psychiatric admission. e. On 01/06/25 at 3:48 AM, a provider note showed “patient still wants to leave against medical advice but is on the involuntary hold.” f. On 01/07/25 at 12:37 PM, a note dated 01/06/25 at 2:13 PM, showed that the patient had a sister who was his Medical Power of Attorney and a financial Power of Attorney. The note showed that the Case Manager contacted both approximately 26 hours after admission. g. The patient was discharged to an assisted living facility on 01/09/25. 3. On 02/06/25 at 3:30 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Manager of Case Management (Staff #916) reviewed portions of the medical record. The Investigator interviewed Staff #916 regarding the process for this hold as documentation did not appear to support a behavioral health crisis. Staff #916 stated that this case did not meet criteria for the involuntary hold as this patient did not meet criteria for a behavioral health crisis. Item #2 Consent for general treatment Based on interview, medical record review, and document review, the hospital failed to ensure that staff obtained consent for treatment for 3 of 3 newborn medical records reviewed (Patients #901, #902, and #903). Failure to properly obtain consent for treatment impedes the patient’s rights and the patient’s participation in the care planning process. Findings included: 1. Document review of the hospital’s “Consent for Treatment,” form number CO24215, last approved 02/09/16, showed that it did not contain any language regarding consent for treatment for a newborn. Document review of the hospital’s policy and procedure titled, “Patient Care Assessment of Patients Administration,” no policy number, last approved 11/21, showed the following: a. Patients enter the hospital as a direct admission by order from a member of the medical staff or by presenting for care in the Emergency Department. b. Patient Access Services initiates the admission process by obtaining patient demographics and a signed consent for admission and general procedures. 2. On 02/04/25 between 3:00 PM and 4:30 PM, Investigator #9 and Clinical Coordinator (Staff #904) reviewed the medical record of a newborn currently admitted to the post-partum unit. The review showed that the newborn did not have a signed Consent for Treatment in the medical record. 3. At the time of the review, Staff #904 verified that there was no signed Consent for Treatment in the medical record. 4. On 02/05/25 at 4:30 PM, Investigator #9 interviewed Patient Access Manager (Staff #906) regarding process for obtaining the Consent for Treatment for a newborn. Staff #906 described the registration process in detail to include that once a patient is admitted for labor, a new account for the newborn is created and sits in a queue. Once the newborn is delivered, registration goes through the fields to admit the newborn to the hospital. When the field for consent is presented in the registration process, the registrar would type “implied” in the field. Staff #906 stated that the process has been that way since the transition to EPIC. 4. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical records of two newborns admitted between 01/15/25 and 01/29/25. The review showed that there were no signed Consent for Treatment documents in the medical records. 5. At the time of the review, Staff #903 verified that there were no signed Consent for Treatment documents in the newborn records. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45663 . Based on record review, interview, and review of hospital policy and procedures, hospital staff failed to obtain/follow a physician’s order for the time frame, placement, and correct application of nonviolent and violent restraints for 4 of 5 restraint patients reviewed (Patients #301, #303, #908, and #909). Failure to obtain the correct restraint order for the appropriate restraint type puts patients and staff at risk of harm. Findings included: 1. Document review of the hospital’s policy and procedure titled “Seclusion and Restraint,” last approved 04/24, showed that Olympic Medical Center (OMC) staff will use restraints according to the order of the licensed independent practitioner who is responsible for the patient’s care. A review of the hospital’s soft restraint manufacturer’s instructions for use (DeRoyal Limb Holder), no date, showed that the limb holder was not to be used on a patient who is or may become highly aggressive or agitated. 2. On 02/06/25 at 8:30 AM, Investigator #3 and the Director of Clinical Informatics (Staff #302) conducted a medical record review. The review showed the following: a. On 01/16/25 at 11:20 AM, the provider placed an order for Patient #301 for non-violent soft restraints for bilateral upper and lower limbs for risk of interruption of treatment and unintentional injury. b. Documentation showed that on 01/17/25 from 10:00 AM to 7:27 PM , the patient was placed in nonviolent soft restraints, bilateral upper limb restraints only. c. Restraints were discontinued on 01/18/25 at 7:45 PM. d. On 01/21/25 at 12:00 PM, the RN documented the patient was placed in nonviolent soft upper bilateral limb restraints for prevention/interference of medical treatment. e. On 01/21/25 at 6:40 PM, the provider placed an order for nonviolent soft upper bilateral limb restraints. Patient #301 was in nonviolent restraints for a period of 6 hours and 40 minutes without a provider order. 3. During the review, Staff #302 confirmed the missing order findings. 4. On 02/06/25 at 12:45 PM, Investigator #3, Director of Clinical Informatics (Staff #302), and the ED Nurse Manager Patient (Staff #301) conducted a medical record review. The review showed the following: a. On 12/21/24 at 8:40 PM , Patient #303 was placed in violent upper left/right and left/right lower limb restraint. b. On 12/21/24 at 8:42 PM, the provider placed an order for violent soft restraints. The location showed 4 point and restraint use reason for being a danger to self and others. c. On 12/22/24 at 12:40 AM, the provider placed a renewal order for violent soft restraints and hard restraints. The location showed 4 point and restraint use reason for being a danger to self and others. e. At 12:45 AM, CNA documentation showed the patient continuing in left upper restraint, left/right lower limb restraint, and a spit hood. The right upper limb restraint was discontinued. g. At 1:10 AM, documentation showed the RN discontinued the spit hood, left/right upper and lower restraints. Investigator #3 found no evidence of an order for the use of a spit hood or clarification for the appropriate restraint type or laterality. 5. During the review, Staff #301 stated that violent restraints are ordered as hard restraints, and staff is aware of using hard restraints for violent patients even though the order stated soft restraints. Staff #301 stated that it was not known if Patient #303 arrived in the spit hood, or how often hoods are used, or if hoods are part of the restraint policy. Staff #301 confirmed the Investigator’s findings. 6. On 01/07/25 at 10:30 AM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical record of a patient placed in restraint. The review showed the following: a. The face-to-face provider note on 01/24/25 at 11:55 AM showed Patient #908 was an imminent threat to self as evidenced by “impulsive and getting out of bed without assistance and falling” and the patient was an imminent threat to others as evidenced by “hitting and threatening harm verbally or physically.” Review of the plan showed “4-point soft restraint starting now due to violent behavior to prevent injury to staff and self.” b. An order was placed on 01/24/25 at 11:57 AM for violent restraint 4 point, soft. c. Nursing note documentation showed that on 01/24/25 at 1:00 PM, the patient became agitated, yelling, threatening, cursing, swinging arms and legs at staff. “Nonviolent wrist and ankle restraints initiated to prevent patient from removing line, harming self or interruption of treatment.” d. At 1:08 PM, there was documentation of application of soft restraint to upper and lower limbs bilaterally. e. At 1:12 PM, there was an order for non-violent bilateral upper and lower soft restraint. 7. At the time of the review, Staff #903 verified the provider and nursing documentation and the 2 different provider orders. 8. On 01/07/25 at 11:00 AM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical record of Patient #909 with an order for restraint. The review showed the following: a. On 12/29/24 at 12:44 PM, a code gray was activated for Patient #909 being aggressive and swinging at staff during medication administration. b. At 12:53 PM, an order for seclusion with violent behavior was entered by a provider for danger to self and danger to others. The Investigator requested to see the restraint flowsheet documentation. There was no documentation of seclusion and no cancellation or modification of the above order. 9. At the time of the review, Staff #903 verified that there was no restraint documentation or cancellation of the order for restraint. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 45663 . Based on record review, interview, and review of hospital policy and procedures, hospital staff failed to discontinue restraints as soon as possible in 2 of 5 patients placed in restraints (Patient #303 and #908). Failure to discontinue restraints at the earliest opportunity risks physical and psychological harm, loss of dignity, and violation of patient rights. Findings include: 1. Document review of the hospital’s policy and procedure titled “Seclusion and Restraint,” last approved 04/24, showed the following: a. Restraints or seclusion must be discontinued as soon as possible, regardless of the length of time identified in the order. b. Restraints must be removed when the patient meets release criteria. 2. On 02/07/25 at 11:46 AM, Investigator #3 and Director of Clinical Informatics (Staff #302) and Director of the Emergency Department (Staff #301) reviewed the medical record of Patient #303 who arrived at the ED in restraints and threatened harm to themself and others. The review showed the following: a. On 12/21/24 at 8:42 PM, the medical provider placed an order for 4-point violent restraints. The order showed that restraints were to be released when the originating behavior was no longer evident or when less restrictive measures were effective. b. At 9:00 PM, the RN documented that the patient’s mental status was confused/disoriented and psychotic, and behavior was combative and psychotic. c. On 12/21/24 between 10:45 PM and 12/22/24 at 12:45 AM, the certified nursing assistant (CNA) documented that the patient’s mental status was sleepy, and behavior response was sleeping. d. At 12:40 AM, the medical provider placed an order for violent restraints. e. At 12:45 AM, the RN discontinued the right wrist restraint. f. At 12:45 AM, the CNA documented continuing in left upper restraint, left/right lower limb restraint, and a spit hood. g. At 1:10 AM, the RN discontinued the spit hood, left/right upper and lower restraints. The patient remained in restraints for 2 hours and 21 minutes while sleeping. f. On 12/22/24 at 3:30 PM, Patient #303 attempted to leave the ED and began yelling at staff. The medical provider placed an order for 4-point violent restraints. The order showed that restraints were to be released when the originating behavior was no longer evident or when less restrictive measures were effective. g. At 3:45 PM, the documentation showed the patient was agitated and belligerent. h. Between 4:00 PM and 5:45 PM, the RN documented that the patient was sleeping and continued 4-point limb restraints. i. At 6:15 PM, the RN documented administration of 2 milligrams intramuscularly. i. At 6:20 PM, the RN documented the patient was sleeping, and the left wrist and right ankle restraints were discontinued. j. From 6:20 PM to 7:45 PM, documentation showed the patient was sleeping and remained in right wrist and left ankle restraints. k. At 7:45 PM, the RN documented the patient was sleeping and discontinued the restraints. The patient remained in violent restraints for 3 hours and 45 minutes while sleeping. 3. On 02/06/25 at 12:53 PM, Investigator #3 interviewed the ED Nurse Manager (Staff #301) about discontinuing restraints. Staff #301 stated that restraints are discontinued when the patient is not at risk to self or others for harm. Staff #301 confirmed the Investigator’s findings that the restraints were not discontinued as soon as possible. 4. On 01/07/25 at 11:00 AM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical record of Patient #908 who was placed in restraint. The review showed the following: a. On 01/25/25 at 1:08 PM, there was documentation of application of soft restraint to upper and lower limbs bilaterally with a clinical justification documented as pulling/reaching for lines, airway, drains or dressings. b. At 7:56 PM, the patient began receiving a Precedex drip (a medication used for sedation). The medication was titrated to a Richmond Agitation Sedation Scale (RASS) of 0 (alert and calm) to -2 (light sedation, briefly making eye contact when spoken to). The patient remained in bilateral upper and lower soft restraint. c. At 8:30 PM, documentation showed the patient had a RASS score of 3 (moderate sedation). Documentation showed the patient remained in bilateral upper and lower restraint. d. Documentation from 10:00 PM until 8:00 AM (a period of 10 hours) showed the patient was sedated with a RASS score of -1 (drowsy) and remained in bilateral upper and lower restraint. e. Documentation showed bilateral lower restraint was released at 8:00 AM with no documentation of reason/change in mental status. f. At 12:45 PM, bilateral upper restraint was discontinued. g. Documentation of elimination/range of motion on 01/24/25 between 10:00 PM and 01/25/25 at 12:45 PM (a period of approximately 15 hours) showed “patient asleep.” h. At 1:00 PM, the Precedex drip was discontinued. 5. At the time of the review, Staff #903 verified the documentation and RASS scores. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 45663 . Based on the interview, record review, and review of the hospital’s policy and procedure, the hospital failed to ensure that patients in violent restraints were assessed for injury and basic needs in 1 of 1 medical record reviews (Patient #303). Failure to assess restraint placement and patient basic needs while in restraints places the patient at risk for injury and psychological harm and is a violation of patient rights. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Seclusion and Restraint,” no policy number, last revised 03/24, showed the following: a. For violent restraints, at the start of a restraint episode, the RN documents restraint notification (attending provider and clinical leadership), the clinical justification, objective evidence, and attempted alternatives. b. During the episode, the RN documents the discontinuation criteria, an explanation of the release criteria, the patient’s response to the restraints, family notification, debriefing with the patient and family, behavior/release assessment, and whether the criteria are met. d. Nursing documents range of motion (ROM)/repositioning, hydration, nutrition, elimination, vital signs, and intake/output every two hours. 2. On 02/26/25 at 12:45 PM, Investigator #3, Director of Clinical Informatics (Staff #302), and the ED Nurse Manager Patient (Staff #301) conducted a medical record review of Patient #303 who was placed in violent restraint on 12/21/24 at 8:45 PM. The review showed the following: a. At 10:00 PM, the range of motion and repositioning field was blank. b. On 12/22/24 at 1:06 AM, the RN discontinued the violent restraints. The Investigator found no 2-hour RN restraint assessment of peripheral neurovascular checks, skin, or basic needs offered after the 10:00 PM RN assessment (a period of approximately 3 hours). c. Patient #303 was placed in violent restraints on 12/22/24 at 3:30 PM. The Investigator found no evidence of a complete restraint assessment showing a peripheral neurovascular check, skin, or basic needs check at the time of application. d. At 3:45 PM, there was no ROM/repositioning or basic need assessment documented. f. From 6:00 PM to 7:00 PM, the Emergency technologist documented restraint monitoring and restraint assessment. The Investigator found no evidence of a complete RN restraint assessment showing a peripheral neurovascular check, skin, or basic needs check between 3:30 PM and 7:15 PM (a period of 3 hours and 45 minutes). 3. During the record review, Staff #302 verified the missing 2-hour RN restraint assessments. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 45663 . Based on interview, record review, and review of the policies and procedures, the hospital failed to ensure that patients received a complete face-to-face assessment within one hour as directed by hospital policy for 3 of 5 patients in violent restraint/seclusion reviewed (Patients #303, #909 and #910). Failure to perform the required face-to-face evaluation to determine whether the patient actually meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Seclusion and Restraint,” no policy number, last revised 03/24, showed that a face-to-face evaluation is completed by the attending provider within 1 hour of the implementation of violent restraint or seclusion and the focus of this evaluation is on the patient’s reaction to the intervention, the patient’s medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. 2. On 01/07/25 at 11:00 AM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical records of patients with orders for restraint. The review showed the following: a. On 12/29/24 at 12:44 PM, a code gray was activated for Patient #909 being aggressive and swinging at staff during medication administration. At 12:53 PM an order was placed for restraint and at 12:53 PM, a face-to-face evaluation was documented by the provider. The face-to-face did not contain the element of the patient’s reaction to the intervention. b. On 11/25/24 at 7:18 PM, Patient #910 had an order for violent restraint for danger to self and danger to others. At 7:50 PM, a face-to-face evaluation was documented by the provider. The face-to-face did not contain the element of the patient’s reaction to the intervention. 3. At the time of the review, Staff #903 verified that the face-to-face documentation did not contain the required elements. 4. On 02/26/25 at 12:45 PM, Investigator #3, the Director of Clinical Informatics (Staff #302), and the ED Nurse Manager Patient (Staff #301) conducted a medical record review. The review showed the following: a. On 12/21/24, at 8:35 PM, Patient #303 arrived at the ED in restraints. At 8:42 PM, the medical provider placed an order for 4-point violent restraints. At 8:48 PM, the provider documented a face-to-face evaluation. The face-to-face evaluation did not evaluate the patient’s reaction to the ordered intervention. b. On 12/22/24, at 3:20 PM, a code gray was activated for Patient #303 for shouting, throwing items, and wanting to leave. At 3:30 PM, the medical provider placed an order for 4-point violent restraints. At 3:31 PM, the provider documented a face-to-face evaluation. The face-to-face evaluation did not assess the implemented interventions. 5. During the review, Staff #301 verified that the face-to-face did not evaluate the implemented interventions. .”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45663 . Item #1 Immediate post cesarean section vital sign orders Based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure staff followed provider orders for vital sign assessments for 2 of 2 surgical patient records reviewed (Patient #904 and #905). Failure to assess vital signs creates risk that patient care needs go unrecognized and unmet and may lead to unrecognition of deterioration in patient status. Findings included: 1. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Director of Education (Staff #915) reviewed the medical records of 2 obstetrical patients who were admitted and delivered by cesarean section between 01/15/25 and 01/29/25. The review showed the following: a. Patient #904 delivered by cesarean section and had a provider order for vital signs per routine to include immediate post-partum vital signs every 15 minutes for 2 hours or more frequently based on patient condition. The patient entered Phase 1 post anesthesia care at 3:39 AM and the first set of vital signs was documented at 3:40 AM. The patient was transferred to the post-partum unit at 4:35 AM. The Investigator found no documentation of every 15-minute vital signs from 4:41 AM until 5:40 AM (the end of the 2-hour immediate post-partum period order period). b. Patient #905 delivered by cesarean section and had a provider order for vital signs per routine to include immediate post-partum vital signs every 15 minutes for 2 hours or more frequently based on patient condition. The patient entered Phase 1 post anesthesia care at 8:55 AM and the first set of vital signs was documented at 8:55 AM. The patient was transferred to the post-partum unit at 9:55 AM. The Investigator found no documentation of every 15-minute vital signs from 9:55 AM until 10:55 AM (the end of the immediate post-partum period order time period). 2. At the time of the review, Staff #903 verified the missing vital signs. Item #2 Treatment orders Based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure staff followed provider orders for treatment for 1 of 2 discharged patient records reviewed (Patient #907). Failure to follow the providers orders for treatment creates risk that patient care needs go unrecognized and unmet and may lead to unrecognition of deterioration in patient status. Findings included: 1. On 02/06/25 at 4:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical record of a discharged patient. The review showed that the patient had a provider order for daily weights. 2 out of 5 daily weights were missing. 2. At the time of the review, Staff #903 verified the missing daily weights. Item #3 Neurological checks and NIHSS orders Based on observation, interview, and record review, the hospital failed to ensure staff followed provider orders for monitoring and assessing patients after receiving fibrinolytic treatment in 1 of 1 medical record reviewed (Patient #306). Failure to follow provider orders for monitoring and assessing patients for complications places the patient at risk for poor health outcomes, injury, or death. Findings included: 1. Document review of hospital policy titled, “Adult Stroke Assessment and Care,” no policy number, last approved 06/11/24, showed that: a. Post medication infusion, neurological checks will be documented every 15 minutes for 1 hour, every 30 minutes for 6 hours, and every 1 hour for 16 hours. Neuro-check frequency is complete 24 hours after administration. Neuro checks will be conducted every 4 hours until discontinued by the provider. b. National Institute of Health Stroke Scale (NIHSS: 11 categories such as sensory and motor ability used to diagnose and assess stroke patients) assessments are completed every 12 hours unless otherwise indicated, assumption of care, or as needed with neurologic determinations. c. Notify the provider for acute neurological deterioration, new headaches, nausea, emesis, and/or atrial fibrillations or bleeding. Document review of the hospital downtime flowsheet titled “Stroke Neuro Checks (with Thrombolytic)” NS24962, dated 3/14/24, showed neurological fields for assessment, including pupil assessments, level of consciousness (LOC), extremity strength, and veni puncture site assessment for bleeding. 2. On 02/06/25, from 12:00 PM to 1:30 PM, Investigator #3, the Director of Clinical Informatics (Staff #302), and the ICU Nurse Manager (Staff #303) completed a medical record review. The review showed that: a. On 11/26/24 at 6:14 AM, Patient #306 arrived at the ICU for monitoring of potential side effects of fibrinolytic treatment and neurological assessments. b. At 5:29 AM, the medical provider placed an order for an NIHSS to be completed per unit routine, at least every 12 hours, upon assumption of care, or as needed for neurological changes. c. The review showed that the provider ordered neurological checks every 15 minutes for 2 hours, then every 30 minutes for 6 hours, every hour for 16 hours, and complete after 24 hours from thrombolytic administration. A second provider order showed neurological checks are to continue after 24 hours post-medication administration hourly until discontinued. d. At 8:00 AM, the medical record showed the RN completed a neurological and NIHSS assessment (categories 1-11.) e. At 8:30 AM, 9:00 AM, 9:30 AM, 10:00 AM, and 10:30 AM, the RN documented a partial NIHSS assessment (category 1-5a complete), a pupil assessment, and an extremity assessment. The cognitive/speech/vision/sensory assessment fields were blank. f. At 11:00 AM, the RN documented a complete neurological and NIHSS assessment. g. At 11:30 AM, the RN documented a partial NIHSS score (category 1-3) and a complete pupil and extremity assessment. The cognitive/speech/vision/sensory assessment fields were blank. h. At 12:00 PM, the RN documented a partial NIHSS score (category 1-6a) and a complete pupil and extremity assessment. The cognitive/speech/vision/sensory assessment fields were blank. i. At 12:30 PM, the RN documented a partial NIHSS assessment (category 1-2) and a complete pupil and extremity assessment. The cognitive/speech/vision/sensory assessment fields were blank. j. At 12:45 PM, the RN documented a completed neurological and NIHSS assessment. k. At 1:00 PM, the RN documented a partial NIHSS assessment (category 1-6b) and pupil and extremity assessment. The cognitive/speech/vision/sensory assessment fields were blank. l. At 2:00 PM, the RN documented a partial NIH assessment (category 1-9) and a pupil and extremity assessment. The cognitive/speech/vision/sensory assessment fields were blank. m. The review showed missing extremity assessments at 8:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM. The Investigator found no 1:30 PM documented neurological assessment. n. The review showed no hourly neurological assessments on 11/27/24 between 4:00 AM and 8:00 AM (a period of approximately 4 hours). o. On 11/27/24 at 8:00 AM, the RN documented a complete neurological and NIHSS assessment. The review showed no further assessments, and the patient was discharged at 3:27 PM. 3. During the review, Staff #302 stated that the staff does a separate neurological exam from the NIHSS. The NIHSS is completed every 12 hours, with a change of shift or change in a neurological exam. Staff #302 stated that completing a partial NIHSS assessment and other neurological categories is not the standard. The required fields for a neurological exam are not currently part of the policy. Staff #302 stated that staff use the downtime neurological form to follow documentation in the electronic medical record (EMR). Staff #302 stated neurological checks were incomplete, frequency was not followed and confirmed the Investigator’s findings. Item #4 Focused assessments Based on interview, document review, and review of the hospital’s policy and procedure, the hospital failed to ensure staff completed focused nursing assessments for 6 of 8 emergency department (ED) medical records reviewed (Patients #304, #307, #308, #310, #311, and #312). Failure to perform focused assessments places the patient at risk for delayed medical treatment, poor outcomes, and death. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Emergency Services: Assessment and Documentation Standards,” no policy number, approved on 09/24, showed the following: a. A focused assessment will be completed according to the patient’s chief complaint. b. More than one focused assessment may be completed every 2 hours when the patient’s condition changes, vital signs significantly change, interventions are aligned, or care is transferred to another registered nurse (RN). 2. On 02/04/25 from 11:25 AM to 12:00 PM, Investigator #3 and the ED Nurse Manager (Staff #301) completed a medical record review. The review showed on 02/04/25 at 2:50 AM, Patient #304 arrived at the ED reporting nausea, facial bruising, and was minimally responding to questions after falling out of bed. Patient #304 was admitted to the hospital at 11:36 AM. The Investigator found no focused assessment after 7:40 AM or at hand off to the admitting RN. 3. At the time of the review, Staff #301 stated that the RN completes a focused assessment at arrival, change in primary nursing, patient status, or condition, and the focused assessment is based on the patient’s chief complaint. Staff #301 verified the Investigator’s findings. 4. On 02/06/25 between 8:30 AM and 11:15 AM, Investigator #3 and the Director of Clinical Informatics (Staff #302) completed medical record reviews. The reviews showed the following: a. On 12/21/24 at 1:42 PM, Patient #307 arrived at the ED with reports of nasal congestion, cough and rash. The Investigator found no focused assessment during the ED visit related to the chief complaint. b. On 01/03/25 at 8:12 PM, Patient #308 arrived at the ED with reports for eye redness. The Investigator found no focused assessment during the ED visit related to the chief complaint. c. On 01/17/25 at 11:18 AM, Patient #310 arrived at the ED with lip laceration, ankle swelling, and pain after a fall. The Investigator found no focused assessment during the ED visit related to the chief complaint. d. On 01/30/25 at 7:33 AM, Patient #311 arrived at the ED reporting abdominal pain, nausea, and frequent burping. The Investigator found no focused assessment related to the chief complaint. e. On 01/17/25 at 12:18 PM, Patient #312 arrived at the ED with an ankle deformity and pain after a fall. The Investigator found no focused assessments during the ED visit related to the chief complaint. 5. During the review, Staff #302 verified the findings of missing focused assessments. Item #5 Initial system assessment Based on interview, medical record review, and document review, the hospital failed to ensure staff completed and documented preoperative system assessment prior to surgery for 1 of 2 cesarean section patients reviewed (Patient #905). Failure to complete preoperative system assessments limits the hospital’s ability to identify issues that might adversely affect a patient going into surgery, and result in inappropriate care or delayed care, and cause patient harm. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Cesarean Section Preparation, Emergent or Scheduled,” no policy number, last approved 10/23, showed that for a scheduled cesarean section, documentation includes a complete admission assessment. 2. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical records of 2 obstetrical patients who were admitted and delivered by cesarean section between 01/15/25 and 01/29/25. The review showed that Patient #905 was admitted for a scheduled cesarean section. The Investigator found no documentation of a physical assessment to include cardiac, respiratory, gastrointestinal and genitourinary systems prior to the surgical procedure. 3. At the time of the review, Staff #903 verified there was no documentation of a physical assessment prior to the surgical procedure. Item #6 Fundal Assessments Based on document review interview, the hospital failed to ensure that staff performed and documented timely and appropriate fundal assessments according to accepted standards of care for 2 of 2 cesarean section patient’s reviewed (Patient #904 and #905). Failure to perform specialized assessments for patients created risk that patients would not receive timely medical treatment appropriate to their care needs and could result in poor patient outcomes or death. Reference: Association of Women’s Health Obstetric and Neonatal Nurses, Practice Brief #12, 2021. “Ongoing assessment of uterine tone every 15 minutes for 2 hours after birth should be considered the standard of care.” Findings included: 1. Document review of the hospital’s policy and procedure titled, “Labor Management of the Patient from Admission through Recovery,” no policy number, last reviewed 03/24, showed the following: a. After the delivery of the placenta, assess and record vital signs every 15 minutes for 2 hours, every 4 hours for the next 12 hours, then every 8 hours until discharge. b. Perform fundal, lochia, perineal, and bladder assessments at these intervals. Document review of the hospital’s policy and procedure titled, “Post Partum Standard of Care,” no policy number, last approved 04/24, showed the following: a. Post-operative cesarean section patients will be assessed per physician order and at least every 4 hours for the first 24 hours, then every 8 hours if their condition remains stable. b. Routine assessment includes vital signs, systems assessments, post operative wound, fundus and lochia, perineal assessment, pain level and response to interventions. Document review of the hospital’s policy and procedure titled, “Post OP Phase 1 Required Documentation Work Standard,” no policy number, last reviewed 05/24, showed the following: a. Minimum charting includes Post Anesthesia Care Unit (PACU) and Adult PCS assessment on every patient which includes airway, respiratory, cardiac, neuro, and safety at beginning of care and throughout phase of care as needed. b. Focused assessment based on procedure performed at beginning of care and when assessment changes. 2. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Director of Education (Staff #915) reviewed the medical records of 2 obstetrical patients who were admitted and delivered by cesarean section between 01/15/25 and 01/29/25. The review showed the following: a. Patient #904 was admitted to Phase 1 of PACU care at 3:39 AM and was transferred to post-partum care at 4:35 AM. At 3:40 AM, an OB/GYN assessment of uterus firm and midline was documented. There were no assessments of uterine height or lochia. The next uterine assessment was documented at 4:41 AM (a period of one hour later), and the next uterine assessment was documented at 12:15 PM (a period of approximately 8 hours later). b. Patient #905 was admitted to Phase 1 of PACU care at 8:55 AM and was transferred to post-partum care at 9:55 AM. At 8:55 AM, an assessment of uterus firm with massage, midline, +2, and moderate lochia was documented. The next uterine assessment was documented at 10:40 AM (a period of 2 hours later and 1 hour after patient arrived to the post-partum unit), 4:00 PM (a period of approximately 6 hours later), 7:57 PM (a period of approximately 4 hours later), and the following day at 8:00 AM (a period of approximately 12 hours later). 3. At the time of the review, Staff #903 verified the assessment documentation. Investigator #9 interviewed Director of Education (Staff #915) regarding the standard of care for uterine assessments. Staff #915 confirmed that the assessments should be completed every 15 minutes for 2 hours and then every 4 hours for 24 hours as per policy. Item #7 Assessment/Reassessment post operative Cesarean Section Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure staff members completed and documented assessments/reassessments for 2 of 2 cesarean section patients reviewed (Patients #904, and #905) . Failure to perform reassessments appropriate to a patient’s illness risks patients not receiving appropriate monitoring or care related to their unidentified health care needs. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Post Partum Standard of Care,” no policy number, last approved 04/24, showed the following: a. Post-operative cesarean section patients will be assessed per physician order and at least every 4 hours for the first 24 hours, then every 8 hours if their condition remains stable. b. Routine assessment includes vital signs, systems assessments, post operative wound, fundus and lochia, perineal assessment, pain level and response to interventions. 2. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Director of Education (Staff #915) reviewed the medical records of 2 obstetrical patients who were admitted and delivered by cesarean section between 01/15/25 and 01/29/25. The review showed the following: a. Patient #904 was transferred to post-partum care at 4:35 AM. The Investigator found no documentation of a system assessment to include cardiac, respiratory, gastrointestinal, genitourinary, Braden or Falls risk assessments until 4:00 PM (a period of approximately 11.5 hours after arrival) and between 4:00 PM and 9:30 PM (a period of approximately 5.5 hours). b. Patient #905 was transferred to post-partum care at 9:55 AM. The Investigator found no documentation of a system assessment between 10:40 AM and 4:00 PM (a period of approximately 5.5 hours), 7:57 PM and 8:00 AM (a period of approximately 12 hours). 3. At the time of the review, Staff #903 verified the missing assessment documentation. .”

“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: 45663 . Item #1 Vital signs Based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure staff followed hospital policy for vital sign assessments for 1 of 1 vaginal delivery patient records reviewed (Patient #906). Failure to assess vital signs creates risk that patient care needs go unrecognized and unmet and may lead to unrecognition of deterioration in patient status. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Labor Management of the Patient from Admission through Recovery,” no policy number, last revised 03/24, showed after delivery, assess and record maternal vital signs (heart rate, oxygen saturation, respiratory rate, and blood pressure) every 15 minutes for 2 hours; every 4 hours for the next 12 hours; then every 8 hours until discharge. 2. On 02/06/25 between 3:00 PM and 4:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Director of Education (Staff #915) reviewed the medical record of a patient who had delivered vaginally. The review showed the following: a. After delivery, the patient had 7 sets of vital signs. 0 of 7 contained a temperature, oxygen saturation or a respiratory rate. b. The patient transferred to post-partum care at 3:11 AM. The next set of vital signs recorded was at 7:30 AM. The Investigator found no vital signs documented between 7:30 AM and 6:54 PM (a period of approximately 11.5 hours). 3. At the time of the review, Staff #903 verified the vital sign documentation. Item #2 Skin injury protection Based on document review, interview, and review of policies and procedures, the hospital failed to ensure that patients with impaired mobility receive repositioning every 2 hours for 2 of 3 records reviewed (Patients #302 and #305). Failure to reposition impaired mobility patients potentially leads to the risk of pressure injuries, discomfort, loss of dignity, and pain. Findings included: 1. Document review of hospital policy and procedure titled, “Skin Assessment and Wound Management,” no policy date, no last approval date, showed that: a. Patients with a Braden score <=18 are at high risk for pressure injury. b. High-risk and immobile patients are repositioned every 2 hours. c. Reposition all individuals at risk or with existing pressure injuries. d. Implement the SKIND protocol within 4 hours. (SKIND protocol: interventions for the prevention, assessment, and management of pressure injuries). Document review of the hospital policy titled, “ICU Telemetry Nursing Care Standards,” no policy number, no last approval date, showed that immobilized patients will be turned and positioned at least every 2 hours. Document review of hospital policy titled, “Nursing Standards of Care Inpatient/Adult,” no policy number, no last approval date, showed to turn immobilized patients at least every two hours. 2. On 02/04/25 from 2:45 PM to 4:45 PM, Investigator #3 and the ICU Nurse Manager (Staff #303) completed a medical record review. a. On 02/02/25 at 9:30 PM, Patient #302 arrived at the intensive care unit for treatment of possible stroke and respiratory failure. b. On 02/03/25 at 12:00 AM, the RN documented an initial Braden score of 14 and a left gluteal pressure injury. At 7:00 PM, the RN documented the Braden score of 11. The Investigator found no documentation of repositioning between 02/03/25 at 8:00 AM and 02/03/25 at 8:00 PM (a period of approximately 12 hours). c. On 02/04/25 at 8:00 AM, the RN documented the Braden score of 12. On 02/04/25 from 8:00 PM until 02/04/25 at 6:00 AM, the medical record showed that the patient was supine (a period of approximately 10 hours). 3. During the review, Staff #303 stated that the RN and certified nursing assistant (CNA) coordinate patient repositioning. Staff #303 verified that Patient #302 had no documented position changes. 4. On 02/06/25 between 3:00 PM and 4:45 PM, Investigator #3 and the 2 West Assistant Nurse Manager (Staff #304) completed a medical record review. The review showed that: a. On 02/01/25 at 3:30 AM, Patient #305 was admitted to the nursing unit for worsening weakness and breathing difficulties. b. At 9:00 AM, the RN documented the initial Braden score of 11. b. At 8:35 PM, the RN documented the Braden score of 12. c. On 02/02/25 at 7:45 AM, the RN documented the Braden score of 12. d. At 8:00 PM, the RN documented the Braden score of 12. On 02/01/25 at 4:01 AM until 02/04/25 at 12:00 AM, the Investigator found no documentation of position changes (a period of approximately 68 hours). e. On 02/05/25 at 3:00 AM, the RN documented that Patient #305 had a small sacral spine wound. 5. At the time of the review, Staff #304 verified that Patient #305 had no documented repositioning changes. Item #3 Hygiene care Based on interview and document review, the hospital failed to ensure that staff performed patient hygiene according to unit standards and policy for 2 of 3 medical record reviews (Patients #302 and #305). Failure to perform patient hygiene increases the risk of infection, patient harm, discomfort, and loss of dignity. Findings included: 1. Document review of the hospital policy titled, “ICU Telemetry Nursing Care Standards,” no policy number, no last approval date, showed that: a. Assistance with oral care will be offered at least every handoff of care and as appropriate for the patient’s condition. b. Unresponsive patients, ventilator patients, or patients with nothing-by-mouth orders will receive oral care every two hours. Document review of hospital policy titled, “Nursing Standards of Care Inpatient/Adult,” no policy number, no last approval date, showed that: a. Assistance with oral hygiene/mouth care will be offered at least every shift. b. Bathing will occur as appropriate. Staff assist patients unable to perform personal hygiene. 2. On 02/04/25 from 2:45 PM to 4:45 PM, Investigator #3 and the ICU Nurse Manager (Staff #303) completed a medical record review. a. On 02/02/25 at 9:30 PM, Patient #302 arrived at the intensive care unit for treatment of a possible stroke and breathing difficulties. b. On 02/02/25 at 9:31 PM, the medical provider placed an order that the patient not receive anything by mouth. c. The hygiene flowsheet showed that Patient #302 had no documented oral hygiene between 02/03/25 at 8:06 AM and 02/04/25 at 4:04 PM (a period of approximately 33 hours). d. The hygiene flowsheet showed that between 02/03/25 at 8:06 AM and 02/04/25 at 3:58 PM, there was no documentation of bath/skincare (a period of approximately 33 hours). 3. During the review, Staff #303 confirmed the Investigator’s findings. 4. On 02/06/25 between 3:00 PM and 4:45 PM, Investigator #3 and the 2 West Assistant Nurse Manager (Staff #304) completed a medical record review. The review showed that: a. On 02/01/25 at 3:30 AM, Patient #305 was admitted to the nursing unit for worsening weakness and breathing difficulties. b. The hygiene flow sheet showed that between 02/01/25 at 4:01 AM and 02/05/25 at 10:33 AM, Patient #305 had no documentation of oral care (a period of approximately 4 days and 7 hours). c. The hygiene flow sheet showed that between 02/01/25 at 4:01 AM and 02/05/25 at 10:33 AM, Patient #305 had one partial bath documented (a period of approximately 4 days and 7 hours). .”

“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: 45663 . Item #1 Neuraxial opioid monitoring orders Based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure staff followed provider orders for assessing vital signs including respirations for 2 of 2 cesarean section patient records reviewed (Patients #904 and #905). Failure to assess vital signs creates risk that patient care needs go unrecognized and unmet and may lead to respiratory depression. Reference: RCW 18.79.040 (1) “Registered Nursing Practice means the performance of acts requiring substantial specialized knowledge, judgement, and skill based on the principles of the biological, physiological, behavioral, and sociological sciences in (e) the executing of medical regimen as prescribed ....” Findings included: 1. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) and Director of Education (Staff #915) reviewed the medical records of 2 obstetrical patients who were admitted and delivered by cesarean section between 01/15/25 and 01/29/25. The review showed the following: a. Patient #904 delivered by cesarean section under spinal anesthesia and received 150 micrograms of Duramorph (an opioid pain medication injected directly into the spinal space by the anesthesia provider) at 2:12 AM. The patient had an order from the anesthesia provider to monitor vital signs and pulse oximetry every 4 hours for 24 hours and to monitor respiratory rate every 1 hour for 12 hours and then every 2 hours for 12 hours (a total of 18 respiratory assessments). The patient was transferred to the post-partum unit at 4:35 AM. The Investigator found no documentation of vital signs between 4:00 PM and 9:30 PM (a period of 5.5 hours) and no documentation of a respiratory rate between 6:59 AM and 9:34 AM (a period of approximately 2.5 hours), 9:34 AM and 12:09 PM (a period of approximately 2.5 hours), 12:09 PM and 4:00 PM (a period of approximately 4 hours), 4:00 PM and 9:30 PM (a period of approximately 5.5 hours) and 9:30 PM and 1:18 AM (a period of approximately 4 hours). b. Patient #905 delivered by cesarean section under spinal anesthesia and received 150 micrograms of Duramorph at 7:42 AM. The patient had an order from the anesthesia provider to monitor vital signs and pulse oximetry every 4 hours for 24 hours and to monitor respiratory rate every 2 hours for 4 hours (a total of 12 respiratory assessments). The patient was transferred to the post-partum unit at 9:55 AM. The Investigator found no documentation of vital signs between 7:57 PM and 4:27 AM (a period of 8.5 hours) and no documentation of a respiratory rate between 11:00 AM and 2:35 PM (a period of approximately 3.5 hours), 4:00 PM and 7:57 PM (a period of approximately 4 hours), 7:57 PM and 4:27 AM (a period of approximately 8.5 hours), and 4:27 AM and 7:43 AM (a period of approximately 3.25 hours). 2. At the time of the review, Staff #903 verified the missing vital signs and respiratory assessments. Item #2 Mild/moderate/severe pain medication orders Based on the interview, document review, and review of the hospital’s policy and procedure, the hospital failed to ensure staff members implemented provider-specific orders for as-needed pain medication administration based on the patient’s pre-medication pain score and reassessment of the pain management intervention in 1 of 1 medical record review (Patient #309). Failure to implement provider orders risks delayed treatment and poor patient outcomes. Findings included: 1. Document review of the hospital’s policy and procedure titled “Lippincott: Pain Management,” no policy number, last reviewed 05/24, showed the following: a. A pain assessment is performed before an intervention to document the pain both before and after the intervention and to show its effectiveness. b. Documentation includes the patient’s rating of pain before and after pain management interventions. c. Use the Olympic Medical Center pain scale appropriate to your patient population. 2. On 02/06/25 between 9:30 AM and 10:30 AM, Investigator #3 and the Director of Clinical Informatics (Staff #302) conducted a medical record review: a. On 01/04/25, Patient #309 was admitted to the hospital for an ankle fracture. The surgeon placed multiple pain medication orders: i. Tylenol 975 milligrams orally every 4 hours as needed for pain. Instructions showed that for mild pain, Tylenol should be given as the first-line medication. If ineffective, an NSAID should be given as ordered. Moderate pain: Give NSAID as ordered. If ineffective, give with an opioid as ordered. For severe pain, give Tylenol with NSAID and opioid as ordered. ii. Norco (5 milligrams Hydrocodone/325 milligrams Tylenol) tablet 1.25 tablet orally every 4 hours as needed for moderate/severe pain. Moderate pain: give if pain is not controlled with Tylenol and NSAID or if not ordered. iii. Advil (NSAID) 400-milligram tablet orally for pain every 6 hours as needed. Mild pain: Administer if Tylenol is not ordered or pain is not controlled with Tylenol. Moderate pain: Give with Tylenol as ordered, or if ineffective, give with the opioid. For severe pain, give NSAID, Tylenol, and opioid as ordered. iv. Morphine intravenously 1-2 milligrams every three hours as needed for breakthrough pain/severe pain. b. On 01/05/25, at 12:40 AM, the patient received Norco 1.25 tablets orally. c. On 01/05/25 at 1:42 AM, the patient received Advil 600 milligrams orally. d. On 01/05/25 at 3:25 AM, the patient received 1 milligram of morphine intravenously. e. On 01/05/25 at 5:56 AM, the patient received 1 milligram of morphine intravenously. 3. The Investigator found no pre-pain assessment to determine the correct pain medication treatment or post-pain intervention assessment after each pain medication administration. 4. During the review, Staff #302 stated that a numeric pain score of 1-3 indicates mild pain, 3-5 indicates moderate pain, 5-7 indicates moderate/severe pain, 7-9 indicates severe pain, and 9-10 indicates the worst pain possible. Staff #302 verified that no pain assessment was completed prior to administering pain medication to implement the provider’s orders and no post-pain assessment was completed. Item #3 Pain assessment/reassessment Based on interview, document review, and review of the hospital’s policy and procedure, the hospital failed to ensure staff members completed and documented pain and PRN (as needed) medication assessments/reassessments for 4 of 4 patients receiving pain medication reviewed (Patients #315, #904, #905, and #907) Failure to assess and reassess a patient’s pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Lippincott: Pain Management,” no policy number, last reviewed 05/24, showed the following: a. A pain assessment is performed before an intervention to document what the pain is currently and after to show its effectiveness. b. Documentation includes the patient’s rating of pain before and after pain management interventions. c. Use the Olympic Medical Center pain scale appropriate to your patient population. Document review of the hospital’s policy and procedure titled “Pain Management,” revision 5, last approved 01/25, showed that Olympic Medical Center (OMC, IMP, OMHH and OMCC clinical areas) recognizes a patient’s right to pain relief and supports a multidisciplinary approach to pain assessment and management. 2. On 02/05/25 at 12:09 PM, Investigator #3 and a Registered Nurse (RN) (Staff #309) reviewed a medical record from the Short Stay Infusion unit. The review showed that Patient #315 was receiving daily antibiotic therapy for a knee infection to start on 01/28/25 and end on 02/25/25. Record review showed that: a. On 01/29/25 at 9:09 AM, Patient #315 scored knee pain a 9. The Investigator found no interventions to address the patient’s pain. b. On 01/30/25 at 9:00 AM, Patient #315 scored knee pain a 9. The Investigator found no interventions to address the patient’s pain. c. On 01/31/25 at 9:11 AM, Patient #315 scored knee pain a 6. The Investigator found no interventions to address the patient’s pain. d. On 02/01/25 at 9:10 AM, Patient #315 scored knee pain a 7. The RN documented the patient’s pain management interventions from home. e. A review of the medication orders showed that Patient #315 had an as-needed order for Tylenol 2-500 milligram tablets every 8 hours for pain while at the infusion center and naproxen 250-milligram tablets, 1-2 tablets daily as needed for pain. 3. During the review, Staff #309 stated that pain management is addressed as an outpatient procedure for infusion patients. The interview showed that the provider orders needed medications for patients seen in the infusion center. The orders showed a start date and end date for antibiotic treatment. Patients have vital signs completed upon arrival to the unit. Staff #309 verified the findings not addressing pain. 4. On 02/06/25 between 10:00 AM and 2:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the medical records of 2 obstetrical patients who were admitted and delivered by cesarean section between 01/15/25 and 01/29/25. The review showed the following: a. On 01/18/25 at 4:20 PM, Patient #904 received Tylenol 650 milligrams orally. The Investigator found no documentation of a pain score prior to or following the medication intervention. b. On 01/19/25 at 3:49 AM, Patient #904 received Tylenol 650 milligrams orally. The Investigator found no documentation of a pain score prior to or following the medication intervention. c. On 01/19/25 at 1:10 PM, Patient #904 received Tylenol 650 milligrams orally. The Investigator found no documentation of a pain score prior to the medication intervention. d. On 01/19/25 at 8:41 PM, Patient #904 received Tylenol 650 milligrams orally. The Investigator found no documentation of a pain score following the medication intervention. e. On 01/30/25 at 4:32 AM, Patient #905 received Oxycodone (an opioid narcotic pain medication) 5 milligrams orally for a pain score of 7. The Investigator found no documentation of a pain score following the medication intervention. f. On 01/30/25 at 1:00 PM, Patient #905 received oxycodone 5 milligrams orally for a pain score of 6. The Investigator found no documentation of a pain score following the medication intervention. g. On 01/30/25 at 5:00 PM, Patient #905 received oxycodone 5 milligrams orally for a pain score of 7. The Investigator found no documentation of a pain score following the medication intervention. 5. At the time of the review, Staff #903 verified the missing pain assessment/reassessment documentation. 6. On 02/06/25 between 3:00 PM and 4:00 PM, Investigator #9 and Clinical Quality Coordinator (Staff #903) reviewed the chart of a discharged patient. The review showed on 01/01/25 at 12:55 AM, the patient received Tylenol 650 milligrams orally (the order was written as needed for pain). The patients preferred pain scale was documented as numeric. The Investigator found no documentation of a pain assessment prior to or after the medication intervention. 7. At the time of the review, Staff #903 verified the documentation. Item #4 RASS and sedation titration Based on document review, interview, and review of policies and procedures, the hospital failed to ensure that hospital staff followed provider orders for sedation medication titration and Richmond Agitation Sedation Scale (RASS) assessment for adult ventilated patients in 1 of 1 critical care patients (Patient #304). Failure to implement its policy and procedures on RASS score and titration of sedation medications while on a ventilator may lead to inappropriate medication doses, causing potential psychological harm, medication toxicity, additional organ dysfunction, or death. Findings included: 1. Document review of the hospital policy and procedure titled “Richmond Agitation Sedation Scale (RASS) Procedure,” no policy number, no last approval date, showed that the policy evaluates the degree of sedation set by the attending clinician for patients requiring mechanical ventilation. (RASS score is from -5 the patient is unarousable to +4 the patient is combative) 2. On 02/07/25, from 8:30 AM to 9:45 AM, Investigator #3 and the Director of Clinical Informatics (Staff #302) conducted a medical record review of Patient #301, who was on mechanical ventilator and continuous sedation. a. On 01/15/25 at 12:30 PM, the medical provider placed an order for the RASS goal 0 to -2 (alert/calm to lightly sedated for less than 10 seconds). Start the propofol infusion at 20 micrograms/kilogram/minute (mcg/kg/min). Increase/Decrease the rate by 5-10 mcg/kg/min every 5 minutes. Titrate the drug per order as tolerated. Titration varies based on the patient’s condition. b. At 12:01 PM, the RN documented a RASS of -2 and propofol infusing at 20 micrograms/kilogram/minute (mcg/kg/min). c. At 4:01 PM, the RN documented propofol infusing at 60 mcg/kg/min. The Investigator found no RASS assessments with propofol titration (a period of 4 hours). d. At 8:34 PM, the RN documented RASS of -3 (moderate sedation response with any movement to voice) and propofol at 60 micrograms/kilogram/minute. The RN documented a decrease of 10 mcg/kg/mil to 50 mcg/kg/mil. The Investigator found no RASS/sedation assessments for a period of approximately 8 hours and 34 minutes. e. At 8:45 PM, the RN documented a RASS of 1 (anxious and apprehensive) and propofol at 60 mcg/kg/mil. f. At 9:00 PM, the RN documented RASS of -3, and the rate remained at 60 mcg/kg/mil. The Investigator found no titration of the propofol to maintain a RASS goal. g. At 10:00 PM, the RN documented RASS of -2, and the rate remained at 60 mcg/kg/mil. 3. During the review, Staff #302 confirmed that the RASS and propofol titration were missing to show titrations/assessment to maintain RASS goal. .”