Kentfield Hospital

“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: 50619 Based on interview and record review, the facility failed to ensure nursing staff followed and had access to established policy & procedures and workflow tools for two out of 30 sampled patients (Patients 1 and 21) when: 1. Nursing staff did not have access to a policy and failed to follow the “Code Sepsis” workflow tool (a step-by-step processes of guiding patient care and tasks used by staff to document and respond to sepsis, a potentially life-threatening bloodstream infection) for Patient 1, and 2. Nursing staff failed to perform wound care as ordered for Patient 21 on six separate occasions. These failures resulted diagnostic and treatment delays for Patient 1 which may have precluded nursing staff and medical doctors from appropriately responding to changes Patient 1’s condition and may have contributed to Patient 1’s death. These failures prevented Patient 21 from receiving ordered wound care, placing the patient at risk for infection, sepsis, and death. Findings: 1. During a review of Patient 1’s History and Physical (H&P), dated 2/23/26, the H&P indicated Patient 1 was admitted to the facility with a history of postoperative cardiac arrest (heart stopped functioning after surgery), atrial fibrillation (irregular heart beat), high blood pressure, a pressure ulcer (wound caused from decreased blood flow to tissues), a tracheostomy (an opening in neck where tube inserted to assist breathing), and was on blood thinner medication. During a concurrent interview and record review on 7/1/26 at 11:11 a.m. with Registered Nurse 1 (RN 1) of an undated, blank document titled, “Code Sepsis”, RN 1 stated nurses use this workflow tool for all septic patients to help them to remember the critical steps for managing a septic patient. RN 1 stated the document is a paper form which is kept at the nursing station. The document included a “start” and “end” section for noting the time the form and steps are initiated. The document included “action” items including drawing labs at set times (laboratory blood test used to measure cells, chemicals, proteins, or other substances in blood), obtaining vital signs in specific intervals (measuring the body’s basic functions including temperature, heart rate, respiratory/ breathing rate, blood pressure, and oxygen saturation of the blood), administering antibiotics (medications that treat bacterial infections) and to provide fluid resuscitation (giving intravenous, IV- small, flexible plastic tube inserted into a vein, fluids). RN 1 stated, other staff can use the tool to help follow the steps if the primary RN was busy or overwhelmed. RN 1 confirmed the “Code Sepsis” document was not part of a patient’s medical record and was discarded after use. Further review of the “Code Sepsis”, tool included: “(1) Draw ... a lactate level (a lab to test for acid in blood to determine if body is getting adequate oxygen) before giving antibiotics. (2) Vital signs every 1-hour x 4, every 2 hours x 4, every 4 hours x 4. (3) Administer broad spectrum antibiotics (antibiotics prescribed when bacteria causing infection is unknown) within 3 hours ... (4) Repeat Lactate level at 4 hours ...”. During a review of Patient 1’s “Vital Sign Flowsheet (VS),” dated 3/2/26, the “VS” indicated the following: At 9:27 a.m., the temperature of 104 degrees Fahrenheit (F- a unit of temperature measurement, 97-99 degrees is normal adult body temperature) Respiratory Rate 22 (RR, normal adult is 12- 20 breaths per minute), Heart Rate 118 (HR- normal adult is 60-100 beats per minute), oxygen saturation of 97% (normal blood oxygen saturation is greater than 90%), and Blood Pressure 113/52 (BP- normal adult is 120/80). At 10:22 a.m., an incomplete set of vital signs was taken with a HR of 100 and at 10:25 a.m., a temperature of 101 F, there was no documented evidence of BP, RR, and oxygen saturation level. At 11:30 a.m. and again at 12:30 p.m., no vital signs were documented to meet the hourly vital signs assessment for the first 4 hours per the “Code Sepsis” tool. At 1:32 p.m., Patient 1 had a temperature of 99.6 F and there was no documented evidence of HR, BP, RR, or oxygen saturation level. Between 1:32 p.m. and 4:38 p.m., no vital signs were documented in Patient 1’s medical record. At 4:38 p.m., Patient 1’s temperature was 101 F, 116 HR, 77/48 BP, and RR 18, and no oxygen saturation level was documented. During a review of Patient 1’s “Discharge Reconciliation Report”, the report indicated the antibiotic, cefepime 2 gm (grams- a unit of measure) IV, was administered on 3/2/26 at 2:50 p.m., more than 3 hours after the “Code Sepsis” workflow started at 9:27 a.m. During a review of Patient 1’s medical record titled, “Results”, dated 3/3/26 at 5:37 a.m., the documented indicated a blood lactic acid level was not drawn prior to giving the IV antibiotic, cefepime as directed by the “Code Sepsis” workflow. Patient 1’s “Results” also indicated a second lactic acid level was not drawn four hours after the initial lactic acid as directed by the “Code Sepsis” workflow. During an interview on 7/1/26 at 11:01 a.m. with Infection Control Preventionist Nurse (ICP), ICP confirmed nursing staff did not obtain or document Patient 1’s vital signs according to the “Code Sepsis” tool and acknowledged there was missing and incomplete vital signs documented. The ICP confirmed the lactic acid blood level was not drawn prior to antibiotic administration and not or redrawn after 4 hours. The ICP indicated ordered antibiotics were not started within 3 hours of initiating the “Code Sepsis” workflow. A policy for management of a sepsis patient was requested on 6/29/26. During an interview on 7/1/26 at 11:46 a.m. with the Chief Operating Officer (COO), the COO stated the policy for sepsis was not accessible by staff at the hospital. 2. During a review of Patient 21’s History and Physical (H&P), dated 5/22/26, the H&P indicated Pt 1was admitted for wound care and rehabilitation with a history of diabetes (elevated levels of sugar in the blood), stroke (tissue damage in the brain due to lack of oxygen) with a recent colectomy (surgery to remove part of colon) with chronic abdominal wound infections. During a review of Patient 21’s “Wound Dressing Order,” dated 5/25/26 at 7:21 p.m., order indicated wound dressing changes to be done “daily to JP drain (Jackson-Pratt drain is a device used to remove excess bodily fluids from an incision site to help heal and prevent infections) site; clean with [saline solution], pat dry, apply split gauze and secure with tape”. During a review of Patient 21’s “Administration History,” dated 5/28/26 through 6/28/26, the “Administration History” indicated the above wound care was not documented on the following dates: 5/26/26, 5/27/26, 6/14/26, 6/15/26, 6/16/26, and 7/3/26. During an interview on 7/1/26 at 11:20 a.m., with the ICP, ICP confirmed there was not documented evidence dressing changes were completed as ordered on 5/25/26, 5/27/26, 6/15/26, 6/16/26, and 7/3/26. The ICP stated this placed Patient 21 at risk for developing and infection at the JP tube site. During a review of the facility’s policy and procedure (P&P) titled, “Skin Integrity and Pressure Injury Prevention,” dated 7/2025, the P&P indicated, “PROCEDURE ...III. ROLES AN RESPONSIBILITY OF CLINICAL STAFF: A. Wound Care Specialist ...6. Completes documentation requirements of the facility related to skin integrity and wound care treatments ...B. Licensed Nurse Responsibilities: 6. Obtains, notes, and implements qualified healthcare provider orders ...””

“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: 50168 Based on interview, record review, and facility policy review, the facility failed to: a. Ensure policies for pain assessment and management were implemented for one of 30 sampled patients (Patient 15) when pain medication ordered for severe pain management was given for moderate pain as reported by the patient, b. Ensure policies for medication administration were implemented for one of 30 sampled patients (Patient 15) when respiratory depression (a condition where breathing is too slow or shallow) was not monitored after giving narcotic pain medication and blood pressure was not documented before and after giving blood pressure medication, and c. Ensure policies for pain medication administration were implemented for four of 30 sampled patients (Patients 20, 24, 27 and 19) when they did not have pain levels reassessed after receiving their pain medications. These failures resulted in Patient 15 experiencing decreased respiratory rate, heart rate and blood pressure requiring emergency treatment and had the potential to render Patients 20, 24, 27 and 19 with inadequate pain control. Findings: a. During a review of Patient 15’s face sheet, dated 1/20/26, the face sheet indicated the patient was admitted with diagnoses including chronic congestive heart failure, acute respiratory failure with hypoxia and acute kidney failure. During a review of Patient 15’s pharmacy orders, dated 1/20/26, the orders indicated Patient 15 had an order for hydromorphone (a strong narcotic pain medication) 0.5mg/0.5ml (mg - milligram, a unit of measure and ml- milliliter, a unit of measure) with instructions to administer the medication slowly by IV push (a technique for administering medication directly into a vein through a syringe) over two to three minutes every four hours as needed for severe pain (rated by patient as 7 to 10 on a 1 to 10 pain scale, where 10 is the worst imaginable pain) and to monitor for signs of respiratory depression before and after administration. During a concurrent interview and record review on 4/7/26 at 2:45 p.m. with the Director of Nursing (DON) of Patient 15’s MAR and policy titled, “Pain Assessment and Management,” dated 7/25, was reviewed. The MAR indicated on 1/31/26 hydromorphone (for severe pain 7-10) was given for a pain level documented as a six (6) and on 1/22/26 hydromorphone was given for a pain level of 5 (five). The Pain Assessment and Management policy defined the pain scale as 1 to 3 mild pain, 4 to 6 moderate pain, and 7 to 10 severe pain. DON stated if a nurse needed pain management orders for moderate pain the expectation was that they should contact the doctor for orders. b. During a concurrent interview and record review on 4/6/26 at 2:25 p.m. with the Director of Case Management (DCM), Patient 15’s Medication Administration Record (MAR) and vital signs flow sheet from 1/30/26 to 1/31/26 was reviewed. The MAR indicated hydromorphone was given at 1 a.m. on 1/31/26 for a pain level of six (6). The vital signs flowsheet did not indicate a documented respiration rate (a measurement of breaths taken in a minute) before or after the medication was given. DCM stated measurement of respiration rate was important for this medication since it was sedating and should have been documented. During a concurrent interview and record review on 4/7/26 at 11:45a.m. with the Chief Operating Officer (COO), Patient 15’s vital sign flow sheet dated 1/31/26 was reviewed. The COO confirmed vital sign flow sheet indicated no vital signs or oxygen therapy was documented between 2:17 a.m. and 7:23 a.m. During a concurrent interview and record review on 4/8/26 at 9:40 a.m. with DON, Patient 15’s MAR was reviewed. The MAR indicated an order to give 10 mg midodrine (medication for low blood pressure) 1 tablet as needed up to three times per day. The MAR indicated this medication was given at 4:23 a.m. on 1/31/26. The DON stated the expectation was nursing staff would document a blood pressure measurement before and after medication administration. During a review of the facility policy titled, “Administration of Medications,” dated 7/25, the policy indicated patients receiving sedation or narcotic pain medication will be observed for respiratory depression following the completion of injection. c. During a review of Patient 20’s History and Physical (H&P), dated 3/21/26, the H&P indicated the patient was admitted with diagnoses including chronic pain and muscle spasms due to spinal cord injury. During a review of Patient 20’s pharmacy orders, dated 3/30/26, the orders indicated an order for oxycodone HCL (a potent narcotic pain medication) 2.5 mg per tube every six hours as needed for severe pain. During a concurrent interview and record review on 4/6/26 at 11:41 a.m. with Registered Nurse (RN) 2, Patient 20’s “Medication Charting History,” dated 4/2/26 to 4/6/26 was reviewed. The history indicated Patient 20 received 2.5 mg of oxycodone HCL on 4/2/26 at 9:06 a.m. for a pain level of 7. RN 2 stated pain should be reassessed an hour after administering an oral pain medication to determine if the medication was effective. RN 2 confirmed there was no reassessment of Patient 20’s pain level after he was given the pain medication on 4/2/26 at 9:06 a.m. During a review of Patient 24’s H&P, dated 2/20/26, the H&P indicated the patient was admitted with diagnoses including right below knee amputation and left lower extremity gangrene (tissue death caused by loss of blood supply or severe infection) consistent with osteomyelitis (a serious bone infection). During a review of Patient 24’s pharmacy orders, dated 3/26/26, the orders indicated an order for oxycodone HCL 5 mg per tube every eight hours as needed for moderate to severe pain. During a concurrent interview and record review on 4/6/26 at 1:57 p.m. with RN 2, Patient 24’s Medication Charting History for oxycodone HCL, dated 3/19/26 to 3/29/26 was reviewed. The history indicated the following entries: a. “3/19/26 at 9:29 a.m., Status: Given” b. “3/19/26 at 3:45 p.m., Comment: effective” c. “3/19/26 at 5:42 p.m., Status: Given” d. “3/20/26 at 8:35 p.m., Status: Given” e. “3/20/26 at 11:10 p.m., Comment: effective” f. “3/27/26 at 6:32 p.m., Status: Given” g. “3/28/26 at 6:52 p.m., Status: Given” h. “3/29/26 at 12:23 p.m., Status: Given” i. “3/29/26 at 5:09 p.m., Comment: effective” RN 2 confirmed Patient 24’s pain was reassessed late on three occasions; approximately six hours after pain medication was given on 3/19/26 at 9:29 a.m., three hours after receiving pain medication on 3/20/26 at 8:35 p.m., and five hours after receiving pain medication on 3/29/26 at 12:23 p.m. RN 2 stated there was no reassessment of Patient 24’s pain after she received the pain medication on the three other occasions. During a review of Patient 27’s H&P, dated 2/19/26, the H&P indicated the patient was admitted with diagnoses including thyroid cancer with metastases (cancer that has spread to other parts of the body) to the bones and lungs. During a review of Patient 27’s pharmacy orders, dated 3/30/26, the orders indicated an order for hydrocodone/acetaminophen (a pain medication containing a combination of a narcotic and non-narcotic pain reliever) 5 mg-325 mg per tube every six hours as needed for severe pain. During a concurrent interview and record review on 4/7/26 at 10:33 a.m. with RN 2, Patient 27’s Medication Charting History for hydrocodone/acetaminophen, dated 3/29/26 to 4/6/26 was reviewed. The history indicated the following pain medication administrations: a. On 3/29/26 at 9:25 p.m., for pain level of 8 b. On 3/30/26 at 4:12 a.m., for pain level of 8 c. On 3/30/26 at 4:51 p.m., for pain level of 7 d. On 3/31/26 at 6:21 a.m., for pain level of 8 e. On 4/1/26 at 2:59 p.m., for pain level of 8 f. On 4/2/26 at 4:26 p.m., for pain level of 7 g. On 4/4/26 at 6:05 a.m., for pain level of 8 h. On 4/6/26 at 4:13 a.m., for pain level of 8 RN 2 stated there were no documented reassessments of Patient 27’s pain after she received the above eight doses. During a review of Patient 19’s H&P, dated 1/9/26, the H&P indicated the patient was admitted with diagnoses including a sacral decubitus ulcer (a bedsore on the tailbone) and right intertrochanteric femur fracture (a type of broken hip) with osteomyelitis. During a review of Patient 19’s pharmacy orders, dated 3/26/26, the orders indicated an order for hydromorphone HCL 0.5mg/0.5mL IV as needed every eight hours for severe pain. During a concurrent interview and record review on 4/7/46 at 11:47 a.m. with RN 2, Patient 19’s Medication Charting History for hydromorphone, dated 3/26/26 to 4/7/26 was reviewed. The history indicated the following pain medication administrations: a. On 3/26/26 at 9:51 p.m., for pain level of 8 b. On 3/27/26 at 6:09 a.m., for pain level of 8 c. On 3/29/26 at 10:24 p.m., for pain level of 8 d. On 3/30/26 at 6:15 a.m., for pain level of 9 e. On 4/2/26 at 9:54 p.m., for pain level of 8 f. On 4/3/26 at 5:55 a.m., for pain level of 9 g. On 4/4/26 at 6:18 a.m., for pain level of 8 h. On 4/6/26 at 6:02 a.m., for pain level of 8 i. On 4/6/26 at 10:15 p.m., for pain level of 8 j. On 4/7/26 at 6:15 p.m., for pain level of 8 RN 2 stated there were no documented reassessments of Patient 19’s pain after she received the above 10 doses. During a review of the facility policy titled, “Pain Assessment and Management”, dated 7/25, the policy indicated, “Management of a patient’s pain includes individualized assessment, intervention and evaluation of pain and pain relief ... Patients that are administered pain medications will be reassessed within 1 hour of administration ...””

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 39700 Based on observation, interviews, and record review, the facility failed to establish an appropriate temperature range within the pharmacy refrigerator monitoring system to ensure medications were stored under proper conditions. This practice had the potential to delay the detection of temperature excursions, placing temperature-sensitive medications, including vaccines, for 39 of 39 patients in the facility, at risk for degradation. During a concurrent observation and interview on 10/21/25 at 2:08 p.m. with the Pharmacist-in-Charge (PIC) in the main hospital pharmacy, the medication refrigerator containing vaccines such as hepatitis B vaccine, a type of vaccine that protects against hepatitis B virus (HBV) infection, which can lead to chronic liver disease, liver cancer, and death, was observed to have a temperature monitoring alert system incorrectly set at 36° F (degrees Fahrenheit, unit of measure) to 53° F. The PIC stated that an email notification is sent when the temperature is out of range. The acceptable temperature range should be set between 36° F and 46° F, as specified by drug manufacturers. The PIC acknowledged that storing medications outside the required temperature range could compromise drug potency and efficacy. During a review of the hepatitis B manufacturer’s label in the pharmacy, the manufacture label on the box indicated, “Store in a refrigerator at 36° F to 46° F.” According to the Centers for Disease Control and Prevention (CDC), refrigerated vaccines must be stored between 36° F and 46° F at all times to maintain their potency and effectiveness. The CDC’s Vaccine Storage and Handling Toolkit emphasizes that failure to maintain proper storage temperatures can result in reduced vaccine efficacy and potential patient harm. Review of the facility policy and procedure titled, “Storage of Medications”, last reviewed 12/24, indicated, “Medications will be stored at appropriate temperatures. Refrigerator temperatures, everywhere medications are stored will be maintained between 36o F and 46o F.””

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 39700 Based on observation, interview, and record review, the facility failed to ensure consistent implementation of its policies and procedures (P&P) regarding high-risk and high-alert medications (those that bear a heightened risk of causing significant patient harm if used in error). The high risk and high alert medications for 39 of 39 patients were stored throughout the pharmacy shelves without any distinct labeling to indicate their classification as high-risk or high-alert. This failure had the potential to increase the risk of medication errors associated with these medications. Findings: During an inspection of the main hospital pharmacy on 10/21/25 at 2:20 p.m., high-risk and high-alert medications were observed to be stored throughout the pharmacy shelves without any distinct labeling to indicate their classification as high-risk and high-alert medications. During an interview on 10/21/25 at 2:25 p.m. with the Pharmacist in charge (PIC), the PIC stated, the pharmacy shelves did not have any labels to identify the high-risk and high-alert medications. During an interview on 10/23/25 at 11:20 a.m. with the PIC, the facility’s P&P were reviewed. The PIC stated, according to the P&P, the high-risk and high-alert medications needed to be identified for the pharmacy staff to prevent medication errors. During a review of the facility’s P&P titled, “High Risk/High Alert Medications,” last reviewed 12/2023, the P&P indicated, “II. Strategies will be developed to mitigate risk for each of the high alert medications and will be included on the hospital’s list of high-risk medications. III. Medications that appear on the list will be identified in the pharmacy as such on the front of the medication storage bins. IV. Medications from the list that are stocked in the pharmacy will be stored in medication bins of color to distinguish them from other medications.” During a review of the facility’s P&P titled, “Storage of Medications,” last reviewed 12/2024, the P&P indicated, “Medications designated on the “look-alike/sound-alike” or “high-alert” lists will be stored separately from other medications and/or appropriately labeled with cautionary statements.” According to the Institute for Safe Medication Practices (ISMP), a nonprofit organization in the United States devoted to the prevention of medication errors, for each medication on a facility’s high-alert medication list, organizations should outline a robust set of processes for managing risk, impacting as many steps of the medication-use process as feasible. This includes strategies such as distinct labeling, segregation, and visual identification to ensure these medications are easily recognized and handled with appropriate caution.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 39700 Based on observation, interview, and record review, the facility failed to ensure a pharmaceutical product available for 39 of 39 patients was stored properly according to the facility’s policies and procedures or manufactures’ specifications and requirements when an injectable vial of pantoprazole, a medication used to treat stomach ulcers or acid reflux, was not protected from light in accordance with manufacturer’s storage requirements. This failure had the potential for medication degradation and administration of potentially ineffective medication. Findings: During an inspection of the pharmacy on 10/21/25 at 2:25 p.m., a vial of pantoprazole 40 mg (milligram, unit of measure) per vial was observed stored outside of the manufacture’s box, placed on a shelf in the main pharmacy room and exposed to light. During an interview on 10/21/25 at 2:30 p.m. with the Pharmacist in Charge (PIC), the PIC stated, “the vial should be protected from light to prevent drug degradation [deterioration leaving the medication less effective].” During a review of the pantoprazole manufacturer’s label in the pharmacy, the manufacture label on the vial indicated, “Protect from light.” During a review of the facility’s policy and procedure (P&P) titled, “Storage of Medications,” last reviewed 12/2024, the P&P indicated, “Medications must be stored under proper conditions of sanitation, light, humidity, ventilation, segregation, and security as determined by the USP/NF compendia and/or manufacturer’s labeling, as well as in compliance with applicable federal and state laws/regulations and accreditation standards.””

“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: 47138 Based on observations, interviews, and record review, the facility failed to involve the Patient’s Representative (PR) in the plan of care and advocate for Patient 1’s necessary care when the facility failed to facilitate necessary outpatient ophthalmology (medical doctor specializing in eye care) consultations for 1 of 28 sampled patients (Patient 1) when: a. The facility failed to inform Patient 1’s PR of an injury to Patient 1’s eye; b. The facility delayed seeking medical care for Patient’s 1’s eye injury from 5/13/24 until 5/15/24; c. The facility failed to follow the instructions from an emergency department physician to seek follow up ophthalmology care within two days; d. The facility failed to ensure case management staff adhered to facility policies and procedures for timely care coordination. These failures resulted in a corneal abrasion (injury to the eye surface) which further deteriorated into a descemetocele (a rare condition when the descemet membrane protrudes through the cornea, a condition usually caused by an untreated corneal injury and ulcer) which had the potential to lead to severe vision loss or blindness. Findings: A review of Patient 1’s “History & Physical (H&P)” indicated Patient 1 was admitted to the facility on in January of 2024 for diagnoses including “Locked in Syndrome” (a disorder caused by damage to the Pons area of the brain resulting in complete paralysis while mental function and awareness are not affected.) Further review of Patient 1’s H&P indicated Patient 1 had a history of bleeding in the brain causing severe brain damage, a tracheotomy (a surgical opening in the neck to place a tube into the windpipe to help air reach the lungs), kidney failure requiring dialysis (artificial means to remove waste from the kidneys), and a PEG tube (a feeding tube that is surgically placed into the stomach through the abdomen for food and nutrition). The H&P included an assessment of both eyes open with conjunctival hemorrhages in both eyes (a bright red patch in the white part of the eye caused by a broken blood vessel in the eye) and no corneal reflexes (involuntary blinking of the eye when stimulated). The H&P indicated Patient 1, “is not following commands” and “intermittent posturing and non-purposeful movement of his toes.” During a review of Patient 1’s medications at admission on 1/24/24 included physicians’ orders for a (trade name) eye antibiotic to be applied to both eyes twice daily and (trade name) artificial tears into both eyes every four hours while awake. In an interview and concurrent observation on 1/21/25 at 8:42 a.m. with Registered Nurse (RN)1, RN 1 stated Patient 1 has never been responsive and has never closed his eyes. RN 1 further indicated she is a dialysis nurse employed by the facility and provides dialysis services to Patient 1 every Monday, Wednesday and Friday for approximately 3.5 hours. Patient 1 was observed in bed receiving dialysis, both eyes were open and the eyelids were flickering, both eyes had clear shields covering the eye. The left eye was observed appearing white and cloudy with scant amount of white drainage and the right eye appeared clear with no drainage. In an interview with Infection Preventionist Registered Nurse (IPRN) on 1/21/25 at 11:07 a.m., IPRN, indicated Patient 1 had a left eye injury on 5/13/24 and was sent to the emergency department on 5/15/24 for evaluation of the eye injury at the request of Patient 1’s PR. The IPRN further indicated there were no documentation in the medical record seeking eye care on 5/13/24 or 5/14/24. In an interview on 1/21/25 at 2:25 p.m., with the Director of Nursing (DON), the DON indicated “(Patient 1’s) eye had been getting progressively worse since admission.” DON further indicated family (PR) had reported concerns about left eye and questioned what the facility was doing to seek ophthalmology care for Patient 1. The DON stated Patient 1 had a “cataract on admission”, however, the DON was not able to provide requested documentation of Patient 1 having a cataract upon admission. The DON indicated case management was responsible for obtaining appointments outside of the facility. In an interview on 1/22/25 at 3:29 p.m. with Registered Nurse (RN) 2, RN 2 indicated he had provided care for Patient 1 “many times” and had never seen Patient 1 close his eyes or have any purposeful movement. RN 2 further indicated he had never seen Patient 1 move his head or give a thumbs up. In an interview on 1/22/25 at 4:11 p.m., with Patient 1’s PR, the PR stated he was not notified in May when the eye injury occurred but discovered what he believes to be an injury when he arrived at the facility on 5/13/24 and observed the left eye which appeared completely white. The PR stated he asked Registered Nurse (RN) 4 what happened to Patient 1’s eye to which he was told she did not know but had noticed what appeared to be a ‘bubble on the left eye.” PR indicated he requested a physician be notified which he believes was done by RN 4. During further interview with Patient 1’s PR, he stated he had requested an ophthalmology physician exam for Patient 1’s left eye “for months” after the May injury and the PR stated he was not aware of any attempts to contact an ophthalmology physician to see Patient 1 until December 2024. In an interview on 1/23/25 at 8:30 a.m., with RN 4, RN 4 indicated she had not noticed anything wrong with Patient 1’s eye until late in her shift on 5/13/2024 when Patient 1’s father (PR) brought concerns about Patient 1’s eye to her attention. RN 4 indicated when she observed Patient 1’s left eye it appeared to have a “white blister on the surface”. RN 4 stated she did not know what happened to Patient 1’s eye. RN 4 indicated she had notified the Medical Director. RN 4 was not aware of any further care for the eye but stated she believed Patient 1 had been seen by an ophthalmologist. Review of an untitled document dated 5/13/24 at 4:42pm and signed by RN 4 reflected, “In afternoon went in to assess patient and notice a bubble had formed in left eye...Notified [Medical Doctor 1]...had this RN consult [MD 2 for an ophthalmologic assessment referral”, and, “Family suggested head flopped onto medical equipment in bed.” Review of a document titled “After Visit Summary” from [Hospital], dated 5/15/24, directed, “Follow up with ophthalmology MD in 2 days”. The document further indicated, “Specialty: Ophthalmology, Pediatric Ophthalmology” ... “Diagnosis Corneal Ulcer (eye injury) of left eye”. Review of a document dated 6/7/24 at 12:00 p.m., titled “Discharge Summary- Attending Only” indicated multiple diagnoses including, “Left Eye Keratopathy (inflammation of the cornea caused by injury and causes blindness)... secondary to exposure or some trauma in the past”. Review of a document dated 7/30/24, titled “Case Management Weekly Progress Note” indicated, “[PR] is requesting ophthalmology appointment for previous trauma to left eye.” Review of a document dated 9/4/24, titled “Case Management Weekly Progress Summary” indicated, “[PR] at bedside requesting follow up regarding eye trauma” ... Review of a document dated 10/14/24 titled “Case Management Weekly Progress Note” indicated “Ophthalmology consult ordered. Awaiting date and time.” ... Review of a document dated 10/14/24, titled “Case Management Note” indicated “Attempted to schedule ophthalmology follow up “Contacted Ophthalmologist MD” ... “ Left voicemail. Awaiting callback. Plan to follow up.” Review of a document dated 11/11/24 titled “Case Management Note” indicated “spoke with [Patient 1’s PR] and updated him on ophthalmologist referrals have been sent to [Hospital] for further evaluation ...” Patient 1 was seen in December 2024 for the eye injury that occurred in May of 2024. Review of a document dated 12/4/24 at 10:00 a.m., titled “OPHTH General”, reflected the corneal ulcer in the [left eye] is “bulging” and “large scar in the center of the cornea which appears to be an old descemetocele that previous perforated (penetration of the clear part of the eye which controls and focuses the entry of light into the eye). Further documentation indicated, “anterior chamber is shallow (the distance between the cornea and lens of the eye is smaller than normal).” The document revealed, “Left iris and left lens: no view (light is no longer passing through the iris or lens needed for vision)”. Review of a facility Policy and Procedure (P &P) titled “Case Management Responsibilities”, dated April 2024, directed, “Policy: The Case Management model assures all case management responsibilities are completed effectively and efficiently and minimize duplication of case management services ...”, “Performs admission and concurrent reviews, including managed care patient coordination/communication ...”, “Coordinates/ facilitates plans of care”, “Performs ongoing discharge planning, arranges for discharge needs, including alternate level of care transfers” and,” Collaborates with community agencies for patient post-acute needs ...”.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 43011 Based on interview and record review, the facility failed to provide nursing care to one of twenty eight sampled patients (Patient 27) when scheduled daily sponge baths were not done. This failure resulted in Patient 27 to feel neglected and unclean, which had the potential to negatively impact his physical and psychological well-being. Findings: During the review of Patient 27’s History and Physical (H&P), the H&P indicated Patient 27 was admitted to the facility on 4/18/22 for diagnosis of Left hemiplegia (paralysis affecting only side of the body) post gunshot wound, multiple fractures, respiratory failure (difficult to breathe on your own and lungs can’t get enough oxygen into the blood) and right temporal (head) wound infection. A review of Patient 1’s discharge note indicated patient 1 was discharged from the facility on 6/29/22. During an interview with the Registered Nurse (RN) 3 on 1/22/25 at 8:54 a.m., RN 3 stated bathing/sponge baths are provided daily to patients. RN 3 stated Certified Nursing Assistant’s are assigned daily and it is documented in the computer (medical record). During a concurrent interview and record review with the HIM Technician (HIM Tech) on 1/22/25 at 11:40 a.m., Patient 27’s “ADL Flowsheets” dated 4/18/22 to 4/29/22 were reviewed. The ADL Flowsheets indicated Patient 27 received 2 sponge baths on 4/20/22 and 4/26/22. The HIM Tech stated there was no documentation that Patient 27 received bath/sponge baths daily. During an interview with the Certified Nurse Assistant (CNA) 2 on 1/23/25 at 10:21 a.m., the CNA 2 stated patient gets sponge bath or shower daily. We are assigned for the schedule daily by the management. We document baths in the computer under ADL’s (Activities of Daily Living). During an interview with the Director of Nursing (DON) on 1/23/25 at 10:35 a.m., the DON indicated they do not have the policy on “Activities of Daily Living Assistance” from 2022. The DON acknowledged if bathing/sponge baths are not documented in the medical record, they were not done.”

“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: 41175 Based on observation, interview and record review, the facility failed to implement their policies and procedures on pressure ulcer prevention and management when four of 28 sampled patients (Patients 12, 13, 15 and 27) were not repositioned per protocol and established care plans. These failures resulted in Patient 13 and Patient 27 to be distressed and upset, and negatively impact the healing of Patients 12 and 15’s existing pressure injuries. Findings: Patient 15 A review of “Intake Information”, dated “02/07/2023”, indicated a complaint related to Patient 15’s pressure injury (a skin injury caused by prolonged pressure on a bony area of the body) and questioned whether he was repositioned every two hours. During an interview on 1/21/25 at 10:50 a.m., CNA (Certified Nursing Assistant) #1 stated patients with pressure injuries and those at-risk were repositioned every two hours to help decrease putting more pressure on their wound sites and other bony areas where pressure injuries might develop. A review of Patient 15’s “History and Physical” indicated he was admitted to the facility on the evening of 9/23/22 with diagnoses including paraplegia (loss of muscle function in the lower half of the body, including both legs) after a motorcycle accident. Patient 15’s “Admission Assessment” indicated he had a pressure wound on his sacrum (lower back) and had a Braden Score of 11 (a number that predicts the risk of a patient developing pressure ulcers. A score of 18 or less is generally considered at-risk.). A review of Patient 15’s “Care Plan”, dated “09/24/22”, indicated, “Pressure Ulcer - Impaired Skin Integrity ... Intervention: TURN AND REPOSITION PATIENT EVERY 2 HOURS USING 30 DEGREE SIDE-LYING POSITION ...” During a concurrent interview and record review on 1/23/25 at 8:33 a.m. with HIM Technician (HIM Tech), Patient 15’s “ADL Flowsheets” dated “9/24/22-9/27/22” were reviewed. The ADL Flowsheet indicated he was on his back on 9/24/22 for approximately nine hours, from 12:08 a.m. to 8:45 a.m. Further review of the flowsheet indicated Patient 15 was lying on his left side on 9/24/22 at 2:30 p.m. and was repositioned to his back at 9:57 p.m., about seven hours later. The flowsheet further indicated Patient 15 was positioned on his left side at 1:57 p.m. on 9/25/22. HIM Tech confirmed there was no documentation of Patient 15 being repositioned from then, until he was turned to his right side almost 10 hours later, at 12:02 a.m. on 9/26/22. The ADL Flowsheet for 9/26/22 indicated Patient 15 was lying on his right side at 2:50 p.m. HIM Tech stated there was no documentation he was repositioned until another 10 hours later, when he was moved to his back at 12:21 a.m. HIM Tech stated there should have been documentation of patient repositioning every two hours. Patient 13 During a concurrent observation and interview on 1/21/25 at 11:02 a.m., Patient 13 stated it was important for her to be repositioned every two hours. Patient 13 stated it was very upsetting to not be repositioned regularly, adding there were shifts when no one would come and move her. Patient 13 stated she had to remind staff to help reposition her regularly, pointing to handwritten signs posted by her bed which read, “OK to wake me up at night when you have to reposition me every 2 hours.” During a concurrent interview and record review on 1/21/25 at 3:21 p.m. with Case Manager (CM), Patient 13’s medical records were reviewed. Patient 13’s “History and Physical”, dated “1/2/25”, indicated she was admitted to the facility with diagnoses including cervical (neck) fracture and paraplegia after a car accident. Patient 13’s nursing care plan, dated 1/2/25, indicated she had a potential for skin breakdown, and among the listed interventions was repositioning every two hours. Further review of Patient 13’s ADLs from a sample period of 1/7/25 to 1/21/25 indicated she stayed in the same supine (on her back) position in bed for six hours (4 p.m. to 10 p.m.) on 1/8/25 and 1/11/25, another six-and-a-half hours (4 p.m. to 10:30 p.m.) on 1/13/25, and another six hours (12 a.m. to 6 a.m.) on 1/15/25. CM confirmed there was no documentation that Patient 13 was repositioned, or why she was not repositioned, during the afternoon shifts on 1/8/25, 1/11/25, 1/13/25 and the night shift on 1/15/25. Patient 12 During a concurrent interview and record review on 1/21/25 at 2:15 p.m. with CM, Patient 12’s medical records were reviewed. Patient 12’s “History and Physical”, dated “12/13/24”, indicated she was admitted to the facility with the a stage 4 pressure ulcer (the most severe stage of a pressure sore, where the damage extends through all layers of the skin, exposing underlying muscle, tendon, or bone, often with significant tissue loss and a high risk of infection) on her sacrum. Patient 12’s care plan, with an initiation date “12/13/24”, indicated repositioning every two hours as part of interventions for her altered skin integrity. A review of Patient 12’s “ADL Flowsheets”, for a sample period of “1/7/25 to 1/21/25”, indicated she was supine for approximately 11 hours, from 4 a.m. until 3 p.m. on 1/20/25. CM confirmed there was no documentation Patient 12 was repositioned during the 11-hour period. CM stated there should have been “something documented”, as Patient 12’s care plan indicated her need to be repositioned every two hours. During an interview on 1/22/25 at 8:40 a.m., Licensed Vocational Nurse #1 stated repositioning every two hours helped prevent current pressure ulcers from worsening. Patient 27 A review of the History and Physical dated 4/18/22 at 5:36 p.m., indicated that Patient 27 was admitted on 4/18/22 status post Gunshot wound with chief complaint of wound care, Neuro (brain injury) recovery Program and Tracheostomy (surgical procedure where a hole is made in front of neck and into windpipe to help with breathing) weaning. There was no documented pressure wounds present on admission. A review of the nursing care flowsheets, dated from 4/19/22 to 4/29/22, indicated that approximately 72 opportunities for turning and repositioning documentation for Patient 27 were missed, with periods ranging from three to sixteen hours without staff documenting turning or repositioning. A review of Patient Anatomical Assessment Report by Wound Team Visit notes, dated 4/23/22 at 12:59 p.m., indicated Patient 27 had sacrum pressure injury Stage 2 measuring 0.5cm x 1.1cm x 0.1cm. A review of the Care Plan dated 4/19/22, indicated the following interventions: Turn and reposition every 2 hours, prn and position at 30 degrees laterally. During an interview with the HIM Tech on 1/21/25 at 11:40 a.m., the HIM Tech confirmed Patient 27 had frequent missed opportunities for the required documentation of turning and repositioning per patient’s care plan. During an interview with the Certified Nurse Assistant (CNA) 2 on 1/23/25 at 10:21 a.m., CNA 2 stated the patient should be reposition every 2 hours and documented in the computer under ADL’s per policy. A review of the facility policy titled, “Wound Care: Skin Integrity and Pressure Injury Prevention”, dated “04/2024”, indicated, “Care plan interventions will be individualized based on the level of risk determined by the total Braden and sub-scale scores as well as additional risk factors (physical assessment findings, clinical complexity/stability and co-morbidities). See Attachment B - example of recommended Care Plan interventions... Licensed nurse responsibilities: 2. Supervises nursing assistants to ensure and assess, the quality of direct patient care on an ongoing basis... obtains notes and implements qualifies health care provider orders... Nursing assistant carries out direct patient care with special emphasis on prevention and skin integrity management. a) Turns and repositions patients...””