Vibra Hospital of Sacramento

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 39051 Based on observation, interview, and record review the hospital failed to provide medical record services adequate to support prompt completion, secure filing, and ready retrieval of medical records in a safe and secure environment which preserves patient confidentiality with a patient census of 47 as evidenced by: 1. The hospital failed to organize the medical record service appropriate to the scope and complexities of the services performed and employ adequate personnel to ensure prompt completion, filing, and retrieval of records. Refer to Tag A0432. 2. The hospital failed to account for a medical record for each inpatient and outpatient, obtain prompt records completion, and provide prompt accessibility. Refer to Tag A0438. 3. The hospital failed to have policies and procedures for release of information to assure release was only to authorized individuals and failed to ensure unauthorized individuals cannot gain access to or alter patient records. Refer to Tag A0441. 4. The hospital failed to obtain Radiology Reports from the Tele-radiology service for 2 of 4 sampled outpatients. Refer to Tag A0467. 5. The hospital failed to effectively review medical record deficiencies, track deficiencies through completion, identify and report delinquent records, and enforce compliance in accordance with hospital policy and medical staff rules and regulations. Refer to Tag A0469. The cumulative effects of these systemic failures resulted in a medical record service that was unable to ensure prompt completion, secure filing, and ready retrieval of medical records in a safe and secure environment. As a result, the hospital could not reliably ensure that patient medical records were complete, accessible, protected from unauthorized access, or available to support clinical decision-making and continuity of care, placing patients at risk for incomplete or delayed clinical information and undermining compliance with federal and state medical record requirements.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 42291 Based on observation, interview, patient record review, and facility document review, the facility failed to ensure nursing staff developed and maintained a nursing care plan (CP) which accurately reflected the personal care needs or activities of daily living for 1 of 31 sampled patients (Patients 1) when Patient 1 developed matted hair requiring it to be cut. This failure compromised the quality of care being delivered by nursing staff when a plan to address patients’ assessed needs was not developed which increased the risk of skin breakdown, infection, and had potential to contribute to pain and psychosocial harm. Findings: During a review of Patient 1’s “History and Physical (H&P),” dated 9/27/25, the H&P indicated, Patient 1 had a subarachnoid hemorrhage (SAH - stroke), and a tracheostomy (hole in the neck for breathing). The H&P indicated Patient 1 could open their eyes with stimulation but was unable to reliably track or follow motor commands with their arms or legs. During a concurrent interview and record review on 1/14/26 at 12:51 p.m., with Nurse Supervisor (NS) 1 and NS 2, Patient 1’s “Wound Care Note (WCN) dated 9/28/25, at 9:12 a.m. was reviewed. The WCN indicated, “opened eyes, alert, verbally nonresponsive, ... not follows up (sic) and not able to turn to her sides, with matted hair.” Continued concurrent interview and record review on 1/14/26 at 12:51 p.m., with NS 1 and NS 2, Patient 1’s Flowsheet titled “Patient Rounding ADL’s (Activities of Daily Living )”, the bed bath and grooming ADLs for dates 9/26/25 to 11/9/25 were reviewed. NS 1 indicated that if Patient 1’s hair was washed, the “hair shampoo” option would be chosen in the flowsheet and if Patient 1 had refused hair washing, the flowsheet would indicate as, “Patient refused.” NS 1 and NS 2 acknowledged there was no documented evidence Patient 1 had her hair washed or groomed from 9/9/25 to 11/9/25. Continued concurrent interview and record review on 1/14/26 at 12:51 p.m., with NS 1 and NS 2, Patient 1’s Care Plan was reviewed. Patient 1’s Care Plan included “ADL decline and decrease in ADL abilities” and there was no documentation or specific plan for grooming for the prevention or treatment of matted hair. NS 1 indicated the only documentation of the matted hair was from the Wound Nurse. NS 1 stated her expectation was to see interventions updated in Patient 1’s Care Plan for grooming. During a review of the facility’s “Plan for Provision of Care (PPC),” revised 1/22, the PPC indicated, “Basic Clinical Activities” and “Nursing process activities are delivered to patients as follows: 1. Assessment - all patients are fully assessed by a Registered Nurse on admission and every shift thereafter as defined by Nursing Standards of Care and Practice (the minimum, baseline rules ensuring nurses provide safe, competent, and consistent care). 2. Planning - A plan of care is developed within 24 hours of admission from data collected during assessment and in conjunction with the physician, patient, family and is coordinated with other disciplines providing care. The Plan of Care is updated as patient needs change, by exception, Patient Problem List, and during IDT & patient care conferences. 3. Intervention - These are the aspects of care that are delivered to each patient as identified on assessment. Major interventions by nursing personnel include but are not limited to: Personal Care.” During a review of the facility’s policy and procedure (P&P) titled, “”Therapy Services, Scope of Services (TSSOS),” last dated reviewed 2/25, the P&P indicated, “Hygiene and Grooming ... Train is specific self-care techniques ... hair care ... to prevent breakdown [pressure injury].””

“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: 51484 Based on observation, interview, and record review, the facility failed to ensure nursing services were provided, nursing staff education, health screening, and policies were followed for three of 31 sampled patients (Patient 1, Patient 13 and Patient 14) and two of 4 nursing staff (Registered Nurse 3 and Registered Nurse 4) when: 1. Patient 1’s intravenous (IV) Peripheral Inserted Central Catheter (PICC - a long thin, flexible, hollow tube inserted into a large vein near the heart for long term use) remained in place without a physician’s orders for 6 days; 2. Patient 1’s orders for Restorative Nurse Aide (RNA- a certified nursing assistant with specialized training who helps patients regain their strength and mobility after an illness or injury) to provide Passive Range of Motion (PROM- the total movement of a joint by a therapist to maintain mobility and increase flexibility, preventing the tightening of muscles) for Bilateral or both Upper Extremities (BUE- arms), 3 times per week was performed only once a week for 6 weeks; 3. Patient 1 expressed having pain in the BUE and legs during RNAs PROM treatment was not treated or communicated to the nurse or Occupational Therapist (OT) for 5 weeks; 4. Patient 13 was unable to use the call light and another device was not provided, and Patient 14’s call light was located under their pillow and was inaccessible; 5. Registered Nurse 3 (RN 3) did not complete annual TB (Tuberculosis- a highly communicable lung disease) screening, and did not complete the annual medication administration, and intravenous prescription medication administration training for 2025; and; Registered Nurse 4 (RN 4) did not complete 2024 and 2025 annual fit testing (test to confirm the fit of any respirator that forms a tight seal to your face before you use it in the workplace) and the annual medication administration and intravenous prescription medication administration training for 2025. These failures had the potential for Patient 1’s increased risk for IV blood stream infection or blood clots related to PICC remaining in place when not needed, possible contractures (a permanent tightening or shrinking of muscles, tendons, skin, or tissues around a joint, making it stiff and difficult to move, the affected area becomes fixed in a bent or twisted position), and deconditioning of the arms. Patient 13’s and Patient 14’s lack of ability to summon assistance had increased risk for delays in staff response to changes in condition, delayed interventions, and potential for adverse events. The lack of nursing staff education and required health screening for RN 3 and RN 4 had potential for safety, compromised patient care, transmission of infections, and risks for both nurses, patients and visitors. Findings: 1. During a review of Patient 1’s “History and Physical (H&P),” dated 9/27/25, the H&P indicated Patient 1 had a subarachnoid hemorrhage (SAH - stroke), and a tracheostomy (hole in the neck for breathing). The H&P indicated Patient 1 could open their eyes with stimulation but was unable to reliably track or follow motor commands with their arms or legs. During a concurrent interview and record review on 1/13/26 at 9:39 a.m. with Nurse Supervisor (NS) 1 and NS 2, Patient 1’s “Nursing Admission Assessment [NAA],” dated 9/26/25, was reviewed. The NAA indicated, Patient 1 had a PICC line in the right forearm. Patient 1 had no documented admission physician order for a PICC line. NS 2 stated, the PICC line was kept in place in case Patient 1 had an emergency such as a code (a patient’s heart stops or they stop breathing and staff provide resuscitation). NS 1 confirmed a physician’s order was required for a PICC line and confirmed there was no physician’s order for a PICC line. During an interview on 1/15/26 at 12:00 p.m. with RN 4 in the Medical/Surgical (MS) unit RN 4 stated, IV lines were maintained in all the patients “in case of a code”. During a review of the facility’s policy and procedure (P&P) titled, “Central Venous Access Device (CVAD), Peripherally Inserted Central Catheter (PICC) and Midline Selection, Insertion, Maintenance, Removal, Documentation ...”, dated 10/25, the P&P indicated, “Prescribed [for] continuous infusion therapy ... Long term intermittent infusion therapy ...Clinical necessity for a CVAD will be assessed daily by nursing ... CVADs will be promptly removed when no longer necessary and in accordance with the LIP (Licensed Independent Practitioner) order. Assess and discuss with the patient’s health care team the continuing need... on a daily basis and remove when it is no longer needed for the plan of care”. 2. During a concurrent interview and record review on 1/13/26 at 2:00 p.m. with OT who provided care for Patient 1, Patient 1’s Occupational Notes (OTN), RNA Daily Activity Record (RNA DAR), and OT orders dated 9/29/25 through 11/11/25 were reviewed. OT indicated, Patient 1’s OT orders written on 9/29/25 at 10:12 a.m. was for an RNA referral to, “provide continued BUE PROM exercises three times a week to prevent further deconditioning and possible contractures...” Continued concurrent interview and record review on 1/13/26 at 2:00 p.m. with OT, Patient 1’s RNA DAR dated 10/6/25, 10/17/25, 10/22/25, 10/29/25, and 11/5/25 were reviewed. OT confirmed documentation revealed an RNA saw Patient 1 only once a week. OT further stated, “[OT] was not aware the three times a week orders for [Patient 1’s] PROM was not followed.” During a concurrent interview and medical record review on 1/15/26 at 2:11 p.m. with the Rehab Director (RD), Patient 1’s DAR and orders were reviewed. The RD stated he would expect staff to follow the prescribed orders and escalate if unable to complete. During a review of a facility manual titled, “Therapy Services, Scope of Services [SOS],” the SOS indicated, “ ...The Occupational Therapist (OTRS) [OT] provide direction/supervision for the Certified Occupational Therapist Assistants in patient care, treatment planning and progression ... Provide referral to other appropriate allied health services [RNs, RNAs, etc] when indicated...” During a review of the facility’s “Plan for Provision of Care [PPC],” revised 1/22, the PPC indicated, “ ...Therapy Services are provided in accordance with professional standards of practice of the respective disciplines, and in accordance with patient needs ...The assessment process identifies the patient’s physical, cognitive, behavioral, emotional, and social status. This includes facilitating factors and possible barriers to the patient reaching his/her goals beyond the presenting problems ...therapy goals and objectives that are measurable, described in functional or behavioral terms, and include estimated or relevant time frames for achievement, taking into consideration the anticipated discharge placement; and a description of facilitating factors and possible barriers to using therapy services or to reaching the therapy goals and objectives. ...” 3. During a concurrent interview and record review on 1/13/26 at 2:00 p.m. with Occupational Therapist (OT), Patient 1’s “RNA Daily Activity Record (RNA DAR) dated 10/6/25, 10/17/25, 10/22/25 and 10/29/25 were reviewed. Patient 1’s RNA DAR on 10/6/25 indicated, “[Patient 1] Expressed tightness and pain in both hands and fingers”. The RNA DAR for 10/17/25 revealed, “[Patient 1] Expressed tightness and pain BUE and LE [Lower Extremities- legs]”, the 10/22/25 RNA DAR revealed, “[Patient 1] Expressing pain in BUE”, and the RNA DAR on 10/29/25 included, “Complaining of pain in her [Patient 1] fingers.” The OT stated he was unaware of Patient 1’s complaint of hand pain during RNA BUE PROM. During a concurrent interview and record review on 1/15/26 at 2:11 p.m. with the Rehab Director (RD), Patient 1’s RNA DAR dated 10/6/25, 10/17/25, 10/22/25 and 10/29/25 were reviewed. RD stated, his expectations were for the RNA and OT to communicate Patient’s 1 response to treatment and treat accordingly. During a review of facility’s P&P titled, “Therapy Services, Scope of Services (TSSOS),” last date reviewed 2/25, the P&P indicated, “The Occupational Therapy department will follow standard methods of treatment ... Provide ongoing evaluation of patient status to determine timing and sequence of task presentation ...Note underlying cause of pain ...When indicated provided immobilization devices (e.g. splints..) for upper extremity ...Provide referral to other appropriate allied health services when indicated.” 4. a. During a review of Patient 13’s “History and Physical [H&P],” dated 12/19/25, the H&P indicated, Patient 13’s diagnoses included Parkinson’s Disease (brain disorder with hard to control movements, shaking, stiffness, and balance problems), chronic back pain, and diabetes (high blood sugar). During an observations with the Director Plant Operations (DPO), the Maintenance Technician (MT), the Rehab Director (RD) and Charge Nurse (CN) 1 on 1/13/26 at 10:25 a.m., on the Medical Surgical Unit (MSU), Patient 13 in room 105 A signaled with left fingers to come to room. Patient 13, who had a tracheostomy and could not speak, was requesting pain medication. CN 1 asked Patient 13 to use the call light by her side three times. Patient 13 repeatedly tapped the side rail with a small fan attached. When Patient 13 was shown how to press the light, Patient 13 mouthed, “It would take a long time for them to come.” During an interview on 1/13/26 at 10:25 a.m., with CN 1, CN 1 confirmed Patient 13 was unable to use the call light and further stated that Patient 13 would benefit from an OT assessment for a different call light. b. During a review of Patient 14’s H&P dated 12/21/25, the H&P indicated Patient 14’s diagnoses included stroke, hip fracture, and chronic right-sided back pain. During an observation with RN 4 and NS 1 on 1/15/26 at 12:00 p.m., in the MSU, Patient 14 was observed laying on his left side with a tracheostomy, left-hand wrist restraint and right hand contracted (inability to open fingers). The call light was observed under Patient 14’s pillow and inaccessible. When Patient 14 was asked how to call the nurse, Patient 14 was unable to use the call light button. During an interview on 1/15/26 at 12:00 p.m., with NS 1, NS 1 acknowledged Patient 14’s call light was not accessible and further stated that Patient 14 would benefit from an OT assessment for a different call light. During a review of the facility’s “Plan for Provision of Care [PPC],” revised 1/22, the PPC indicated, “ ...Nursing acts in concert with the other hospital departments. ... Inpatient Therapy including PT/OT/ST, ... It is the goal of the clinical team to plan, implement, evaluate and, when necessary, modify patient care provided to meet the total needs of the patients as well as meet the recognized standards of care and practice for all clinical departments ... An initial physical ..., functional screening ... assessment is conducted on each patient: ...the initial assessment of physical, ...status determines the need for care, the type of care provided, and the need for any further assessment. Referrals are initiated based on initial assessment .... The need for assessing the patient’s functional status is determined, including a functional assessment for patients referred for rehabilitative services ... Each patient is reassessed at regularly scheduled times related to the patient’s course of treatment to determine response to treatment, including when a significant change occurs in the patient’s condition and/or when a significant change occurs in a patient’s diagnosis.” During a review of a facility’s P&P titled, “Therapy Services, Scope of Services [TSSOS],” last date reviewed 2/25, the P&P indicated, “Recommend and/or provide adaptive/assistive equipment ...Evaluate specific needs ...Select/order and/or proved specific equipment ...” 5. a. During a review on 1/14/26 at 3:15 p.m., of RN 3’s personnel file, there was no evidence of required 2025 annual training for medication administration and intravenous prescription medication administration being completed. There was no evidence of required 2025 annual TB screening in RN 3’s personnel file. During an interview on 1/14/25 at 4:30 p.m., with the Professional Developmental Coordinator (PDC), RN 3’s personnel file was reviewed, the PDC acknowledged RN 3 was missing the 2025 annual education and training. The PDC stated RN 3’s annual education and training should have been completed by now. The PDC stated RN 3 should have been suspended or taken off the schedule until it was completed. During an interview on 1/14/25 at 4:35p.m., with Infection Control Nurse (ICN), RN 3’s personnel file was reviewed, the ICN confirmed that RN 3 had not completed 2025 annual TB screening. ICN stated RN 3 should have been taken off the schedule. b. During a review on 1/14/26 at 3:45 p.m., of RN 4’s personnel file, there was no evidence the required 2025 annual training for medication administration and IV medication administration being completed. RN 4 had also not completed her required annual fit testing for 2024 and 2025. During an interview on 1/14/25 at 4:30 p.m., with the PDC, RN 4 personnel file was reviewed, the PDC acknowledged RN 4 was missing the 2025 annual education and training. The PDC stated RN 4’s annual education and training should have been completed by now. The PDC stated RN 4 should have been suspended or taken off the schedule until it was completed. During an interview on 1/14/25 at 4:35 p.m., with Infection Control Nurse (ICN), RN 4’s personnel file was reviewed, the ICN confirmed that RN 4 had not completed the 2024 and 2025 annual fit testing. ICN stated RN 4 should have been taken off the schedule. During a review of the facility’s policy titled, “Nursing Plan for Provision of Care,” last reviewed 1/2025 showed under the Departmental Scope of Services, Employee Health, “The Employee Health program is designed to include aspects of care that maintain the wellness of employees. The scope of service for employee health includes but is not limited to the following: ...Annual TB skin tests or screening and Tuberculosis mask fit testing ....” During a review of the facility’s policy titled, “Nursing Plan for Provision of Care,” last reviewed 1/2025 indicated under the Departmental Scope of Services, Education section, “Staff education and competency are assessed to ensure a level of staff competency is maintained that will meet federal, state and hospital regulations/requirements for delivering patient care. All staff will have their competency assessed upon hire and annually. All staff will be given continuing education during their employment.” 42291”

“ORGANIZATION AND STAFFING CFR(s): 482.24(a) The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. This Standard is not met as evidenced by: 39051 Based on observation, interview and record review, the hospital failed to organize the medical record service appropriate to the scope and complexities of the services performed and employ adequate personnel to ensure prompt completion, filing and retrieval of records. This failure increased the risk of incomplete or delinquent medical records, delayed access to clinical information necessary for continuity of care, and inability to effectively enforce documentation standards and regulatory compliance. Findings: During the facility entrance conference on 1/12/26 at 9:21 a.m. the DOQ (Director of Quality) stated that there is one onsite employee a HIMT (Health Information Management Technician) and that the HIMD (Health Information Management Director) is on call and available by phone. During a concurrent observation and interview with a tour of the Medical Records Department led by the HIMT on 1/12/26 at 10:00 a.m., the HIMT was observed to be alone in the department and she locked the department when she left for any reason. A supply of her business cards was in a pocket attached to the outside of the entrance door for use by anyone trying to reach the HIMT. The HIMT stated she works onsite in the department Monday through Friday, 8:00 a.m. to 4:30 p.m. She stated callers to the department, when the HIMT is not there, leave messages on her voicemail which she accesses once she is in the department. The House Supervisor has access to the department to cover if needed after hours. A white board on the wall of the department lists “[Hospital Name] Resources” with names only of contacts for Dictation, Billing, Legal and IT/Coding. The HIMT stated she has worked for the hospital two years, initially for Case Management and then for Medical Records over the past year, with no prior experience in hospital records. Document review of the Medical Record Department’s organization chart, job descriptions, credentials, staff roster and staff assignments schedule was conducted. The HIMD has a direct reporting line to the CEO (Chief Executive Officer) and a dotted line of communication to the Regional HIM Director. The organization chart listed two employees directly report to the HIMD, the HIMT, and a Coder. The organization chart also indicated HIMD also serves as the Hospital Privacy Officer. Both the HIMD and the Coder hold current HIM credentials as required in their respective job descriptions. The HIMD is assigned to work remotely “as needed” and the Coder works remotely out-of-state Monday through Friday, 7:00 am to 3:30 pm. During document review the HIM policy titled “Legal Medical Record”, last reviewed March 2025, noted under Section IV. “Ownership, Responsibility and Security of Health Information” paragraph 4. to state that “The Director of Health Information is designated as the person responsible for assuring that there is a complete and accurate medical record for every patient.” During an interview with the HIMD onsite at the hospital on 1/13/26 at 1:16 pm, she stated she has worked for the hospital since May 2021, initially as Director of HIM and Quality, and then converted to an HIMD per diem in May 2024. She stated she is employed full time outside of the hospital. The HIMD confirmed that she also serves as the Facility Privacy Officer. During document review of the “Job Description and Competencies for HIM Manager/Director,” dated May 2017, approximately 35% of the time, it states the HIMD “Directs, plans, develops and implements health information management efforts for the hospital. Develops and maintains department policies and procedures to meet quality requirements and addresses all appropriate standards/requirements of The Joint Commission, CARF and other regulatory bodies. Ensure standards are met on all documentation, records flow, and completion. Keeps abreast of new laws and regulations affecting medical records. Projects the workload, staffing, equipment and other operating requirement for current and projected new services or programs. Enters the medical staff data and maintains the physician roster in the electronic database.””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 39051 Based on observation, interview and record review, the hospital failed to account for a medical record for each inpatient and outpatient, obtain prompt records completion and provide prompt accessibility. This failure impeded the hospital’s ability to ensure the existence, completeness, and timely availability of medical records and increased the risk of incomplete or unavailable clinical information, delayed access to patient records, and noncompliance with medical record retention and accessibility requirements. Findings: 1. During concurrent observation on hospital rounds and interview on 1/13/26 at 9:16 a.m. of the HIMT as she picked up paper records from unit locations, the HIMT did not utilize an Admission/Discharge/Transfer report or other means of reconciliation with the census to assure the existence of a medical record for each inpatient and outpatient. The HIMT stated she depends on what is found in her work queue in the hospital’s electronic health record system. During an onsite interview with the HIMD on 1/13/26 at 1:16 p.m. the HIMD confirmed that there is not a reconciliation mechanism to assure a medical record exists for each inpatient and outpatient. During document review of the HIM policy titled “Legal Medical Record” last reviewed March 2025, it was noted to say under Section V. “Maintenance of the Medical Record” paragraph 2. “A medical record shall be maintained for every individual who is evaluated or treated as an inpatient or outpatient of a Vibra hospital ....” 2. During interview of the HIMT on 1/13/26 at 9:30 a.m. she stated her duties include Admission and Discharge audits as priority with concurrent review of H&P’s (history and physical exams), consults, orders, and verbal orders signed within 48 hours, and discharge review for presence of a discharge progress note, and discharge summaries. The HIMT stated she prepares Admission Packets and does the death certificate worksheets with a goal to complete deficiency analysis by next day following discharge/service date. The HIMT stated she prepares the Release of Information, including legal, and are current to last week. HIMT stated the scanning expected turnaround time is within 48 hurs of receipt. HIMT acknowledged there is a backlog going back to late November. The HIMT stated there are bi-weekly meetings with leadership to check in regarding any backlogs. During an onsite interview with the HIMD on 1/12/26 at 9:30 a.m. she stated she was not aware of the extent of the scanning backlog situation. 3. During an interview with the HIMT on 1/13/26 at 9:30 a.m. the HIMT stated that while medical record retention is for ten years, she has direct access only to patient records in the current electronic health record system, installed in late 2022. The HIMT stated she does not have the necessary privileges to access the previous electronic record system used and that she is required to contact a corporate individual who does have access. 4. During a concurrent observation and interview with a tour of the Medical Records Department led by the HIMT on 1/12/26 at 10:00 am the HIMT opened the manual moveable files and paper medical records from 2015 were observed on the shelves. When asked about additional storage locations, the HIMT stated there are medical records stored with [Contracted Offiste Medical Record Storage Company] offsite. The hospital was unable to provide an approved program flexibilty filed with the Department approving offsite medical records storage as required by California Code of Regulations, Title 22, Division 5, Chapter 1, Article 7 §70751 requires “Medical records shall be filed in an easily accessible manner in the hospital or in an approved medical record storage facility off the hospital premises.””

“PROTECTING PATIENT RECORDS CFR(s): 482.24(b)(3) The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. This Standard is not met as evidenced by: 39051 Based on observation, interview and record review, the hospital failed to have policies and procedures for release of information to assure release only to authorized individuals and failed to ensure that unauthorized individuals cannot gain access to or alter patient records. This failure limited the hospital’s ability to ensure that patient records were accessed, disclosed, and protected in accordance with authorization requirements, increasing the risk of unauthorized access, use, or disclosure of protected health information and compromised the hospital’s ability to maintain the integrity and confidentiality of the medical record. Findings: 1. During document review on 1/13/26 at 3:10 p.m. the table of contents for the Medical Records department policies and procedures was reviewed and did not include hospital level policies and procedures for release of information. The policies and procedures offered and reviewed from the organization-wide HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy Manual, “Patient’s Right to Request Access to PHI” (Protected Health Information) last reviewed November 2025 and “Use and Disclosure of Health Information” last reviewed November 2022 are global corporate guidance rather than steps to follow at the hospital level. During interviews with the HIMT on 1/12/26 at 1:54 p.m. and with the HIMD on 1/13/26 at 1:16 p.m., both employees confirmed that they do not have local hospital policies and procedures to guide release of patient information. 2. During a concurrent observation and interview with a tour of the Medical Records Department led by the HIMT on 1/12/26 at 10:00 am, storage of paper records was observed as follows: a. Discharged patient records stored on the manual moveable file shelving; b. Scanned patient records held for two weeks post scanning until quality control checks are completed, stored on the manual moveable file shelving; c. Patient records awaiting scanning, stored on the manual moveable file shelving; d. Patient records in a tall, locked and completely full [Contracted Offiste Medical Record Storage Company] storage bin awaiting pickup for shredding; e. Patient records on top of the storage bin and on top of the front desk in open boxes awaiting pickup for shredding; f. Hospital department records on top of long tables and under those tables on the floor in approximately three dozen closed boxes intended for offsite storage; g. Additional patient records awaiting scanning, in stacks on top of a long table. When the HIMT was asked who has access to the Medical Records Department besides herself, she identified the following individuals: a. House Supervisor b. Engineer/Plant Services c. Hospital Department Managers with records stored in the Medical Records Department d. Director of Quality e. Chief Executives All of these individuals have the ability to access the Medical Records Department when the HIMT is not present there. When asked how often paper records are picked up for shredding, the HIMT stated [Contracted Offiste Medical Record Storage Company] was picking up every two weeks. When asked why other departments’ records are stored in the Medical Records department, the HIMT stated the boxed records are inventoried and awaiting removal to [Contracted Offiste Medical Record Storage Company] , however the hospital is looking at contract renewal versus use of another service.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 39051 The hospital failed to obtain Radiology Reports from the Tele-radiology service for two of four sampled outpatient Radiology encounters. This failure had the potential to result in incomplete diagnostic information in the medical record and delay or impede clinical decision-making related to patient evaluation and treatment. Findings: 1. During concurrent interview and record review on 1/13/26 at 9:45 a.m. in the Medical Records Department with the HIMT, two of four outpatient Radiology records reviewed (Patient 26 and Patient 30) were missing study interpretations by the tele-radiologist. Patient 26 had a right wrist x-ray performed on 11/6/25 at 1:14 pm. Patient 30 had T-spine (thoracic) and L-spine(lumbar) limited x-rays performed on 1/9/26 at 3:02 pm. Reports were not in PACS (Picture Archiving and Communication System, a digital technology used to store, retrieve, manage, and distribute medical images) requiring the HIMT call the Tele-radiology group to obtain the missing reports for the hospital’s records. When asked what the expected turnaround time was for receiving interpretation reports from the Teleradiology group, the HIMT stated she did not know. When asked whether outpatient Radiology records are screened post encounter for presence of study interpretation reports, the HIMT stated she does not do so.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 39051 Based on interview and record review, the hospital failed to effectively review medical record deficiencies, track deficiencies through completion, identify and report delinquent records, and enforce compliance in accordance with hospital policy and medical staff rules and regulations. This systemic failure to effectively identify, track, report, and enforce completion of delinquent medical records resulted in a prolonged pattern of incomplete, unsigned, or missing physician documentation well beyond State and Federally-mandated timeframes. The lack of timely and complete medical records compromised the hospital’s ability to ensure continuity of care, support accurate clinical decision-making, validate services rendered, and demonstrate compliance with Federal and State requirements. The failure also limited the hospital’s ability to hold practitioners accountable under its own medical staff rules, placing patients at risk for incomplete clinical information at discharge and undermining the integrity of the designated record set. Findings: 1. On 1/12/26, a report of deficient medical records, including deficiency type, aging, and responsible provider was requested as of that date. The hospital provided the report on 1/15/26. An untitled report in spreadsheet format consisting of 17 pages was reviewed on 1/15/26 at 2:00 p.m. The report contained five columns with the headings “Patient Name,” “Discharge Date,” “Staff Type,” “Deficiency,” and “Comment.” The report contained 429 individual deficiency line items affecting 326 discharged patient records from December 2022 through December 2025. All reported deficiencies were attributed to Physician staff. The deficiencies were categorized as follows: Deficiency Category Count % of Total (n = 429) Missing / incomplete / unsigned Discharge Summaries 80 18.6% Missing Discharge or Transfer Orders 82 19.1% Missing / incomplete / unsigned Progress Notes 62 14.5% Missing / incomplete / unsigned Consultation Notes 55 12.8% Missing / incomplete History & Physicals 20 4.7% Missing / unsigned Operative / Procedure Reports 24 5.6% Other physician documentation deficiencies* 106 24.7% Total 429 100% *”Other” included therapy notes, unclear or missing orders not clearly tied to discharge, combined documentation gaps, and entries referencing multiple note types without a single dominant category. The presence of deficiencies spanning up to three years post-discharge demonstrated a sustained failure to ensure medical records were completed within required timeframes. 2. Review of the “Job Description and Competencies for HIM Clerk/Technician” dated March 2016, found that approximately 45% of the time, the HIMT “Audits records for deficiencies and completeness. Confirms presence of authorized signatures and minimum required patient identification. Makes note of progress notes, lab reports, x-rays, consultations, etc. that have been omitted from the record to ensure these are retrieved and included in the record before it is permanently filed. Reports statistics to HIM Manager/Director. Develops and maintains appropriate communications with physicians, nurses and the hospital staff regarding charting and medical records issues. Assists physicians and other staff members with any problems and/or questions concerning the documentation requirements of the medical records.” Review of the “Job Description and Competencies for HIM Manager/Director” dated May 2017, found that approximately 35% of the time, the HIMD “Directs, plans, develops and implements health information management efforts for the hospital. Develops and maintains departmental policies and procedures to meet quality requirements and addresses all appropriate standards/requirements of The Joint Commission, CARF and other regulatory bodies. Ensures standards are met on all documentation, records flow, and completion. Keeps abreast of new laws and regulations affecting medical records. Projects the workload, staffing, equipment and other operating requirement for current and projected new services or programs. Enters the medical staff data and maintains the physician roster in the electronic database.” Despite these defined responsibilities, there was no evidence of an effective process for resolving long-standing physician documentation deficiencies. 3. Review of the HIM policy and procedure “Medical Record Documentation Requirements LTCH and IRF” last reviewed June 2025, found in paragraph 36 on page 9 of 13 “Medical Records will be complete within 30 days of the patient’s discharge; 14 days for the state of California.” The prolonged existence of delinquent records beyond 14 days and in many cases years demonstrated failure to implement and enforce the hospital’s own policy. 4. During interview of the HIMT on 1/13/26 at 9:30 a.m. when asked regarding backlogged work in the department, only scanning was mentioned. The HIMT stated that bi-weekly meetings with leadership are held to check in regarding backlogs. No mention was made of physician documentation delinquencies, tracking mechanisms, or escalation processes. 5. During review of the hospital’s “2025 Performance Improvement Plan” HIM’s reporting frequency to the Utilization Review/Health Information Management Committee is stated a “Minimum Quarterly” and Agenda items may include: H&P Completion Reports, Discharge Summary Reports, Delinquency Rates and Medical Record review summaries. Review of the last available report to the Committee for the first three quarters of 2025 showed reporting from HIM on History and Physical Compliance Tracking, Discharge Summary Tracking and Verbal Orders Signed Within 48 Hours Compliance - Overall. Actions for the first two metrics: “Followed up with MD immediately upon discovery.” Action for the third metric: “Improved compliance overall. Month 3 of Quarter 3, a new process was started with one assigned MD to review all verbal orders daily.” Documented actions were limited to immediate physician follow-up or isolated process changes and did not address the sustained backlog of delinquent records identified in the January 2026 report. 6. Review of the Medical Staff Bylaws, Rules and Regulations dated 1/2/24, on pg. 80, 12.3-4 Medical Records found the statement “Failure to timely complete records after written notice, provided in accordance with hospital policy, shall result in an automatic suspension....If after 30 consecutive days of suspension, the Practitioner remains suspended, the Practitioner will be considered to have voluntarily resigned from the Medical Staff.... Nothing in the foregoing shall preclude the implementation, by Medical Executive Committee, of a monetary fine for delinquent medical records.” During an interview on 1/14/26 at 1:19 p.m. with the Executive Assistant Medical Staff (EAMS), who had served in that role since 2022, the EAMS stated she was not aware of any medical staff suspensions for delinquent medical records.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 35704 Based on observation, interview and record review the hospital failed to ensure therapy evaluations were completed upon admission for six of 31sampled patients (Patients 2, 3, 5, 6, 7, 33) by identifying discharge plans and documenting a full evaluation/assessment as per the hospital’s Policy and Procedure (P&P). This failure had the potential to result in substandard care. Findings: 1. Review of the P&P titled Therapy Services Evaluation, Assessment, Treatment Planning, last reviewed on 2/2025 showed the following: Procedure: 3.7 Status at time of initial evaluation Pain, Safety/Fall Risk/Training 3.9 Goals - identify short-term goals and long-term goals. Goals are to be objective, measurable, realistic, and related to function. 3.10 Treatment plan - list specifically all modalities/treatment methods used to increase patient’s function. 3.16 Estimated discharge date, needs and further recommendations for care in home and in the community as appropriate (discharge planning). 2. Review of P&P titled Plan for the Provision of Care, Treatment and Services, last reviewed on 1/2025 showed the following: Page 14 - Therapy Services are provided in accordance with professional standards of practice of the respective disciples, and in accordance with patient needs. Page 15 - The assessment process identifies the patient’s physical, cognitive, behavioral, emotional and social status. Page 30 - Our patient’s discharge planning begins upon admission and is revised, as needed, throughout the hospital stay based on any changes in the patient’s condition. 3. Review of the form: PT Initial Evaluation in the hospital’s EHR system showed 13 pages with sections including: Patient History, Safety Awareness, Preferred Language, Vision Functional, Orientation, Hearing Functional, Vision Functional, Level of Consciousness, Follows Commands, Cognitive Behaviors, Communication, Rancho Level, Communication Barriers, Adaptive Equipment, Prior Device Use, Vitals, Prior Level of Function, Pain, Non-Pharmacologic Interventions provided by PT, Posture/Tone/Endurance, Balance/Sensation, Sitting/Standing Dynamic, ROM/Strength, ADL’s, PT current functional mobility, PT Goals/Discharge Planning, PT Barriers to Discharge, PT Education, and PT Assessment and Plan. 4. Review of the form: OT Initial Evaluation (Vibra LTAC) in the hospital’s EHR system showed 14 pages with sections including: Patient History, Prior level of function, Safety Awareness, Preferred Language, Hearing Functional, Vision Functional, Level of Consciousness, Follows Commands, Cognitive Behaviors, Communication, Rancho Level, Communication Barriers, Adaptive Equipment, Prior Device Use, Vitals, Prior Level of Function, Pain, Non-Pharmacologic Interventions provided by OT. Posture/Tone/Endurance, Balance/Sensation, Sitting/Standing Dynamic, ROM/Strength, ADL’s, PT current functional mobility, OT Goals/Discharge Planning, OT Barriers to Discharge, OT Education, and OT Assessment and Plan. On 1/12/26 at 2:00 p.m., record reviews were conducted accompanied by Registered Nurse 1 (RN 1) and Dialysis Director (DD) who verified the following information. Review of Patient 2’s record showed the following: Patient 2 was admitted on 12/17/25. (a) Initial OT evaluation dated 12/18/25 was incomplete. Sections were blank in the following areas of the evaluation: Self Care, Cognition, Home Environment, Hearing, Vision, Communication, Cognition, Memory, Balance, Strength and ADL’s. (b) Initial PT evaluation dated 12/18/25 was incomplete. Time spent on the evaluation was documented from 2:20 pm to 2:30pm (10 minutes). Sections were blank in the following areas of the evaluation: Hearing, Vision, Level of Consciousness, Orientation, Communication, Adaptive Equipment, and Barriers to Discharge. Review of Patient 3’s record showed the following: Patient 3 was admitted on 12/24/25. (a) Initial OT evaluation dated 12/28/25 was incomplete. Sections were blank in the following areas of the evaluation: Communication, Cognitive Behaviors, Memory, Hand Dominance, Vital Signs, Posture, Head Control, Trunk Control, Strength, Visual Perception, ADL’s and Discharge Goals. Review of Patient 7’s record showed the following: Patient 7 was admitted on 1/7/26. (a) Initial OT evaluation dated 1/7/26 was incomplete Patient history showed they were admitted with PRAFO (Pressure Relief Ankle Foot Orthosis) and LUE (left upper extremity) hand splint. The OT Evaluation section for hand dominance, upper extremity range of motion and education were blank and the narrative notes did not include references to the PRAFO and LUE splint. (b) Initial PT evaluation dated 1/7/26 was incomplete. Patient history of PRAFO and LUE were missing from the current functional mobility section and no measurable goals were noted in the evaluation. On 1/14/26 at 9:00 a.m. record reviews were conducted accompanied by DD and the Director of Rehabilitation (DOR). The DOR verified the policies for Therapy Services Evaluation and Plan and Provision of Care as well as the PT and OT Initial Evaluation forms. The DOR verified that the Initial Evaluation Form for all rehab disciplines (PT/OT and ST) should not have blank sections and the therapist evaluating should write a narrative note or place N/A (not applicable) in the sections that were not completed and follow up to complete the sections at a later date if needed. Review of Patient 5’s record showed the following: Patient 5 was admitted on 12/17/25. (a) Initial OT evaluation was incomplete. There were no discharge goals and no measurable short and long term goals stated. The section was blank. (b) Initial PT evaluation was incomplete. There were no discharge goals and no measurable short and long term goals stated. The section was blank. Review of Patient 6’s record showed the following: Patient 6 was admitted on 12/17/25. (a) Initial OT evaluation dated 12/18/25 was incomplete. The evaluation did not address the patient’s pain level at the time of evaluation and did not address discharge planning including discharge goals. (b) Initial PT evaluation dated 12/18/25 was incomplete. The evaluation did not address the patient’s pain level at the time of evaluation and did not show discharge planning including discharge goals. Review of Patient 33’s record showed the following: Patient 33 was admitted on 1/2/26. (a) Initial OT evaluation dated 1/2/26 was incomplete. Sections were blank in the following areas of the evaluation: Communication, Cognitive Behaviors, Memory and Discharge Goals. (b) Initial PT evaluation dated 1/2/26 was incomplete. Sections were blank in the following areas of the evaluation: Communication, Cognitive Behaviors, Memory, Hand Dominance, Posture, and Discharge Goals. The DOR verified the above information. Glossary: ADL - Activities of Daily Living OT - Occupational Therapy PT - Physical Therapy ST - Speech Therapy”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 46237 Based on interviews, medical record, document and policy review, the hospital failed to effectively organize and deliver safe, quality care to patients on the medical until as evidenced by: A. The facility failed to ensure that the policy for pulse oximetry monitoring of patients on the Medical Unit was implemented for one of 23 sampled patients (Patient 2) on the morning of 1/20/24. (Refer to A 0144) B. The facility failed to ensure Licensed Nursing Staff were notified when Patient 2’s oxygen saturation was below 84%. C. The facility failed to ensure monitor alarms were consistently responded to by the Monitor Technician (MT) and/or nursing staff on 1/20/24 as per facility policy and physician’s orders. D. The facility failed to ensure the Monitor Technician (MT) was trained and qualified to respond to changing patient conditions. E. The facility failed to ensure the nursing staff on the medical unit adhered to facility policies and procedures. F. The facility failed to ensure the monitor alarms at the nursing station were loud enough to be heard clearly. These failures put patients on the medical unit at increased risk for poor health outcomes, injuries, adverse events, and death. These failures contributed to Patient 2’s death by staff failing to respond to monitor alarms on the morning of 1/20/2024. The cumulative effect of these failures resulted in the hospital’s inability to provide effective, lifesaving care in accordance with the statutorily-mandated Conditions of Participation Patient Rights.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 46237 Based on interviews and record review, the facility failed to protect patients on the medical/surgical unit from harm when the staff failed to respond to a physiological monitor alarm (a monitor used to measure heart rate, breathing and temperature) in order to provide necessary, lifesaving interventions for 1 of 23 sampled patients (Patient 2) when: a. Monitor alarms were not consistently responded to by the Monitor Technician (MT) and/or nursing staff on 1/20/24 as per facility policy and physician’s orders. b. Camera footage of the MT’s desk shows the MT sitting at the monitor clicking on the boxes on the screen, the MT did not attempt to contact nursing staff regarding the alarms sounding. c. The facility failed to ensure medical/surgical nursing staff adhered to facility policies and procedures. d. The facility failed to ensure the monitor alarms at the nursing station were loud enough to be heard clearly. These failures contributed to the death of a patient (Patient 2) and resulted in an unsafe environment for patients in the facility when neither the MT, nor the licensed nursing staff responded to a monitor alarm indicating Patient 2’s oxygen saturation was dropping to dangerously low levels. Findings: A review of Patient 2’s History and Physical (H&P), dated 12/3/23, indicated Patient 2 was admitted to the hospital on 12/3/2023 after “multiple cardiac arrests, stroke, heart failure, pulmonary tuberculosis (bacterial infection that affects the lungs) and pulmonary hypertension (type of high blood pressure that affects the arteries in the heart and lungs). The H&P indicated Patient 2 had a tracheostomy (an opening in the neck into the windpipe for breathing) and was placed on “room air T mist at 5 liters per minute (the amount of supplemental oxygen a patient is receiving) (liter is a unit of measure).” The “ABG” (Arterial Blood Gas- blood drawn from an artery to check oxygen levels) was reported as “normal on room air.” The H& P included an electrocardiogram (EKG- tracing of the electrical activity of the heart) which showed “rate controlled afib” (atrial fibrillation- a heart condition causing irregular and rapid heartbeat). The document indicated Patient 2 was a “partial code: do not do chest compressions, do not defibrillate or perform synchronized cardioversion (administration of a controlled electric shock to restart a person’s heart); do not perform temporary transcutaneous pacing (a device used to temporarily pace a patient’s heart during a medical emergency).” Further review of the H&P indicated, “alert, nonverbal, neuro [relating to the nervous system], cannot be tested patient does not follow command, flat affect, suspected of anoxic brain injury [death of brain cells caused by a lack of oxygen] effect ...” During an interview on 6/25/24 at 1:05 p.m. with chief operating officer (COO), COO indicated there was a delay in staff responding to the monitor alarm that indicated Patient 2 was having trouble breathing. COO further indicated MT 1 had not notified the nursing staff for 20-25 minutes that the oxygen sensor was alarming, or Patient 2 was in distress. COO further indicated it was the responsibility of the MT to notify nursing staff when there was an alarm so the nurse could check the status of the patient. During an interview with the CEO on 6/25/24 at 1:05 p.m., CEO stated the monitor alarms were not loud enough for staff to hear with the rest of the noise around the monitoring station. CEO further indicated MT 1 had multiple tasks including answering the phone, reading, and interpreting cardiac rhythm strips, answering questions from nursing staff and visitors. CEO further indicated MT 1 and nursing were suffering from “alarm fatigue” (a term used when workers are busy and become desensitized to safety alerts and as a result ignore or fail to respond). Review of a computer generated report titled, “Patient Trend Analysis Report (PTAR)” with a Report Start Date 1/20/24 6a.m. and Report End Date 1/20/24 10a.m., PTAR indicated Patient 2 had an SpO2 (percentage of oxygen in the blood, normal is 90% or higher) less than 88% for 28 minutes and 40 seconds. Further review of the document indicated Patient 2 had 11 episodes of SpO2 below 88% with the lowest at 46% at 9:19 a.m. on 1/20/24, with the longest episode of low SpO2 lasting 23 minutes and 40 seconds. During an interview on 6/25/24 at 1:30 p.m. with Director of Nurses (DON), DON indicated she had given MT 1 a break at from 8:13 a.m. until 8:30 a.m. The DON indicated she did not receive a “hand off” report from MT 1 nor does she remember hearing a specific patient’s monitor alarm sounding. The DON indicated she looked at the monitor while doing break relief and believes Patient 2 was “saturating okay”. DON indicated the MT or the person sitting at the monitor is responsible to ensure the patients are receiving enough oxygen , “the monitors alarming are not the responsibility of the licensed nurse (LN) but of the MT.” During an interview and concurrent document review of Patient 2’s medical record on 6/26/24 at 3:00p.m., with the Infection Prevention/Employee Development Nurse (IC/ED), IC/ED stated oxygen saturation below 90% and heart rate below 60 beats per minute (normal heart rate is 60 beats per minute or above) was to be reported to the LN. The IC/ED stated when notified, the LN is to “go to the bedside and check on the patient or make sure someone does”. IC/ED stated the LN is ultimately responsible for the safety of the patient which includes responding to monitor alarms. The IC/ED stated Patient 2 had not received his morning medications and that the licensed nurse had not confirmed Patient 2’s vital signs which were completed at 6:44 a.m., on 1/20/24 by the Certified Nurse’s Aide (CNA). The IC/ED indicated the record reflected the only intravenous (IV - through the vien) insertion site Patient 2 had been a “22 angio cath” (size and type of intravenous catheter) which was placed in Patient 2’s right antecubital site (area between the upper and lower arm, the anterior surface of the elbow) on 12/25/23. IC/ED was not able to locate documentation of the condition of the IV site or if it was a functioning IV. The IC/ED confirmed the IV site and care should be documented on the IV flow sheet per facility policy. Review of an undated, untimed facility document, the chief executive officer (CEO ) had identified as “notes” of the review of the camera footage of the nurse’s station and monitors on 1/20/24 indicated MT 1 returned from his break at 8:32 a.m. and began “doing tasks”. At 8:40 a.m., the same document indicated the monitor “stops transmitting data.” The note further indicated at 8:53 a.m., MT 1 appears to notice the lack of transmission and clicks on Patient 2’s monitor box and “scrolls back to look at data” and at 9:24 a.m., MT 1 “sees the RN [registered nurse]” (LN3) and tells her to go check on the patient. The document further read at 9:28 a.m., staff “rush to room for code blue (used to indicate the critical nature of a patient usually one who is in immediate need of care related to cardiac or respiratory arrest).” Review of Patient 2’s medical record document titled, “Resuscitation [process of reviving someone] Order Form (ROF)”, dated 12/3/23 at 8:30 a.m., ROF indicated, “Limited code, Limitations to Resuscitation” and “Do not do chest compressions, Do not defibrillate, or perform synchronized cardioversion ...” Review of Patient 2’s medical record a document titled “Rapid Response Team Care Record (RRTCR)”, dated 1/20/24 at 9:20 a.m., RRTCR indicates “patient not responding, no vital signs, no pulse, no BP.” Review of a document titled “Emergency Cardio-Pulmonary Record (ECPR), dated 1/20/24 at 9:20 a.m., ECPR indicated, Patient 2 received 6 doses of “Epinephrine 1mg”, (primary drug used for cardiac arrest to increase cardiac output, mg- Milligram unit of measure) first dose was given at 9:23 a.m., the last dose at 9:38 a.m., and 1 dose of Sodium Bicarbonate at 9:33 a.m.. The EKG rhythm was documented as “flat line” 6 times with no cardiac rhythm identified. Further documentation indicated “no vital signs” 6 times. End of code was documented at 9:40 a.m., Patient 2 was pronounced deceased by the physician. Review of a document titled “Statement Taken from MT” dated 1/23/24, not timed, MT 1 indicated when he was relieved for break at about 8:15 a.m., he noticed that Patient 2 was “satting” (saturating, a percentage of oxygen within the blood) “around 84 [%]”. MT 1 indicated he “assumed DON would tell the respiratory therapist (RT).” When MT 1 returned from break at 8:30 a.m., MT 1 noticed Patient 2 was still “satting, low in the 80’s.” Approximately “20 minutes later” MT 1 noticed the monitor was not transmitting data for Patient 2. MT 1 indicated he was working on a task approximately 20 minutes before he “saw the primary RN and notified her to check” Patient 2. Review of the facility’s policy and procedure (P&P) titled, “Nursing, Clinical Alarms”, dated 1/13 [January 2013] and updated 12/23 [December 2023], the P& P indicated, “All clinical alarms and medical equipment alarm systems utilized for patient care are properly operational and alarms are activated when the appropriate settings are in use ... “Clinical staff will perform routine testing of clinical alarms prior to use of medical equipment/devices on the patient population:” ... “An environmental assessment of the alarm will be performed annually to assure the alarm can be heard within an appropriate distance and with competing noise in the unit where the medical device/equipment is being used” ... “Clinical staff will not silence alarms without first checking on the patient” ... During a concurrent interview and document review on 6/27/24 at 1:41 p.m., with Human Resource Director(HRD) , HRD indicated MT 1 was hired on 9/11/2023 as a monitor technician. A review of a document titled “Telemetry Monitor Tech” (observes and records the activity of monitors attached to patients in the hospital) dated January 16, 2023 was identified by HRD as the “job description for MT 1’s position”. The document indicated the following: “Responsible for continual monitoring of telemetry units and promptly alerting appropriate personnel of significant changes in readings. Additional Qualification/Skills: One (1) year of experience in healthcare with previous telemetry monitoring experience and/or equivalent education in telemetry monitoring and reading ...” “Completion of Medical Terminology course ... Job Function: Continually observe and analyze telemetry monitors and immediately report significant changes in rhythms to the appropriate personnel.” During the continued concurrent interview and document review on 6/27/24 at 1:41 p.m., with HRD, copies of MT 1’s training and monitor technician class completion document were requested and were not provided. MT 1’s resume was reviewed with HRD with no evidence of prior health care experience, medical terminology, or monitor technician training found.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 46237 Based on interview, patient record review, and facility document review, the hospital failed to ensure nursing staff developed and maintained a nursing care plan (CP) which accurately reflected the needs of 2 of 23 sampled patients (patients 1 and 2). These failures had the potential to negatively impact the care of the patients. Patient 1 was admitted to the hospital on 4/20/24 with a nasogastric tube (NGT a plastic tube through the nose, down into the stomach) to provide nutritional support and administration of medications. During a review of Patient 1’s “Note Discipline: Registered Nurse (NDRN)”, dated 5/17/24, the NDRN indicated, “NG tube removed.” During a concurrent interview and patient record review on 6/26/24, at 9:55 a.m. with Licensed Nurse (LN) 8, LN 8 confirmed Patient 1’s CP initiated on 4/21/24, indicated, “Alteration in Nutrition and Hydration related to tube feeding as evidenced by the presence of NGT.” LN 8 stated, Patient 1’s NG tube was removed on 5/17/24. On 5/20/24, Patient 1’s CP had not been updated to reflect this change of condition. During an interview on 6/26/24 at 1:20 p.m. with the Director of Nursing (DON), DON stated, Patient 1’s CP should have been updated on 5/17/24 to reflect the NGT removal. Patient 2 was admitted to the hospital on 12/3/23 with a peripherally inserted central line (PICC) (long catheter that is inserted through a vein in the arm, ends in a large vein near the heart. Used to administer medications or draw blood). During a review of Patient 2’s medical record on 6/26/24 at 3:00 p.m., with Infection Control/Educator (IC/ED), the IC/ED indicated the PICC was no longer in place, CP was not updated to reflect this change in condition. During an interview on 6/26/24 at 1:20 p.m. with the DON, DON stated, Patient 2’s CP should have been updated to reflect the PICC line removal. During a review of the facility’s policy and procedure (P&P) titled, “Care Planning”, dated 12/23, the P&P indicated, “The plan of care is maintained and updated based upon ongoing patient assessments and the patient’s response to care, treatment and services.””