Kindred Hospital Riverside

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure patients were provided care in a safe setting when; 1. For Patient 2, a change of condition (COC) was not communicated to the physician when a critically low hemoglobin (Hgb - red blood cells that carry oxygen to the body) was reported to Registered Nurse (RN) 1 by the Lab Supervisor (LS). (Refer to A0144); and 2. The facility failed to ensure competent nursing personnel were assigned to care for patients in the Intensive Care Unit (ICU, a unit for critically ill patients) when RN 1 did not have any prior ICU experience, did not complete critical care modules, and did not complete ICU training competencies. (Refer to A0144). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients in the ICU, and may cause delays in the provision of patient care.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42512 Based on interviews and record review, the facility failed to ensure nursing services were followed when; 1. The facility did not assign competent nursing personnel to care for patients in the Intensive Care Unit (ICU, a unit for critically ill patients) when the registered nurse (RN) 1 did not have any prior ICU experience, did not complete critical care modules, and did not complete ICU training competencies. (Refer to A-0397); 2. For Patient 2, RN 1 failed to communicate a change of condition (COC) to the physician in a timely manner after receiving a report from the Lab Supervisor (LS) indicating a critically low hemoglobin (Hgb- red blood cells that carry oxygen to the body) level. Additionally, RN 1 did not initiate a transfusion of packed red blood cells in a timely manner and may have contributed to Patient 2’s death. (Refer to A-0398); 3. For Patient 2, the facility failed to ensure a redraw of a blood specimen was timely and documented after the lab requested a re-draw at 8 a.m. (Refer to A-0398); 4. For Patients 17, and 19, blood specimens were not processed within four hours of the specimen collection/draw. (Refer to A-0398); 5. For Patient 11, turning and repositioning, and a bath was not provided. (Refer to A-0398); 6. For Patient 12, Intravenous Fluid (IVF - liquid administered directly into a patient’s vein through), nutrition, and medications were not started on admission as ordered and the physician was not notified. (Refer to A-0398). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.”

“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: 42512 Based on interview and record review, the facility failed to ensure patients were provided care in a safe setting when; 1. For Patient 2, a change of condition (COC) was not reported to the physician after receiving a report from the Lab Supervisor (LS) indicating a critically low hemoglobin (Hgb- red blood cells that carry oxygen to the body) level. Additionally, RN 1 did not initiate a transfusion of packed red blood cells in a timely manner and may have contributed to Patient 2’s death. 2. The facility assigned care for patients in the Intensive Care Unit (ICU, a unit for critically ill patients) to a registered nurse (RN) 1 who did not have any prior ICU experience, did not complete critical care modules, and did not complete ICU training competencies. These failures had the potential to delay patient care, cause harm or injury, and/or death to patients. Findings: 1. On December 9, 2025, at 10 a.m., a review of Patient 2’s medical record was conducted with the Director of Quality Manager (DQM). A facility document titled, “History and Physical,” dated October 20, 2025, indicated Patient 2 was admitted to the facility on October 20, 2025, with the diagnosis of acute and chronic respiratory failure (sudden inability of the lungs to oxygenate blood). A facility untitled document dated October 27, 2025, at 11:37 a.m., was reviewed. The document indicated, “...HGB [hemoglobin] 4.85...busy w/ [with] rapid [a system and team that quickly intervenes when a patient shows early signs of getting worse] [name of RN 2] @ [at] 1200 [12 p.m.] 10/27/25 [October 27, 2025]...” A facility document titled, “Critical Lab Values,” dated, October 27, 2025, was reviewed. The document indicated, “...CORRECTED RESULT...Specimen collected...10/27/2025 [October 27, 2025]...01:25 [1:25 a.m.]...Test reported...10/27/2025 [October 27, 2025] 14:06 [2:06 p.m.]...Hemoglobin [protein responsible for transporting oxygen in the blood - Normal range 12.5 to 16.3 g/dL (grams/deciliter unit of measurement) 4.9 g/dL...CRITICAL LOW...result...called to and read back by...[name of Registered Nurse] (RN) 2...@ [at] ...1200 [12 p.m.]...results verified by repeat collection analysis...@ [at] 0742 [7:42 a.m.] Result was 5.8 previously 7.7. Notified [name of Registered nurse] (RN)1...@ [at] 0800 [8 a.m.] for critical result and requesting for recollect...” A facility untitled document dated October 27, 2025, was reviewed. The document indicated, “...Type and crossmatch [lab test ordered before a blood transfusion to ensure patient-donor blood compatibility]... for 2 [two] unit...start...10/27/2025 [October 27, 205] 12:09 [p.m.] A facility untitled document dated October 27, 2025, was reviewed. The document indicated, “...Packed red blood cells...2 units...IV [intravenous - in the blood vessel] infusion...start...10/27/2025 [October 27, 205] 12:09 [p.m.]. During the review of Patient 2’s medical record with the DQM, there was no documented evidence RN 1 notified Patient 2’s physician of the low Hgb of 5.8 or that Patient 2 received the ordered packed red blood cells. On December 10, 2025, at 9:52 a.m., an interview and concurrent record review was conducted with Laboratory Supervisor (LS). A facility untitled document dated October 27, 2025, at 7:05 a.m., was reviewed. The document indicated, “...HGB..5.85...” A facility untitled document dated October 27, 2025, at 7:07 a.m., was reviewed. The document indicated, “...HGB...5.83...” A facility untitled document dated October 27, 2025, at 7:42 a.m., was reviewed. The document indicated, “...HGB...5.80...Notify/recollect [name of RN 1] @ [at] 0800 [8a.m.]...” During a concurrent interview, the LS stated when laboratory results differ from the day before, the Clinical Laboratory Scientist (CLS) or the LS will process the blood specimen again to ensure the accuracy of the result. The LS stated Patient 2’s Hgb on October 26, 2025, was 7.7. She stated that due to the sudden drop she processed the specimen three times. She further stated she called Patient 2’s registered nurse at 8 a.m., to give her the results of the critically low Hgb and requested Patient 2’s nurse to re-draw a new blood specimen to ensure the accuracy of the blood specimen. The LS stated the lab did not receive the new specimen until after 11 a.m. LS stated she called the results of the new critically low Hgb of 4.9 at 12 p.m., and gave the results to RN 2. LS stated she received a specimen for the type and cross around 12:30 p.m., and processed it. She stated she called RN 1 at 2:30 p.m., when the blood products were ready but was told it was too late. On December 10, 2025, at 8:09 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not have Intensive Care Unit (ICU - a unit that provides specialized care to critically ill patients) experience. RN 1 stated she did not complete the critical care online modules training and did not complete the critical care skills check-off list. RN 1 stated the lab called her at 8 a.m. and informed her of the critically low hemoglobin of 5.9 [normal 12.5-16.3 g/dL - (grams/deciliter - unit of measurement]. RN 1 stated the lab staff requested that she draw another specimen to be ran again for accuracy. RN 1 stated she did not call Patient 2’s physician to inform her of the critically low Hgb and she should have. RN 1 stated she did not document the 8 a.m., critical lab value on the Change of Condition (COC) notes and she should have. On December 10, 2025, at 9:14 a.m., an interview was conducted with RN 2. RN 2 stated the hospital does not have individual phones for each nurse. RN 2 stated he was at the nursing station when lab called at 12 p.m. RN 2 stated lab informed him Patient 2’s Hgb was critically low at 4.9. RN 2 stated RN 1 was not on the unit. RN 2 called Patient 2’s physician and received orders to type and cross (determining a person’s blood type) and transfuse packed red blood cells (concentrated blood to be used to transfer into a patient who needs blood). On December 10, 2025, at 11:58 a.m., an interview was conducted with Staff 1. Staff 1 stated Patient 2 had a history of cancer, liver cirrhosis (condition of advance scarring due to liver disease) and gastrointestinal bleeds (type of bleeding that starts in the gut). Staff 1 stated when a Hgb drops from 7.7 to a 4.9, this could be an indication of a bleed. Staff 1 stated when she was notified of the Hgb being critically low at 4.9 she ordered a transfusion of packed red blood cells. Staff 1 stated she was not made aware of the low Hgb until 12 p.m. Staff 1 stated if Patient 2 was actively bleeding she could have stabilized the patient and transferred him to higher level of care. Staff 1 stated she was not made aware of the critical low Hgb of 5.8 at 8 a.m. Staff 1 stated from 8 a.m. to 2:30 p.m. nothing happened and care was slow. On December 11, 2025, at 12 p.m., an interview was conducted with the DQM. The DQM stated RN 1 should have called Patient 2’s physician regarding the critical low Hgb of 5.8 at 8 a.m. The DQM further stated RN 1 should have documented the notification to the physician under the Change of Condition (COC) notes. The DQM stated there was no documentation of the low Hgb or the physician notification in the COC notes. A review of the facility’s Policy and Procedure (P&P) titled, “Critical Values Reporting,” was conducted. The P&P indicted, “...Critical tests are understood to be any resultant test value or interpretation, which suggest life-threatening conditions and where delays in reporting have the potential for causing serious adverse outcomes for patients...Licensed staff (RN...) caring for the patient is responsible for notifying the appropriate physician...All notifications must be documented in the patient’s electronic medical record...Critical values are reported by nursing to the licensed independent practitioner (LIP) responsible for the patient as soon as possible, but no longer than 60 minutes of receiving the results from the laboratory...Nursing Staff...The licensed healthcare provider reporting the critical test result to the patient’s LIP, will document the critical test, the date and time the result was reported, and the name of the LIP receiving there result...under “Change of Condition”...” A review of the facility’s P&P titled, “Core: Interdisciplinary Assessment and Re-Assessment,” dated June 2023, was conducted. The document indicated, “...To determine the appropriate care treatment and services to meet the patient’s needs during hospitalization...Patient reassessment is based on but not limited to the following...To evaluate patient response to care, treatment, and services...To respond to a significant change in status and / or diagnosis or condition...Interdisciplinary Communication...The RN is accountable for the care outcomes of his/her patients...the RN must effectively communicate the plan to meet the needs of the patient...Touch points with clinical team members to identify changes that need to be addressed...Reporting/Notification of a Change in Condition...An acute change of condition is a clinically important change from a patient’s established and documented baseline...An acute change in condition may occur abruptly...presenting as physical changes...nurses as well as physicians must recognize a change in condition...Notification Responsibilities...Change in Condition...The nurse assigned to the patient...is responsible for notification of and communication to the patient’s primary physician...Document change of condition, notification and interventions in the medical record...document under the “Change of Condition” Pathway...” 2. A review of RN 1’s employee file was conducted on December 11, 2025, at 1 p.m., with the Director of Quality Manager (DQM). A facility document titled, “PERSONNEL ACTION REQUEST,” was reviewed. The document indicated, “...Effective Date...04/15/2025 [April 15, 2025] 11:00 a.m...Employee Name...[name of RN 1]...New Hire...Department name...CCU/ICU [CCU/ICU - critical care unit, specialized unit for severely ill patients, intensive monitoring, and life support]...Job Title...Reg Nurse-Adv Skills...Job Code 9100068...” A facility document titled, “Job Description,” dated April 15, 2025, was reviewed. The document indicated, “...Job Title...Registered Nurse...Job Code...9000144...Job Title: Registered Nurse...Experience: Minimum six months’ Medical/Surgical experience in acute care setting preferred...” The DQM stated the job description RN 1 signed was for a medical surgical department nurse. The DQM stated the personnel action request indicated RN 1 was hired for the ICU unit. The DQM stated the job description, and the personnel action request did not match. The DQM stated if RN 1 met the ICU requirements, the job description job title would have indicated “Registered Nurse Critical Care.” A facility document titled, “RN Critical Care/High Observation Initial Competency Checklist,” dated April 29, 2025, was reviewed. The document indicated, “...ALL ITEMS TO BE COMPLTED [sic] BY END OF ORIENTATION PERIOD...HD Initial Core Competecny [sic] Registered Nurse (RN) Critical Care Program...All items must be individually checked. Do not draw lines down column...Competency Assessment Dates...Initial orientation date...04/15/2025 [April 15, 2025] to Orientation release date...06/11/2025 [June 11, 2025]...Extend Orientation...No...Release from Orientation...Yes...Employee Signature...Blank...Manager...[signature of Director of Nursing Care Services (DNCS)...” A review of RN 1’s work history was conducted with the DQM. It indicated RN 1 was employed at a skilled nursing facility from January 25, 2024, to August 15, 2024 (6 months 21 days). RN 1 was employed at an acute care hospital from December 2, 2024, to April 2025 (4 months) as a new graduate medical surgical/telemetry nurse. On December 11, 2025, at 1:10 p.m., an interview with the DQM was conducted. The DQM stated an experienced registered nurse would only require six to nine shifts of unit orientation. The DQM stated RN 1 was hired as an experienced registered nurse on April 15, 2025, but she did not have the experience needed to work in the ICU. The DQM stated the RN Critical Care Checklist was not completed in its entirety prior to RN 1 being released from orientation and should have been. The DQM further stated the checklist should have been signed by RN 1, but it was not. The DQM stated RN 1 did not have prior ICU experience and did not meet the requirements to be hired as an ICU nurse at this facility per the job description. The DQM stated the former DNCS oversaw RN 1’s orientation. The DQM stated the facility did not typically hire outside nurses with no ICU experience, so there was no established timeframe for orienting an inexperienced nurse to the ICU. The DQM stated the former DNCS was terminated for assigning RN 1 to an ICU position despite RN 1 not being qualified. A review of the facility document titled, “HD Orientation/Annual Guidelines,” dated July 2018, was conducted with the DQM, on December 11, 2025, at 1 p.m. The document indicated, “Orientation Guidelines...Following 8 [eight] hours of General Hospital Orientation, these are the recommendations for Department Orientation...discipline...Experienced RN...16 hours Nursing Classroom...72-108 hours Unit Orientation (6-9 shifts)...New Graduate RN...Recommendation...40 hours classroom Clinical Systems Review...360 hours of unit orientation...””

“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: 42512 Based on interviews and record review, the facility failed to ensure that competent nursing personnel were assigned to care for patients in the Intensive Care Unit (ICU, a unit for critically ill patients) when the registered nurse (RN) 1 did not have prior ICU experience, did not complete critical care modules, and did not complete ICU training competencies. This failure had the potential to delay patient care, cause harm or injury, and/or death to patients. Findings: On December 11, 2025, at 1 p.m., a review of RN 1’s employee file was conducted with the Director of Quality Manager (DQM). A facility document titled, “PERSONNEL ACTION REQUEST,” was reviewed with the DQM. The document indicated, “...Effective Date...04/15/2025 [April 15, 2025] 11:00 a.m...Employee Name...[name of RN 1]...New Hire...Department name...CCU/ICU [CCU/ICU - critical care unit, specialized unit for severely ill patients, intensive monitoring, and life support]...Job Title...Reg Nurse-Adv Skills...Job Code 9100068...” A facility document titled, “Job Description,” dated April 15, 2025, was reviewed with the DQM. The document indicated, “...Job Title...Registered Nurse...Job Code...9000144...Job Title: Registered Nurse...Experience: Minimum six months’ Medical/Surgical experience in acute care setting preferred...” A concurrent interview was conducted with the DQM. The DQM stated the job description RN 1 signed was for a medical surgical department nurse. The DQM stated the personnel action request indicated RN 1 was hired for the ICU unit. The DQM stated the job description, and the personnel action request did not match. The DQM stated if RN 1 met the ICU requirements, the job description job title would have indicated “Registered Nurse Critical Care.” A facility document titled, “RN Critical Care/High Observation Initial Competency Checklist,” dated April 29, 2025, was reviewed with the DQM. The document indicated, “...ALL ITEMS TO BE COMPLTED [sic] BY END OF ORIENTATION PERIOD...HD Initial Core Competency [sic] Registered Nurse (RN) Critical Care Program...All items must be individually checked. Do not draw lines down column...Competency Assessment Dates...Initial orientation date...04/15/2025 [April 15, 2025] to Orientation release date...06/11/2025 [June 11, 2025]...Extend Orientation...No...Release from Orientation...Yes...Employee Signature...Blank...Manager...[signature of Director of Nursing Care Services [DNCS]...” A review of RN 1’s work history was conducted with the DQM. It indicated RN 1 was employed at a skilled nursing facility from January 25, 2024, to August 15, 2024 (6 months 21 days). RN 1 was employed at an acute care hospital from December 2, 2024, to April 2025 (4 months) as a new graduate medical surgical/telemetry nurse. A review of the facility document titled, “HD Orientation/Annual Guidelines,” dated July 2018, was conducted with the DQM, December 11, 2025, at 1 p.m. The document indicated, “Orientation Guidelines...Following 8 [eight] hours of General Hospital Orientation, these are the recommendations for Department Orientation...discipline...Experienced RN...16 hours Nursing Classroom...72-108 hours Unit Orientation (6-9 shifts)...New Graduate RN...Recommendation...40 hours classroom Clinical Systems Review...360 hours of unit orientation...” An interview was conducted with the DQM on December 11. 2025, at 1:10 p.m. The DQM stated an experienced registered nurse would only require six to nine shifts of unit orientation. The DQM stated RN 1 was hired as an experienced registered nurse on April 15, 2025, but she did not have the experience needed to work in the ICU. The DQM stated RN 1 did not have prior ICU experience and did not meet the requirements to be hired as an ICU nurse at this facility per the job description. The DQM further stated the former DNCS oversaw RN 1’s orientation. The DQM stated the facility did not typically hire outside nurses with no ICU experience, so there was no established timeframe for orienting an inexperienced nurse to the ICU. The DQM stated the former DNCS was terminated for assigning RN 1 to an ICU position despite RN 1 not being qualified. The DQM stated the RN Critical Care Check list was not completed in its entirety prior to being released from orientation and should have been. The DQM stated the checklist should have been signed by RN 1, but it was not.”

“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: 42512 Based on interview and record review, the facility failed to follow their policies and procedures (P&P) for five of 20 sampled patients (Patients 2, 11, 12, 17 and 19) when; 1. For Patient 2, Registered Nurse (RN) 1 did not communicate a change of condition (COC) to the physician in a timely manner after receiving a report from the Lab Supervisor (LS) indicating a critically low hemoglobin (Hgb- red blood cells that carry oxygen to the body) level. Additionally, RN 1 did not initiate a transfusion of packed red blood cells in a timely manner and may have contributed to Patient 2’s death; 2. For Patient 2, the facility did not redraw a blood specimen timely after the lab requested a re-draw; 3. For Patients 17, and 19, blood specimens were not processed within four hours of the specimen collection/draw; 4. For Patient 11, turning and repositioning, and a bath was not provided; 5. For Patient 12, Intravenous Fluid (IVF - liquid administered directly into a patient’s vein through), nutrition, and medications were not started on admission as ordered and the physician was not notified. These failures had the potential to delay patient care, cause harm or injury, and/or death to patients. Findings: 1. On December 9, 2025, at 10 a.m., a review of Patient 2’s medical record was conducted with the Director of Quality Manager (DQM). A facility document titled, “History and Physical,” dated October 20, 2025, indicated Patient 2 was admitted to the facility on October 20, 2025, with the diagnosis of acute and chronic respiratory failure (sudden inability of the lungs to oxygenate blood). A facility untitled document dated October 27, 2025, at 11:37 a.m., was reviewed. The document indicated, “...HGB [hemoglobin] 4.85...busy w/ [with] rapid [a system and team that quickly intervenes when a patient shows early signs of getting worse] [name of RN 2] @ [at] 1200 [12 p.m.] 10/27/25 [October 27, 2025]...” A facility document titled, “Critical Lab Values,” dated, October 27, 2025, was reviewed. The document indicated, “...CORRECTED RESULT...Specimen collected...10/27/2025 [October 27, 2025]...01:25 [1:25 a.m.]...Test reported...10/27/2025 [October 27, 2025] 14:06 [2:06 p.m.]...Hemoglobin [protein responsible for transporting oxygen in the blood - Normal range 12.5 to 16.3 g/dL (grams/deciliter unit of measurement) 4.9 g/dL...CRITICAL LOW...result...called to and read back by...[name of Registered Nurse] (RN) 2...@ [at] ...1200 [12 p.m.]...results verified by repeat collection analysis...@ [at] 0742 [7:42 a.m.] Result was 5.8 previously 7.7. Notified [name of Registered nurse] (RN)1...@ [at] 0800 [8 a.m.] for critical result and requesting for recollect...” A facility document titled, “BLOOD/BLOOD COMPONENT TRASNFUSION RECORD,” dated October 27, 2025, was reviewed. The document indicated, “...Requested Date...10/27/2025 [October 27, 2025]...Time 12:00 [p.m.]...PRIORITY...STAT [immediate]...Date Collected...10/27/2025 [October 27, 2025]...Time Collected...1230 [12:30 p.m.]...Compatibility Testing...Completing Date...10/27/2025 [October 27, 2025]...Time...1425 [2:25 p.m.] A facility untitled document dated October 27, 2025, was reviewed. The document indicated, “...Type and crossmatch [lab test ordered before a blood transfusion to ensure patient-donor blood compatibility]... for 2 [two] unit...start...10/27/2025 [October 27, 205] 12:09 [p.m.] A facility untitled document dated October 27, 2025, was reviewed. The document indicated, “...Packed red blood cells...2 units...IV [intravenous - in the blood vessel] infusion...start...10/27/2025 [October 27, 205] 12:09 [p.m.]. During the record review with the DQM, there was no documented evidence Patient 2 received the ordered blood transfusion or packed red blood cells. A facility document titled, “Rapid Response Team and Code H Record, dated October 27, 2025, was reviewed and indicated, “...Location...ICU...Time Called...1150 [11:50 a.m.]...Event Ended...1155 [11:55 a.m.]...Situation/Reason for Call...BP [blood pressure] 37/12 [Normal 120/80]...Recent Lab Results...Hgb...[low]...” A facility document titled, “Rapid Response Team and Code H Record, dated October 27, 2025, was reviewed and indicated, “...Location...ICU...Time Called...1250 [12:50 p.m.]...Event Ended...1255 [12:55 p.m.]...Situation Reason for Call...Staff...were concerned...40 [heart rate - normal 60-100 beats per minute]...” A facility document titled, “CODE BLUE FLOWSHEET,” dated October 27, 2025, was reviewed and indicated, “...Time Code Called...1422 [2:22 p.m.]...Time Ended 14:39 [2:39 p.m.]...Code Called by...[Name of DNCS]...Summary of Events Preceding Code...Cardiac Rhythm Change...Hypotension...Bradycardia...CPR Stopped...Death...Expired...Time Pronounced 14:40 [2:40 p.m.]...” Six hours and 40 minutes from the initial critically low Hgb. On December 10, 2025, at 9:52 a.m., a review of Patient 2’s medical record was conducted with Laboratory Supervisor (LS). A facility untitled document dated October 27, 2025, at 7:05 a.m., was reviewed. The document indicated, “...HGB..5.85...” A facility untitled document dated October 27, 2025, at 7:07 a.m., was reviewed. The document indicated, “...HGB...5.83...” A facility untitled document dated October 27, 2025, at 7:42 a.m., was reviewed. The document indicated, “...HGB...5.80...Notify/recollect [name of RN 1] @ [at] 0800 [8a.m.]...” During the review of Patient 2’s medical record with the LS, there was no documented evidence RN 1 notified Patient 2’s physician of the low Hgb of 5.8...” On December 10, 2025, at 10:12 a.m., an interview was conducted with the LS. The LS stated when the laboratory results differ from the day before, the Clinical Laboratory Scientist (CLS) or the LS will process the blood specimen again to ensure the accuracy of the result. The LS stated Patient 2’s Hgb on October 26, 2025, was 7.7. She stated that due to the sudden drop she processed the specimen three times. She further stated she called Patient 2’s registered nurse at 8 a.m., to give her the results of the critically low Hgb and requested Patient 2’s nurse to re-draw a new blood specimen to ensure the accuracy of the blood specimen. The LS stated the lab did not receive the new specimen until after 11 a.m. LS stated she called the results of the new critically low Hgb of 4.9 at 12 p.m., and gave the results to RN 2. LS stated she received a specimen for the type and cross around 12:30 p.m., and processed it. She stated she called RN 1 at 2:30 p.m., when the blood products were ready but was told it was too late. On December 10, 2025, at 8:09 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she did not have Intensive Care Unit (ICU - a unit that provides specialized care to critically ill patients) experience. RN 1 stated she did not complete the critical care online modules training and did not complete the critical care skills check-off list. RN 1 stated the lab called her at 8 a.m., and informed her of the critically low hemoglobin of 5.9 (normal 12.5-16.3 g/dL - (grams/deciliter - unit of measurement). RN 1 stated the lab staff requested that she draw another specimen to be ran again for accuracy. RN 1 stated she did not call Patient 2’s physician to inform her of the critically low Hgb and she should have. RN 1 stated she did not document the 8 a.m., critical lab value on the Change of Condition (COC) notes and she should have. On December 10, 2025, at 9:14 a.m., an interview was conducted with RN 2. RN 2 stated the hospital does not have individual phones for each nurse. RN 2 stated he was at the nursing station when lab called at 12 p.m. RN 2 stated lab informed him Patient 2’s Hgb was critically low at 4.9. RN 2 stated RN 1 was not on the unit. RN 2 called Patient 2’s physician and received orders to type and cross (determining a person’s blood type) and transfuse packed red blood cells (concentrated blood to be used to transfer into a patient who needs blood). On December 10, 2025, at 11:58 a.m., an interview was conducted with Staff 1. Staff 1 stated Patient 2 had a history of cancer, liver cirrhosis [condition of advance scarring due to liver disease] and gastrointestinal bleeds [type of bleeding that starts in the gut]. Staff 1 stated when a Hgb drops from a 7.7 to a 4.9, this could be an indication of a bleed. Staff 1 stated when she was notified of the Hgb being critically low at 4.9 she ordered a transfusion of packed red blood cells. Staff 1 stated she was not made aware of the low Hgb until 12 p.m. Staff 1 stated if Patient 2 was actively bleeding she could have stabilized the patient and transferred him to higher level of care. Staff 1 stated she was not made aware of the critical low Hgb of 5.8 at 8 a.m. Staff 1 stated from 8 a.m. to 2:30 p.m. nothing happened and care was slow. On December 11, 2025 at 12 p.m., an interview was conducted with the DQM. The DQM stated RN 1 should have called Patient 2’s physician regarding the critical low Hgb of 5.8 at 8 a.m. The DQM further stated RN 1 should have documented the notification to the physician under the Change of Condition (COC) notes. The DQM stated there was no documentation of the low Hgb of 5.8 g/dL or the physician notification in the COC notes. The DQM further stated there were no notes RN 1 redrew blood specimen for Patient 2 after lab requested a redraw at 8 a.m. The DQM stated there was a delay and missed opportunity for blood transfusion when Patient 2 had a critical lab value for Hgb of 5.8 g/dL at 8 a.m. The DQM stated RN 1 did not transfuse blood to Patient 2. She stated if RN 1 would have called Patient 2’s physician at 8 a.m., after first low Hgb, the transfusion might have happened sooner, and the outcome may have been different. A review of the facility’s Policy and Procedure (P&P) titled, “Critical Values Reporting,” was conducted. The P&P indicted, “...Critical tests are understood to be any resultant test value or interpretation, which suggest life-threatening conditions and where delays in reporting have the potential for causing serious adverse outcomes for patients...Licensed staff (RN...) caring for the patient is responsible for notifying the appropriate physician...All notifications must be documented in the patient’s electronic medical record...Critical values are reported by nursing to the licensed independent practitioner (LIP) responsible for the patient as soon as possible, but no longer than 60 minutes of receiving the results from the laboratory...Nursing Staff...The licensed healthcare provider reporting the critical test result to the patient’s LIP, will document the critical test, the date and time the result was reported and the name of the LIP receiving there result...under “Change of Condition”...” A review of the facility’s P&P titled, “Core: Interdisciplinary Assessment and Re-Assessment,” dated June 2023, was conducted. The document indicated, “...To determine the appropriate care treatment and services to meet the patient’s needs during hospitalization...Patient reassessment is based on but not limited to the following...To evaluate patient response to care, treatment, and services...To respond to a significant change in status and / or diagnosis or condition...Interdisciplinary Communication...The RN is accountable for the care outcomes of his/her patients...the RN must effectively communicate the plan to meet the needs of the patient...Touch points with clinical team members to identify changes that need to be addressed...Reporting/Notification of a Change in Condition...An acute change of condition is a clinically important change from a patient’s established and documented baseline...An acute change in condition may occur abruptly...presenting as physical changes...nurses as well as physicians must recognize a change in condition...Notification Responsibilities...Change in Condition...The nurse assigned to the patient...is responsible for notification of and communication to the patient’s primary physician...Document change of condition, notification and interventions in the medical record...document under the “Change of Condition” Pathway...” 2. On December 9, 2025, at 10 a.m., a review of Patient 2’s medical record was conducted with the Director of Quality Manager (DQM). The facility document titled “History and Physical,” dated October 20, 2025, indicated Patient 2 was admitted to the facility on October 20, 2025, with the diagnosis of acute and chronic respiratory failure (sudden inability of the lungs to oxygenate blood). A facility untitled document dated October 27, 2025, at 7:05 a.m., was reviewed. The document indicated, “...HGB [Hgb - Hemoglobin] 5.85 g/dL...CRITICAL LOW...” A facility untitled document dated October 27, 2025, at 7:07 a.m., was reviewed. The document indicated, “...HGB...5.83 g/dL...” A facility untitled document dated October 27, 2025, at 7:42 a.m., was reviewed. The document indicated, “...HGB [hemoglobin] 5.80...Notify/recollect [name of RN 1] @ [at] 0800 [8a.m.]...” There was no documented evidence RN 1 notified Patient 2’s physician of the low Hgb of 5.8...” A facility untitled document dated October 27, 2025, at 11:37 a.m., was reviewed. The document indicated, “...HGB...4.85 g/dL...[handwritten note]busy w/ [with] rapid [a system and team that quickly intervenes when a patient shows early signs of getting worse] [name of RN 2] @ [at] 1200 [12 p.m.] 10/27/25 [October 27, 2025]...” There was no documented evidence RN 1 notified Patient 2’s physician of the low Hgb of 4.85 g/dL...” A facility document titled, “Critical Lab Values,” dated, October 27, 2025, was reviewed. The document indicated, “...CORRECTED RESULT...Specimen collected...10/27/2025 [October 27, 2025]...01:25 [1:25 a.m.]...Test reported...10/27/2025 [October 27, 2025] 14:06 [2:06 p.m.]...Hemoglobin...4.9 g/dL...CRITICAL LOW...result...called to and read back by...[name of Registered Nurse 2]...@ [at]...1200 [12 p.m.]...results verified by repeat collection analysis...@ [at] 0742 [7:42 a.m.] Result was 5.8...previously 7.7. Notified [name of Registered nurse] (RN)1...@ [at] 0800 [8 a.m.] for critical result and requesting for recollect...” An interview with the LS was conducted. The LS stated when the laboratory results differ from the day before, the Clinical Laboratory Scientist (CLS) or the LS will process the blood specimen again to ensure the accuracy of the result. The LS stated Patient 2’s Hgb on October 26, 2025, was 7.7. She stated that due to the sudden drop she processed the specimen three times. She further stated she called RN 1 at 8 a.m. to give her the results of the critically low Hgb of 5.85 and requested RN 1 to draw a new blood specimen to ensure the accuracy of the blood specimen. The LS stated the lab did not receive the new specimen until after 11 a.m., but the facility’s electronic record does not have the capacity to document the re-draw so there is no way to know when RN 1 redrew it. The LS stated if the lab calls for a recollection of the blood specimen, the lab will use the same specimen number so the new result will override the original and this is why the electronic record does not how the original Hgb of 5.8. The LS stated she did not receive the new blood specimen until after 11 a.m. She stated when she called Patient 2’s nurse at 12 p.m., she was unavailable. The LS stated she gave the new critical lab value of 4.85 to another licensed registered nurse (RN) 2. On December 10, 2025, at 8:09 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated laboratory staff called her the morning of October 27, 2025, at 8 a.m., to report a critical lab value for Hgb 5.9. RN 1 stated the lab staff told her the Hgb was low and that she needed to re-draw the blood specimen again. RN 1 stated she drew the blood specimen and took it to the lab but the electronic record did not have a way to document when she drew it. RN 1 stated she could have completed a change of condition note (COC) but she did not. RN 1 stated she was not present when the lab called to give the results of the second specimen. RN 1 stated the DNCS sent her to lunch. RN 1 stated she did not document the critical low Hgb on the COC notes or call the physician to report the critical lab. On December 11, 2025, at 12 p.m., an interview was conducted with the DQM. The DQM stated RN 1 should have documented the redraw of labs under the COC. The DQM further stated there were no notes RN 1 redrew blood specimen for Patient 2 after lab requested a redraw at 8 a.m. A review of the facility’s Policy and Procedure (P&P) titled, “Critical Values Reporting,” was conducted. The P&P indicted, “...Critical tests are understood to be any resultant test value or interpretation, which suggest life-threatening conditions and where delays in reporting have the potential for causing serious adverse outcomes for patients...Licensed staff (RN...) caring for the patient is responsible for notifying the appropriate physician...All notifications must be documented in the patient’s electronic medical record...Critical values are reported by nursing to the licensed independent practitioner (LIP) responsible for the patient as soon as possible, but no longer than 60 minutes of receiving the results from the laboratory...Nursing Staff...The licensed healthcare provider reporting the critical test result to the patient’s LIP, will document the critical test, the date and time the result was reported and the name of the LIP receiving there result...under “Change of Condition”...” 38479 3a. On December 10, 2025, at 8:39 a.m., a review of Patient 17’s medical record was conducted with the Radiology Manager (RM). A review of facility document titled, “Laboratory Results” indicated, “Specimen collection 11/07/25 [November 7, 2025], 00:00 [midnight]...Test Reported 11/07/2025, 7:28 [7:28 a.m.]...Hemoglobin 6.3 g/dL CRITICAL LOW...Called comment Critical result (s) called to and read by...(name of Licensed Vocational Nurse/LVN)...” During the review of Patient 17’s medical record there was no documented evidence Patient 17’s physician was notified of the critical hemoglobin lab of 6.3 On December 10, 2025, at 9:46 a.m., an interview was conducted with the LS. The LS stated they have a phlebotomist that comes in from 10:00 p.m., to 6:30 a.m. to draw and collect blood specimens. The LS stated the specimen collected should have been processed within four hours. The LS explained, “It was processed late because I usually come in at 6 in the morning.” The LS stated, “Blood was not processed on time, it delayed the blood transfusion. If the patient was bleeding and not corrected early, blood count may drop, and patient safety will be compromised.” On November 11, 2025, at 10:45 a.m., an interview was conducted with the DQM. The DQM stated the policy was not followed, result was not within 4 hours. The DQM stated result was critical low, there may be a chance of more decrease in hemoglobin level due to the delay in processing the specimen. The DQM stated if hemoglobin was critically low, there should be a physician notification and stat (immediate) order for blood type, cross and transfusion. The DQM stated physician notification should be documented by the nurse under change of condition. The DQM stated patient care will be compromised, and condition can potentially decline if blood was not drawn and critical low result was not addressed on a timely manner. 3b. On December 10, 2025, at 11:15 a.m., Patient 19’s medical record was conducted with the RM. The facility document titled, “Laboratory results” dated November 29, 2025, was reviewed and indicated “Specimen collection 11/29/25 [November 29, 2025], 00:59 [12:59 a.m.]...Test Reported 11/29/2025, 7:12 [7:12 a.m.]...Hemoglobin 6.8 g/dL CRITICAL LOW...” On November 11, 2025, at 10:30 a.m., an interview was conducted with the DQM. The DQM stated the policy was not followed, the result was not within 4 hours. The DQM stated result was critical low, there may be a chance of more decrease in hemoglobin level due to the delay in processing the specimen. The DQM stated if hemoglobin was critically low, there should be a physician notification and stat (immediate) order for blood type, cross and transfusion. The DQM stated physician notification should be documented by the nurse under change of condition. The DQM stated patient care will be compromised, and condition can potentially decline if blood was not drawn and critical low result was not addressed on a timely manner. A review of the undated facility P&P titled, “CRITICAL LABORATORY VALUES REPORTING,” indicated, “PRINCIPLE ...Critical test value or “panic” values...are understood to be any resultant test value or interpretation, which suggest life-threatening conditions and where delays in reporting have the potential for causing serious adverse outcomes for patients. These results must be reported to a responsible licensed caregiver within time frames established by the laboratory...POLICY... ...Laboratory to communicate critical test results to the nurse...to take action...Licensed staff (LVN/RN/RT) caring for the patient is responsible for notifying the appropriate physician...Critical values are reported by the laboratory to the licensed nurse responsible for the care of the patient as soon as possible, but no longer than 15 minutes...Critical values are reported by nursing to the licensed independent practitioner (LIP) responsible for the patient as soon as possible, but no longer than 60 minutes of receiving the results from the laboratory...” A review of the facility P&P titled, “CLINICAL LABORATORY Turnaround Times for Patient Results,” dated November 25, 2025, indicated, “Policy...In House Testing - Laboratory personnel will assay and report results according to the turn around times as defined below...Principle...To establish a guideline for the amount of time it takes to perform the various “In House” and “Referral” tests. In addition, when testing is delayed the requesting physician must be notified when such notification is important for patient care...Procedure...For the purpose of this procedure, Turnaround Time will be defined as the interval between specimen receipt (receiving) by laboratory personnel and result reporting...All routine Hematology, Urinalysis and Blood Bank done “In House” will be reported within the time indicated...CBC [completed blood count] < [less than] 4 HOURS...HGB [hemoglobin]& [and] HCT [hematicrit] < [less than] 4 HOURS...” 4. On December 8, 2025, at 9:45 a.m., a review of Patient 11’s medical record was conducted with the Radiology Manager (RM). A review of the facility document titled, “HISTORY AND PHYSICAL,” indicated Patient 11 was “found down at home...now do not resuscitate [DNR] but remained on vent [ventilator- a mechanical breathing device] being fed by the PEG [Percutaneous Endoscopic Gastrostomy, a feeding tube placed directly into the stomach through the abdominal wall, allowing for long-term nutrition, fluids, and medication for people unable to swallow or eat].” A review of the facility document titled, “Flowsheet: Reposition”, indicated no documented evidence Patient 11 was turned and repositioned, nor a bath was provided on September 21, 2025, from 7 p.m., through 7 a.m. On December 11, 2025, at 8:54 a.m., an interview was conducted with the Director of Quality Management (DQM). The DQM stated there was no documented evidence Patient 11 was turned or repositioned, nor was a bath provided on September 21, 2025, from 7 p.m., through 7 a.m. The DQM stated, physician orders should be followed timely and every two hours as ordered. The DQM stated the Certified Nurses Assistant (CNA) should have documented turning and repositioning Patient 11 because it validates Patient 11 was turned and repositioned on his shift. The DQM stated the CNA did not follow the physician’s order, and there were chances of developing skin breakdown, and if there were any wounds, it could potentially worsen the wound. A review of the facility policy and procedure titled, “CORE: Clinical Guidelines for Non-Pressure Related Wounds,” dated June 6, 2022, indicated, “POLICY...is to ensure...Standard interventions for all patients can include but are not limited to...Repositioning (minimum Q2 Hours turns)...Consideration turning schedule Q1 hours if patient is unable to turn and reposition self, has poor nutrition, multiple wounds, a recent change of condition...poor cognition, skin is moist or at risk for friction/shear injury...Documentation...Interventions initiated...Within the electronic/paper medical record document...Date...Execution of order...” A review of the facility policy and procedure titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated June 2023, indicated, “PURPOSE...To outline a systematic process for gathering information about each patient...To determine the appropriate care, treatment and services to meet the patient’s needs during hospitalization...POLICY...Coordination of care by sharing patient information internally and externally with other caregivers. The patient information will be documented on the hospital’s...designated pathway in the EMR...The patient information may include patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these...Documentation...m. Any other forms determined necessary to document and provide quality patient care...” 5. On December 11, 2025, at 9:50 a.m., a review of Patient 12’s medical record was conducted with the DQM. A review of the facility document titled, “physician orders,” dated November 12, 2025, indicated: a. “sodium chloride 0.9% [a sterile, isotonic solution of salt and water used widely in medicine for fluid replacement]: 1000 ml [milliliters, unit of measurement] IV [intravenous, inside a vein] infusion, rate 75 ml/hr [militers per hour] ***STOP INFUSION AFTER NGT [nasogastric tube, tube inserted in through the nose into the stomach] PLACEMENT IS VERIFIED*** Start ASAP 11/12/25 [November 12, 2025]...” It further indicated these were administered on November 13, 2025, at 6:37 p.m., approximately 22 hours from time of admission; b. “propranolol hcl [a generic prescription beta-blocker medication used to treat various heart conditions, high blood pressure, and other conditions like migraines and essential tremors]: per feeding tube tab, 20 mg [milligrams, unit of measurement], Start 11/13/25 [November 13, 2025] 09:00 [9 a.m], tid [three times a day]...” Administered November 14, 2025, at 6:19 p.m., approximately 44 hours from time of admission; c. “levetiracetam [an antiepileptic medication used to prevent and control seizures in people with epilepsy]: per feeding tube soln. [solution], 1,500 mg, Start 11/13/25 09:00, q12h [every 12 hours]...” Administered on November 13, 2025, at 9 p.m., approximately 24 hours after time of admission; d. “amlodipine [prescription medication in the class of drugs known as calcium channel blockers used to treat high blood pressure and prevent chest pain]: per feeding tube tab, 10 mg, Start 11/13/25 [November 13, 2025] 09:00 [9 a.m.], daily...” Administered November 15, 2025, at 8:12 a.m., approximately 60 hours from time of admission; e. “psyllium [natural fiber promoting fullness for weight management, and acting as a prebiotic]: per feeding tube powder, 1 packet, Start 11/13/25 [November 13, 2025] 09:00 [9 p.m.], tid [three times a day]...” Administered November 14, 2025, at 6:19 p.m., approximately 46 hours from time of admission; f. “sodium chloride [over-the-counter medication and supplement used primarily to prevent and treat low sodium levels (hyponatremia) caused by excessive sweating, dehydration, or certain medical conditions]: per feeding tube tab, 2 g [grams, unit of measurement], Start 11/13/25 [November 13, 2025] 9:00 [9 a.m.], tid [three times a day]...” Administered 46 hours from time of admission; g, “lidocaine patch ER [Extended release] 4% [topical analgesics/pain relievers that work by numbing the skin and blocking nerve signals in a specific area]: topical patch, 4 %. To RLE [right lower extremity]. Start 11/13/25 [November 13, 2025] 09:00 [9 a.m.], daily...” Administered November 14, 2025, at 10 a.m., approximately 38 hours from time of admission; h. “multivitamin [supplement containing multiple vitamins and minerals]: per feeding tube tab, 1 tab, Start 11/13/25 [November 13, 2025] 09:00 [9 a.m.], daily...” Administered November 15, 2025, at 8:15 a.m., approximately 60 hours from time of admission; i. “famotidine [medication used to decrease stomach acid production]: per feeding tube tab, 20 mg, Start 11/13/25 [November 13, 2025] 09:00 [9 a.m.], q [every]12h...” Administered November 13, 2025, 11/13/25, at 9 p.m., approximately 24 hours from time of admission; j. “aspirin, children’s [common nonsteroidal anti-inflammatory drug [NSAID] used to relieve pain and fever, reduce inflammation, and as a blood thinner to prevent heart attacks and strokes]: per feeding tube tab, 81 mg, Start 11/1325 [November 13, 2025] 09:00 [9 a.m.], daily...” Administered November 15, 2025, at 5:15 a.m., approximately 60 hours from time of admission; k. “tamsulosin HCL [medication primarily used to treat symptoms of an enlarged prostate in men]: PO [by mouth] cap [capsule], 0.4 mg, Cannot crush. Start 11/13/25 [November 13, 2025] 09:00 [9 a.m.], daily...” Administered November 15, 2025, at 8:15 a.m., approximately 60 hours from time of admission; and l. “acetaminophen [medication for treating mild to moderate pain and reducing fever]: per feeding tube tab, 650 mg, Routine per PTA. Start 11/13/25 [November 13, 2025] 00:00 [midnight], q6h...” Administered November 14, 2025, at 8:19 p.m., approximately 46 hours from time of admission; and - “NPO [nil per os/nothing by mouth] except for tube feedings...” A review of facility record “Abdomen XR 1 View AP Portable (KUB) [a medical X-ray, imaging for kidney, ureters, and bladder, for diagnostic purposes],” completed on November 13, 2025, at 11:19 a.m., indicated, “NGT in stomach” and was ready for use. During the review with the DQM, there was no documented evidence tube feedings and IVF’s were held, nor NGT placement issues were referred to the physician. An interview was conducted with the DQM. The DQM stated the expectation is for staff to address nutrition and hydration as early as possible on admission. The DQM stated for Patient 12, NGT feeding was started 34 hours after admission on November 14, 2025, at 6:10 a.m., and IVF’s was administered on November 13, 2025, 6:37 p.m., approximately 22 hours from time of admission. The DQM stated NGT issues should have been addressed early to prevent delay in medication administration. The DQM stated there was no documented evidence that Patient 12’s physician was notified of Patient 12’s IVF’s and medications were held and not administered as ordered. The DQM stated the physician should have been informed the IVF’s and medications were not administered as ordered. The DQM stated the delay may cause complications for the Patient 12 if not administered as ordered. A review of the facility document titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated June 2023, indicated, “PURPOSE...This procedure establishes guidelines to assure...appropriate care, treatment and services to meet the patient’s needs...Physician...The physician is responsible for the patient’s treatment...Reporting / Notification of a Change in Condition...An acute change in condition may occur abruptly...Notification Responsibilities...Change or Suspected Change in Condition...a. The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient’s primary physician or designee using appropriate channels and chain of command for assuring that there is physician response.””

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 38479 Based on interview and record review, the facility failed to implement standard of care for medical record keeping for two of 20 sampled patients (Patients 11, and 12), when: 1. For Patient 11, turning and repositioning, and provision of patient hygiene/bath was not documented on September 21, 2025, from 7 p.m., through 7 a.m.; and 2. For Patient 12, there was no documented evidence the physician was notified when intravenous fluids (IVF), Nasogastric (NG) tube (tube inserted through the nose, down the throat and esophagus, and into the stomach) feeding, and medication administration was not started as ordered on admission on November 12, 2025. The facility failure resulted in an inaccurate and incomplete patient record that did not reflect necessary services patient’s should have received to meet their needs. Findings: 1. A review of Patient 11’s medical record was conducted on December 8, 2025, at 9:45 a.m., with the Radiology Manager (RM). The facility document titled, “HISTORY AND PHYSICAL” was reviewed and indicated, “Patient [Patient 11]...found down at home...now do not resuscitate [DNR] but remained on vent [ventilator- a mechanical breathing device] being fed by the PEG [Percutaneous Endoscopic Gastrostomy, a feeding tube placed directly into the stomach through the abdominal wall, allowing for long-term nutrition, fluids, and medication for people unable to swallow or eat].” A facility document titled, “Flowsheet: Reposition”, dated September 21, 2025, from 7p.m., to 7 a.m., indicated Patient 11 was not turned and repositioned, nor a nurses note that a bath was provided. During the record review with the RM, the RM stated there was no documented evidence Patient 11 was turned/repositioned, nor a bath was provided on September 21, 2025, from 7p.m., to 7 a.m. On December 11, 2025, at 8:54 a.m., an interview was conducted with the Director of Quality Management (DQM). The DQM stated there was no documented evidence Patient 11 was turned/repositioned nor was a bath provided on September 21, 2025, from 7 p.m., through 7 a.m. The DQM stated, “Yes”, order should be followed timely and every two hours as ordered. The DQM stated the Certified Nurses Assistant (CNA) should have documented turning and repositioning because this validates turning and repositioning was completed on his shift. The DQM stated CNA 1 did not follow the physician’s order. A review of the facility policy and procedure titled, “CORE: Clinical Guidelines for Non-Pressure Related Wounds,” dated June 6, 2022, indicated, “POLICY...4. Standard interventions for all patients can include but are not limited to...Repositioning (minimum Q2 Hours turns)...Documentation... Interventions initiated...Within the electronic/paper medical record document...Date...Execution of order...” A review of the facility policy and procedure titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated June 2023, indicated, “PURPOSE...2. To outline a systematic process for gathering information about each patient...5. To determine the appropriate care, treatment and services to meet the patient’s needs during hospitalization...POLICY...6. Coordination of care by sharing patient information internally and externally with other caregivers. The patient information will be documented on the hospital’s...designated pathway in the EMR...The patient information may include patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these...13. Documentation...m. Any other forms determined necessary to document and provide quality patient care...” 2. On December 11, 2025, at 9:25 a.m., the DQM was interviewed regarding medical record for accuracy, completeness, and timeliness. Patient 12’s record indicated there was no documented evidence physician notification was made for IVF, NGT Feeding, and medication administration was held on November 12, 2025, admission. The DQM stated documentation should be timely, based on the order of physician, on how frequently it should happen, and for expectation for documentation of services provided. The DQM stated they have no policy for when documentation should be made and what to document in the medical record. The DQM stated “Policy” is for the facility to follow the guidelines, to put processes in place, and anyone can refer to it when in doubt, to standardized the practice, and for consistency throughout the department.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50122 Based on observation, interview, and record review, the facility failed to promote patient rights for six (Patients 9,10,16,17,18, and 20) of 24 sample patients, when: 1. For Patients 9 and 17, care was not provided in a safe setting (A0144); 2. For Patients 9, 10, 16, and 17, informed consent was not obtained prior to a procedure or discharge from the facility (A0131); 3. For Patients 16 and 17, an MD-to-MD consultation was not conducted prior to transfer (A0131); 4. For Patient 18, nursing staff shared unsubstantiated information alleging Patient 18 was involved in human trafficking; (A0142) and 5. For Patient 20, safety was not ensured when Patient 20 was observed in bed with four side rails up (A0144). The cumulative effects of these systemic failures had the potential to jeopardize the safety of the patient, cause harm to the patient’s health and well-being, and may cause delays in the provision of care.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50122 Based on interview, and record review, the facility failed to follow their policy and procedure (P&P) for four (Patients 9, 10, 16, and 17) of 24 sample patients when; 1. For Patient 16, a vasopressor (a medication that causes blood vessels to narrow in order to increase blood pressure) medication was stopped without a physician order prior to transfer; (A0398) and 2. For Patient 9, 10, 16, & 17, informed consents were not completed prior to a procedure or discharge from the facility (A0398). The cumulative effects of these systemic failures had the potential to jeopardize the safety of the patient, cause harm to the patient’s health and well-being, and may cause delays in the provision of care.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to ensure surveillance, prevention, and control of infectious diseases to reduce development and transmissions of Hospital Acquired Infections (HAIs, an infection that develops in a hospital or other healthcare setting after being admitted for treatment of another condition) were in place when; 1. For Patient 1, laboratory and nursing staff did not refer a critical QuantiFERON-TB Gold Test (a qualitative indirect test for Mycobacterium tuberculosis infection)result to the physician (Refer to A0770); 2. The facility failed to implement early prevention and control measures to mitigate transmission of potential infection (Refer to A0770); 3. The facility failed to provide notification for potential exposure to HAIs for unknown number of visitors and vendors on July 7, 2025, through August 6, 2025 (Refer to A0770); and 4. Facility staff did not wear appropriate Personal Protective Equipment (PPE) while assisting a patient to conduct oral/mouth self-suctioning (Refer to A0749). The cumulative effects of these systemic failures had the potential to delay identification and control of the infecting organism, impact the health and treatment of the patients and visitors and may cause delays in the provision of patient care.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50122 Based on interview, and record review, the facility failed to promote patient’s rights for four (Patients 9, 10, 16, and 17) of 24 sample patients, when: 1. For Patients 9 and 10, there was no second witness for telephone consent; and 2. For Patients 16 and 17, there was no documented informed consent prior to transfer to a higher level of care. This failure had the potential to cause the patient or family to not be informed of the risks and benefits of the procedure/transfer, complications that could result from the procedure/transfer, and jeopardize the patient’s health, safety, and well-being. Findings: On September 22, 2025, at 8:30 a.m., an unannounced complaint validation survey was conducted at the facility. 1 a. On September 22, 2025, at 1:30 p.m., a review of the Patient 9’s medical record was conducted with the Radiology Manager (RM). On September 22, 2025, at 1:35 p.m., a review of the facility document titled, “History and Physical,” dated June 9, 2025, at 12 a.m., authored by Medical Doctor (MD) 2, was conducted. The document indicated Patient 9 had a medical history of hypertension (high blood pressure), diabetes (a chronic metabolic disease characterized by high blood sugar levels), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and encephalopathy (a condition where the brain’s function is impaired). Patient 9 was admitted to the facility for acute-on-chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 22, 2025, at 1:40 p.m., a review of the facility document titled “Physician orders,” dated August 21, 2025, at 5:16 a.m., authored by MD 3 was conducted. The document indicated an order for general surgery consultation by MD 3 for placement of a temporary hemodialysis catheter (the insertion of a two-way catheter into a large vein in the neck, chest, or leg to provide immediate, but short-term, blood access for hemodialysis). On September 22, 2025, at 1:42 p.m., a review of the facility document titled, “Informed Consent for Surgical and Special Procedures,” dated August 22, 2025, at 9:35 a.m., was conducted. The document indicated a printed name of Patient 9’s daughter and a box checked that indicated “Telephone Consent.” The document indicated one witness signature. There was no documented evidence of a second witness. On September 22, 2025, at 1:45 p.m., a review of the facility document titled, “Operative/Procedure Note,” dated August 22, 2025, at 10:20 a.m., authored by MD 3 was conducted. The document indicated placement of a temporary hemodialysis catheter was performed on August 22, 2025 at 10:15 a.m. 1b. On September 23, 2025, 9 a.m., a review of Patient 10’s medical record was conducted with the RM. The facility document titled, “History and Physical,” dated March 1, 2025, at 1:03 p.m., was reviewed. The document indicated Patient 10 had a medical history of atrial fibrillation (irregular heartrate), hypertension (high blood pressure), chronic kidney disease (kidneys have suffered moderate damage and are not filtering waste and fluid like they should), and Barrette’s syndrome (a medical condition in which the normal cells lining the lower esophagus are replaced by abnormal intestinal-like cells). It further indicated Patient 10 was admitted to the facility for acute-on-chronic respiratory failure. On September 22, 2025, at 9:10 a.m., a review of an untitled facility document, dated August 7, 2025, at 12:14 p.m., authored by MD 2 was conducted. The document indicated an order for a “...Fiberoptic endo eval-swallowing [diagnostic test performed by a speech-language pathologist that uses a thin, flexible camera (an endoscope) inserted through the nose to visualize the throat and assess swallowing function in real-time]...telephone...[name of MD 2]...” On September 22, 2025, at 9:15 a.m., a review of the facility document titled, “Informed Consent for Surgical and Special Procedures,” dated August 7, 2025, at 10 a.m., authored by MD 2, was conducted. The document indicated Patient 10’s signature and a signature from MD 2. There was no documented evidence of a witness signature. On September 23, 2025, at 9:20 a.m., a review of the facility document titled, “Speech Notes,” dated August 7, 2025, at 11 a.m., was conducted. The document indicated, the Fiberoptic endo eval-swallowing test was conducted. On September 24, 2025, at 2:30 p.m., an interview was conducted with the Director of Quality Management (DQM). The DQM stated, “...they read the policy as the physician could be a witness to the consent...the policy is confusing...it states nurses may participate...I did not know it was mandatory...” On September 24, 2025, a review of the facility policy and procedure (P&P) titled, “...Informed Consent,” dated June 2021, was conducted. The document indicated, “...Hospital staff members (including all nurse and other employees) may participate in the informed consent process by witnessing the patient’s, patient’s representative, or physician’s signature regarding informed consent...Telephone consents...Informed consent may be received by phone from a patient’s legal representative...should be confirmed by two witnesses who also speak to the legal representative...” 2a. On September 23, 2025, at 10:59 a.m., a review of the facility document titled, “History and Physical,” dated March 26, 2025, at 6:05 p.m., authored by MD 1, was conducted. The document indicated Patient 16 had a medical history of rheumatoid arthritis (a chronic autoimmune disease causing inflammation, pain, and damage to joints and sometimes other organs), systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues and organs), anemia (low blood count), hypertension (high blood pressure), and on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own). It further indicated Patient 16 was admitted to the facility for acute on chronic respiratory failure. On September 23, 2025, at 11 a.m., a review of the facility document titled, “Change of Condition,” dated July 26, 2025, at 4:30 p.m., was conducted. The document indicated, “...Emergency discharge...Attending physician notified...[name of physician]...Family present...911 was called...” There was no documented evidence of an informed consent for transfer to a higher level of care facility. On September 23, 2025, at 11:10 a.m., a review of the facility document titled, “Discharge Summary,” dated July 26, 2025, with no time, was conducted. The document indicated Patient 16 was discharged from the facility to be transferred to a higher level of care facility due to tachycardia (fast heartrate), elevated BP (blood pressure-higher than usual blood pressure), and tachypnea (abnormal, fast breathing). On September 24, 2025, at 2 p.m., a review of the facility document titled, “Interhospital Patient Transfer Information,” form was conducted. The document indicated, “...Transfer Form...Transfer To...Physician Certification- Transfer acknowledgement & Consent...Transfer Risks...Transfer Benefits...Signature of Transferring Physician...Signature of Patient...” 2b. On September 22, 2025, at 3:45 p.m., a review of the facility document titled, “History and Physical,” dated July 22, 2025, at 7:36 p.m., authored by MD 1, was conducted. The document indicated Patient 17 had a medical history of atrial fibrillation (irregular heartrate), contractures of the upper extremities (a chronic loss of mobility arms, caused by the shortening and stiffening of soft tissues like muscles, tendons, and ligaments) diabetes, neuromuscular disease (a disorder that impacts the nervous system’s ability to control muscles, causing symptoms like muscle weakness, wasting, or spasms), and Stage 3 chronic kidney disease (kidneys have suffered moderate damage and are not filtering waste and fluid like they should, with an estimated glomerular filtration rate (eGFR) between 30 and 59 mL/min. Stage 3 has an eGFR of 30-59. This stage can result in complications like high blood pressure, anemia, and bone disease). Patient 17 was admitted to the facility on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own), and treatment for acute-on-chronic hypoxic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 23, 2025, at 3:25 p.m., a review of the facility document titled, “Discharge Patient,” dated July 30, 2025, at 6:06 p.m., was conducted. The document indicated a telephone order from Nurse Practitioner (NP) 1. The document indicated, “...Discharge patient...to hospital [name of Facility B] ER [emergency room]...” On September 23, 2025, at 3:28 p.m., a review of the facility document titled, “Discharge Summary,” dated July 30, 2025, at 9:41 p.m., was conducted. The document indicated Patient 17 was discharged to [name of Facility B] for higher level of care for the left comminuted humerus fracture (a severe break of the upper arm bone). On September 24, 2025, at 2:45 p.m., an interview was conducted with the DQM. The DQM stated, “...They need consent prior to transfer so they can notify the patient or family of the risks and benefits involved with the transfer...we do not have a transfer policy in place...the house supervisor is responsible for arranging transport of the patient...The only thing we have in place is an intrahospital form...this was not done...” On September 24, 2025, at 3:45 p.m., an interview was conducted with the house supervisor (HS) 2. The HS 2 stated, “...HLOC [Higher level of care] transfer process...he would...get an order to transfer the patient for higher level of care...determine the type of care the patient needs that they are not able to provide. After getting an order...they send the patient to the emergency department [ED]...They get an official [name of facility] form that needs to be filled out for ED transport...Necessary transfer packet...” A review of the facility P&P titled, “...Emergency Care,” dated June 2023, was reviewed. The P&P indicated, “...The physician...is consulted when it is determined that patient care needs exceed the services provided...components used to evaluate the effectiveness of the provision of emergency services performed include...complete and accurate transfer agreement...execution of applicable consents based on informed decisions making by responsible party...””

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 48326 Based on interview and record review the facility failed to ensure patients’ rights were protected when nursing staff shared unsubstantiated information for one (Patient 18) of 24 sample patients. This failure had the potential to create an unsafe and hostile environment for the patient, exposing them to stigma, humiliation, or harassment by staff. Findings: On September 22, 2025, at 1 p.m., Patient 18’s medical record was reviewed with the Director of Pharmacy (DP). The facility document titled History and Physical (H&P), dated May 16, 2025, was reviewed. The document indicated “...was admitted with encephalopathy [a condition where the brain is damaged because of an illness]...CVA [Cerebrovascular Accident, stroke, blood flow to part of the brain is blocked or blood vessels bursts]...infective endocarditis [heart infection]...meningitis [infection of the brain and spinal cord coverings]...renal infarct [damage to the kidneys from blocked blood flow]...severe aortic insufficiency [leaky heart valve]...aortic mass [a lump in the largest blood vessel of the heart]...CHF [Congestive Heart Failure, heart is too weak or stiff to pump blood properly causing fluid buildup]...hypertension [high blood pressure], GERD [Gastroesophageal Reflux Disease, stomach acid keeps coming up into the food pipe, causing heart burn], chronic kidney disease stage two [mild kidney damage]...admitted for further management...” On September 23, 2025, at 9:04 a.m., an interview was conducted with the Director of Nursing and Clinical Services (DNCS). The DNCS stated she received a complaint from Patient 18’s representative that one of the nursing staff said Patient 18 was part of human trafficking. The nurse was sharing this information with other staff. The DNCS stated she investigated the complaint and spoke to the nurse, who stated this information was exchanged during handoff (nurse to nurse report), and she does not know where it originated from. The DNCS stated there was no information during the handoff from the referring hospital, and there was no documentation in her chart to confirm that the patient was part of human trafficking. The DNCS stated the complaint received from Patient 18’s representative was substantiated, and she educated the nurse about hearsay, spreading misinformation and reinforced respecting patient’s rights. The DNCS stated this was a violation of patient rights. A Policy & Procedure (P&P) titled “[Facility Name] Core: Patient Rights and Responsibilities,” dated June 2022, was reviewed. The policy indicated “...provide an environment that respects and protects the rights of patients and families and conducts all activities related to care with primary concern for the...dignity of patients...””

“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: 50122 Based on interview, and record review, the facility failed to provide care in a safe setting for three (Patients 9, 16, and 17) of 24 sample patients when: 1. For Patient 9, there was no documented evidence of vital signs and reaction to sedation during a procedure; 2. For Patient 17, a fracture (a break of a bone) of the left humerus (the single long bone of the upper arm) was sustained while receiving an ultrasound (high frequency sound waves used to obtain an image of a part of the body) of the left arm; and 3. For Patients 16, and 17, no MD-to-MD (physician) consultation was completed prior to transfer to a higher level of care (HLOC) facility (Facility B). These failures had the potential to cause an increase in the patient’s pain, jeopardized the health, safety, and well-being of the patient, cause an increase in stay at the facility, and contribute to further complications in the patient’s health. Findings: On September 22, 2025, at 8:30 a.m., an unannounced complaint validation survey was conducted at the facility. 1. On September 22, 2025, at 1:30 p.m., a review of Patient 9’s medical record was conducted with the Radiology Manager (RM). On September 22, 2025, at 1:35 p.m., a review of the facility document titled, “History and Physical,” dated June 9, 2025, at 12 a.m., authored by Medical Doctor (MD) 2, was conducted. The document indicated Patient 9 had a medical history of hypertension (high blood pressure), diabetes (a chronic metabolic disease characterized by high blood sugar levels), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and encephalopathy (a condition where the brain’s function is impaired). Patient 9 was admitted to the facility for acute-on-chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 22, 2025, at 1:40 p.m., a review of the facility document titled “Physician orders,” dated August 21, 2025, at 5:16 a.m., authored by MD 3 was conducted. The document indicated an order for general surgery consultation by MD 3 for placement of a temporary hemodialysis catheter (the insertion of a two-way catheter into a large vein in the neck, chest, or leg to provide immediate, but short-term, blood access for hemodialysis). On September 22, 2025, at 1:45 p.m., a review of the facility document titled, “Operative/Procedure Note,” dated August 22, 2025, at 10:20 a.m., authored by MD 3 was conducted. The document indicated the procedure was completed using “...Anesthetic...MAC [monitored anesthesia care] with local [a combination of a local anesthetic, which numbs a specific area of the body, and systemic sedatives and analgesics administered by an anesthesia provider to keep the patient drowsy, provide pain relief, and monitor their vital signs throughout a diagnostic or surgical procedure]...” On September 22, 2025, at 1:50 p.m., a review of the facility document titled, “Physician Orders,” dated August 22, 2025, at 10:13 a.m., was conducted. The document indicated, “...Midazolam [Versed - brand name for midazolam - is a short-acting benzodiazepine [medications that slow down activity in your brain and nervous system] ...IV [intravenous] inj [injection]4 mg [milligram - unit of measurement]...push [to administer a medication through the IV of a patient]...HD catheter placement...” The document indicated that on August 22, 2025, at 10:13 a.m., “...4 mg...inj...periph [peripheral-close to the skin] IV [a small, flexible tube inserted into a peripheral vein]...administered by [name of Registered Nurse (RN) 1]...” On September 22, 2025, at 1:55 p.m., a review of the facility document titled, “Invasive Procedures Without Sedation,” dated August 22, 2025, at 10:15 a.m., authored by RN 1 was conducted. The document did not indicate, “Type of Procedure” being performed. The document indicated, at 10:13 a.m., “...Versed medication that produces sedation (the administering of a drug to produce a state of calm or sleep)]...IV Push...[initials of RN 1]...4 mg...” During the review, there was no documented evidence of breath sounds bilaterally (listening to breathing on both sides of the chest), vent (mechanical device that breathes for patients who are not able to breathe effectively on their own), if airway was clear, pain or RASS score (The Richmond Agitation Sedation Scale (RASS) is an instrument designed to assess the level of alertness and agitated behavior in critically-ill patients when using sedation medications). There was no documented evidence of Patient 9’s vital signs, RASS score, or toleration of the procedure during or after the procedure was completed. On September 22, 2025, an interview was conducted with RN 2. RN 2 stated, “...the preprocedural checklist is not present in [Patient 9’s] the chart...Not sure where it is...[name of RN 1] was the RN for the procedure...vital signs and RASS is done before, after and continuously monitored throughout the procedure when sedation was given...it is important to know how the patient tolerated the procedure and sedation and if the patient returns back to their baseline following the procedure...” On September 24, 2025, an interview was conducted with the Director of Quality (DQM). The DQM stated, “...I did not find any documentation by nursing for the procedure and there should have been documentation...It is important to have this to check the state of the patient and the reason for the vital signs to be taken is to identify when the level of sedation is impacting the patient...” A review of the facility policy and procedure (P&P) titled, “Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation,”, dated June 2022, was reviewed. The P&P indicated, “...Nursing...are to maintain a log of all...invasive procedures...Invasive Procedures Under Moderate Sedation...Procedure Checklist...Perioperative Record...Post-Anesthesia Nursing Care Record...Pre/Post Anesthesia Evaluation...Anesthesia Administration...” A review of the facility P&P titled, “Guideline-Moderate Sedation Analgesia,” dated February 2024, was reviewed. The P&P indicated, “...Monitoring of patient response to verbal commands should be routine during moderate sedation. Monitoring should also include the patient’s level of consciousness, RASS, pulmonary ventilation [breathing effectiveness], oxygenation [the process of supplying and distributing oxygen to the body’s tissues], and hemodynamics [the study of the flow of blood through the heart]...should be assessed and recorded at a set frequency (minimally pre and post procedure)...a designated individual...should be present to monitor the patient throughout the procedure...Following sedation/analgesia, patients should be observed...until their baseline level of consciousness and are no longer at risk...” 2. On September 22, 2025, at 3:45 p.m., a review of the facility document titled, “History and Physical,” dated July 22, 2025, at 7:36 p.m., authored by Medical Doctor (MD) 1, was conducted. The document indicated Patient 17 had a medical history of atrial fibrillation (irregular heartrate), contractures of the upper extremities (a chronic loss of mobility arms, caused by the shortening and stiffening of soft tissues like muscles, tendons, and ligaments) diabetes (a chronic metabolic disease characterized by high blood sugar levels), neuromuscular disease (a disorder that impacts the nervous system’s ability to control muscles, causing symptoms like muscle weakness, wasting, or spasms), and Stage 3 chronic kidney disease (kidneys have suffered moderate damage and are not filtering waste and fluid like they should, with an estimated glomerular filtration rate (eGFR-the volume of fluid filtered from the glomerular capillaries in the kidneys and serves as the most important measure of overall kidney function) between 30 and 59 mL/min. Stage 3 has an eGFR of 30-59. This stage can result in complications like high blood pressure, anemia, and bone disease). Patient 17 was admitted to the facility on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own), and treatment for acute and chronic hypoxic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 22, 2025, at 4 p.m., a review of the facility document titled, “Up [upper] Ext [extremity] Vein Duplex Study Limit LT [left][a medical exam that uses sound waves to evaluate the blood vessels in a person’s left arm using a combination a traditional ultrasound and a Doppler ultrasound],” dated July 30, 2025, at 7:15 a.m., was reviewed. The document indicated an order for an ultrasound of the upper arm to rule out a deep vein thrombosis (a non-invasive diagnostic test that uses sound waves to examine the deep veins of the arm and shoulder for blood clots). On September 22, 2025, at 4:05 p.m., a review of the facility document titled, “Change of Condition,” dated July 30, 2025, at 12:42 p.m., by RN 1, was reviewed. The document indicated, “pt’s [patient’s] middle of left humerus looks bent inward. Notified to NP [nurse practitioner] 1 at 07/30/2025 12:42...US [ultrasound] tech tried to stretch the pt’s [patient’s] left humerus then US tech heard the popping sound. Pt’s left humerus looks bent inward. [name of nurse practitioner (NP) 1] ordered x ray (a type of medical imaging that uses a small dose of electromagnetic radiation to create black and white images of the inside of the body) for left humerus...When US tech gently stretched pt’s left humerus, US tech found out that pt’s left humerus is bent inward...left humerus is bent...” On September 23, 2025, at 8:30 a.m., a review of the facility document titled, “Change of Condition,” dated July 30, 2025, at 6:14 p.m., was reviewed. The document indicated, “Other change of condition...Comminuted displaced fracture of midshaft left humerus [a complex and severe break in the middle section of the long bone of the upper left arm]...[Name of NP 1] ordered to discharge the pt [patient] to [Facility B] ER [Emergency Room]. Called and noticed [sic-notified] to pt’s daughter...[Name of NP 1] also called and notified about fractures and discharge pt to [name of facility B] ER...ordered transfer to HLOC ER. Call placed to [name of ambulance company]...” On September 23, 2025, at 9 a.m., a review of the facility document titled, “Event,” no date, was conducted. The document indicated a statement from the ultrasound technician conducting the ultrasound of the left arm for Patient 17. The statement indicated, “...On July 30, 2025, I was asked to give an [sic] left upper extremity venous ultrasound exam to the patient...The protocol for this exam requires that the patient’s arm be maneuvered away from the body far enough for transducer [device placed against the patients skin to obtain an image] placement...I gently and gradually moved the patient’s left arm away from her body an inch or so at a time, pausing in between until the patient relaxed her arm in the new position, then continued this process of maneuvering until the arm was about five or so inches from her body...I began placing a pillow to hold her arm in place, when I heard a pop, and the arm gave way...I visually inspected her arm, and found it appeared to be misshapen compared to her right arm...” On September 23, 2025, at 3:20 p.m., a review of the facility document titled, “Order Humerus 2+ Views LT (x-ray image of the left arm using two directional images), dated July 30, 2025, indicated an x-ray of the left upper arm was completed. The document indicated, Patient 17 had sustained a, “...comminuted displaced fracture of the midshaft left humerus...” On September 23, 2025, at 3:20 p.m., a review of the facility document titled, “Discharge Summary,” dated July 30, 2025, at 9:41 p.m., was reviewed. The document indicated that Patient 17 was discharged to [name of facility B] for higher level of care for the left comminuted humerus fracture. On September 23, 2025, at 3:30 p.m., an interview was conducted with the RM. The RM stated, “...The US tech was in the room...she heard a pop...they ordered an Xray of the left arm...Immediately they let the RN know and called the radiologist [a physician who specialized in reading imaging tests] to read stat [immediately]...administration was made aware of the occurrence...In regard to the US tech gently manipulating the arm slowly during her exam, in my opinion it would not be normal for someone to sustain a fx [fracture] from that...” On September 24, 2025, at 8:20 a.m., an interview was conducted with the chief operating officer (COO). The COO stated, “...an ultrasound is not a common procedure that would ever cause a fracture...it was immediately escalated...” A review of the facility document titled, “[name of facility] Plan for Provision of Patient Care, Treatment And Services,” revised February 2025, indicated, “...It is our goal to recognize and respect each patient in the provision of care, treatment, and services in accordance with fundamental human, civil, constitutional, and statutory rights...Patient services at [name of facility] occur through an organized and systematic process designed to ensure the delivery of safe, effective and timely care, treatment, and services...” A review of the facility policy and procedure titled, “Patient Rights and Responsibilities,” dated June 2022, indicated, “...establishes guidelines to provides an environment that respects and protects the rights of patients...conducts all activities related to care with primary concern for the values and dignity of patients...effective patient care and in promotion of the confidence and trust which must exist between the patient, the physician, and [name of facility]...and its medical staff present and support the following...the right to considerate and respectful care...” 3a. On September 23, 2025, at 10:59 a.m., a review of the facility document titled, “History and Physical,” dated March 26, 2025, at 6:05 p.m., by MD 1, was reviewed. The document indicated Patient 16 had a medical history of rheumatoid arthritis (a chronic autoimmune disease causing inflammation, pain, and damage to joints and sometimes other organs), systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues and organs), anemia (low blood count), hypertension (high blood pressure), and on a mechanical ventilator. Patient 17 was admitted to the facility for acute on chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 23, 2025, at 11 a.m., a review of the facility document titled, “Change of Condition,” dated July 26, 2025, at 4:30 p.m., was reviewed. The document indicated, “...Emergency discharge...Attending physician notified...name of physician]...Family present...911 was called...” On September 23, 2025, at 11:05 a.m., a review of the facility document titled, “Patient Transfer/Discharge-Change In Level Of Care,” dated July 30, 2025, was reviewed. The document indicated, “...Transferring Physician Name...name of NP 1]...” There was no documented evidence of “...Receiving Facility Contact...Title...Phone...” There was no documented evidence of a MD-to-MD consult prior to transfer from Facility A to Facility B. On September 23, 2025, at 11:10 a.m., a review of the facility document titled, “Discharge Summary,” dated July 26, 2025, with no time, was reviewed. The document indicated, Patient 16 was discharged from the facility to be transferred to a higher level of care facility due to tachycardia (fast heartrate), elevated BP (blood pressure-higher than usual blood pressure), and tachypnea (abnormal, fast breathing). On September 24, 2025, at 2 p.m., a review of the facility document titled, “Interhospital Patient Transfer Information,” form was reviewed. The document indicated, “...Transfer Form...Transfer To...Physician Certification- Transfer acknowledgement & Consent...Transfer Risks...Transfer Benefits...Signature of Transferring Physician...Signature of Patient...” 3b. On September 22, 2025, at 2:30 p.m., a review of the facility document titled, “History and Physical,” dated July 22, 2025, at 7:36 p.m., and authored by MD 1, was conducted. The document indicated Patient 17 had a medical history of atrial fibrillation, contractures of the upper extremities, diabetes, neuromuscular disease, and Stage 3 chronic kidney disease. Patient 17 was admitted to the facility on a mechanical ventilator and treatment for acute-on-chronic hypoxic respiratory failure. On September 23, 2025, at 2:45 p.m., a review of the facility document titled, “Discharge Patient,” dated July 30, 2025, at 6:06 p.m., indicated a telephone order from NP 1. The document indicated, “...Discharge patient...to hospital [name of Facility B] ER...” On September 23, 2025, at 3:28 p.m., a review of the facility document titled, “Discharge Summary,” dated July 30, 2025, at 9:41 p.m., was reviewed. The document indicated that Patient 17 was discharged to [name of facility] for higher level of care for the left comminuted humerus fracture. On September 24, 2025, at 3 p.m., a review of the facility document titled, “Change of condition,” dated July 26, 2025, at 4 p.m., was conducted. The document indicated, “...It was noted that physician to physician communication was not completed appropriately...” On September 24, 2025, at 3:15 p.m., an interview was conducted with the DQM. The DQM stated, “...It is important for this facility to notify the accepting MD of the information about the patient and care they have received prior to transfer...we do not have a transfer policy in place...The only thing we have in place is an intrahospital form...it was not done...they should have documentation showing they did everything they could prior to the transfer to cover patient information was given prior to transferring to HLOC via Ambalance...” On September 24, 2025, at 3:45 p.m., an interview was conducted with the house supervisor (HS) 2. The HS 2 stated, “...HLOC transfer process...he would...get an order to transfer the patient for higher level of care...determine the type of care the patient needs that they are not able to provide. After getting an order...they send the patient to the emergency department [ED]...They get an official [name of facility] form that needs to be filled out for ED transport...It is required for a peer-to-peer communication...attending physician needs to speak with the ED physician to give endorsement...” On September 26, 2025, at 1:40 p.m., an electronic message was sent from the Director of Radiology (DOR). The DOR indicated, “I reviewed our policies and consulted with [name of COO] and [name of DQM]. We do not have a discharge policy...” A review of the facility P&P titled, “...Emergency Care,” dated June 2023, was reviewed. The P&P indicated, “...The physician supervises the delivery of care...is consulted when it is determined that patient care needs exceed the services provided...evaluate potential transfer or discharge options using capacity and capability information provided by potential receiving facilities...complete and accurate transfer agreement...Ensuring evaluation of capability and capacity of receiving facility prior to transfer...””

“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: 50122 Based on interview, and record review, the facility failed to follow their policy and procedure (P&P) for five (Patients 9, 10, 16, 17, and 20) of 24 sample patients when: 1. For Patient 16, a vasopressor (a medication that causes blood vessels to narrow in order to increase blood pressure) medication was stopped without a physician order prior to transfer; 2. For Patient 9, 10, 16, & 17, informed consents were not completed prior to a procedure or discharge from the facility; and 3. For Patient 20, there was no physician order for the four bed rails to be up on Patient 20’s bed. These failures had the potential to jeopardize the safety of the patient, cause harm to the patient’s health and well-being, and may cause delays in the provision of care. Findings: On September 22, 2025, at 8:30 a.m., an unannounced complaint validation survey was conducted at the facility. 1. On September 22, 2025, at 1:30 p.m., Patient 16’s medical record was reviewed with the Radiology Manager (RM). On September 23, 2025, at 10:59 a.m., a review of the facility document titled, “History and Physical,” dated March 26, 2025, at 6:05 p.m., authored by Medical Doctor (MD) 1, was conducted. The document indicated Patient 16 had a medical history of rheumatoid arthritis (a chronic autoimmune disease causing inflammation, pain, and damage to joints and sometimes other organs), systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues and organs), anemia (low blood count), hypertension (high blood pressure), and on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own). Patient 16 was admitted to the facility for acute on chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 23, 2025, at 11:30 a.m., a review of the facility document titled, “Complete order...,” dated July 24, 2025, at 9:05 p.m., was conducted. The document indicated an order for “...Norepinephrine [brand name Levophed - a medication used to treat dangerously low blood pressure]...IV [intravenous - in the vein]...4 [four]...mg [milligrams-unit of measurement]...Start dose 5 mcg/min [micrograms per minute - unit of measurement over a period time (60 seconds)]...Titrate up or down...start today 07/24/2025 [July 24, 2025]...” On September 23, 2025, at 11:45 a.m., a review of the facility document titled, “Controlled Substance/Sedative Infusion Flowsheet,” dated July 26, 2025, at 3:45 p.m., was conducted. The document indicated norepinephrine was administered on July 26, 2025, at 3:45 p.m., by HS [house supervisor 2]. The starting rate was 5 mcg/min. On September 24, 2025, at 12 p.m., a review of the facility document titled, “Change of Condition,” dated July 26, 2025, at 5:24 p.m., authored by Registered Nurse (RN) 4 was conducted. The document indicated, “...Resp [respiratory] distress [a condition where breathing becomes difficult or labored]...Patient shows signs of resp distress, notified [name of physician]...ordered to transfer patient...HS called 911...” On September 24, 2025, at 12:30 p.m., a review of the facility document titled, “Change of Condition,” dated July 26, 2025, at 9:11 p.m., authored by RN 3 was conducted. The document indicated, “...911 was called...to transfer the patient...Ambulance had soon arrived but there was an issue that they could not have any pumps during their transit, but as to not delay care, the pt [patient] was still able to be transferred without any IV medications...” During the review of Patient 16’s medical record, there was no documented evidence of an order to stop the medication of norepinephrine. On September 24, 2025, at 2:45 p.m., an interview was conducted with the Director of Quality Management (DQM). The DQM stated, “...the supervisor or nurse should have communicated with the physician prior to stopping the drips...May have been miscommunication and lack of documentation...” On September 24, 2025, at 3 p.m., an interview was conducted with the HS 2. The HS 2 stated, “...process is when you have a patient with a Levophed...cannot recall who stopped the drip...The patient will crash if stopped abruptly due to hypotension [low blood pressure]...an MD was not called...we cannot stop a drip. We can suspend, but not stop unless we have a physician’s order...” A review of the facility policy & procedure (P&P) titled, “...Vasoactive Infusions,” dated June 2022, was conducted. The P&P indicated, “...Vasoactive medications will not be titrated to ‘OFF’ unless specifically ordered by the Prescriber...” 2a. On September 22, 2025, at 1:35 p.m., a review of the facility document titled, “History and Physical,” dated June 9, 2025, at 12 a.m., authored by MD 2, was conducted. The document indicated Patient 9 had a medical history of hypertension (high blood pressure), diabetes (a chronic metabolic disease characterized by high blood sugar levels), tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing), and encephalopathy (a condition where the brain’s function is impaired). Patient 9 was admitted to the facility for acute-on-chronic respiratory failure. On September 22, 2025, at 1:40 p.m., a review of the facility document titled “Physician orders,” dated August 21, 2025, at 5:16 a.m., authored by MD 3 was conducted. The document indicated an order for general surgery consultation by MD 3 for placement of a temporary hemodialysis catheter (the insertion of a two-way catheter into a large vein in the neck, chest, or leg to provide immediate, but short-term, blood access for hemodialysis). On September 22, 2025, at 1:42 p.m., a review of the facility document titled, “Informed Consent for Surgical and Special Procedures,” dated August 22, 2025, at 9:35 a.m. was conducted. The document indicated a printed name of Patient 9’s daughter and a box checked that indicated “Telephone Consent.” The document indicated one witness signature. There was no documented evidence of a second witness. On September 22, 2025, at 1:45 p.m., a review of the facility document titled, “Operative/Procedure Note,” dated August 22, 2025, at 10:20 a.m., authored by MD 3 was conducted. The document indicated the procedure was conducted. 2b. On September 23, 2025, 9 a.m., a review of the facility document titled, “History and Physical,” dated March 1, 2025, at 1:03 p.m., was conducted. The document indicated Patient 10 had a medical history of atrial fibrillation (irregular heartrate), hypertension (high blood pressure), chronic kidney disease (kidneys have suffered moderate damage and are not filtering waste and fluid like they should), and Barrette’s syndrome (a medical condition in which the normal cells lining the lower esophagus are replaced by abnormal intestinal-like cells). Patient 10 was admitted to the facility for acute-on-chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 22, 2025, at 9:10 a.m., a review of an untitled facility document, dated August 7, 2025, at 12:14 p.m., by MD 2 was conducted. The document indicated an order for a “...Fiberoptic endo eval-swallowing [is a diagnostic test performed by a speech-language pathologist that uses a thin, flexible camera (an endoscope) inserted through the nose to visualize the throat and assess swallowing function in real-time]...telephone...[name of MD 2]...” On September 22, 2025, at 9:15 a.m., a review of the facility document titled, “Informed Consent for Surgical and Special Procedures,” dated August 7, 2025, at 10 a.m., by MD 2, was conducted. The document indicated Patient 10’s signature and a signature from MD 2. There was no documented evidence of a witness signature. On September 23, 2025, at 9:20 a.m., a review of the facility document titled, “Speech Notes,” dated August 7, 2025, at 11 a.m., was conducted. The document indicated, the Fiberoptic endo eval-swallowing test was conducted. On September 24, 2025, at 2:30 p.m., an interview was conducted with the DQM. The DQM stated, “...they the policy read that the physician could be a witness to the consent...the policy is confusing...it states nurses may participate...I did not know it was mandatory...” On September 24, 2025, a review of the facility P&P titled, “...Informed Consent,” dated June 2021, was conducted. The document indicated, “...Hospital staff members (including all nurse and other employees) may participate in the informed consent process by witnessing the patient’s, patient’s representative, or physician’s signature regarding informed consent...Telephone consents...Informed consent may be received by phone from a patient’s legal representative...should be confirmed by two witnesses who also speak to the legal representative...” 2c. On September 23, 2025, at 10:59 a.m., a review of the facility document titled, “History and Physical,” dated March 26, 2025, at 6:05 p.m., by MD 1, was conducted. The document indicated Patient 16 had a medical history of rheumatoid arthritis (a chronic autoimmune disease causing inflammation, pain, and damage to joints and sometimes other organs), systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues and organs), anemia (low blood count), hypertension (high blood pressure), and on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own). Patient 16 was admitted to the facility for acute on chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 23, 2025, at 11 a.m., a review of the facility document titled, “Change of Condition,” dated July 26, 2025, at 4:30 p.m., was conducted. The document indicated, “...Emergency discharge...Attending physician notified...name of physician]...Family present...911 was called...” There was no documented evidence of an informed consent for transfer to a higher level of care facility. On September 23, 2025, at 11:10 a.m., a review of the facility document titled, “Discharge Summary,” dated July 26, 2025, with no time, was conducted. The document indicated, Patient 16 was discharged from the facility to be transferred to a higher level of care facility due to tachycardia (fast heartrate), elevated BP (blood pressure-higher than usual blood pressure), and tachypnea (abnormal, fast breathing). On September 24, 2025, at 2 p.m., a review of the facility document titled, “Interhospital Patient Transfer Information,” form was conducted. The document indicated, “...Transfer Form...Transfer To...Physician Certification- Transfer acknowledgement & Consent...Transfer Risks...Transfer Benefits...Signature of Transferring Physician...Signature of Patient...” 2d. On September 22, 2025, at 3:45 p.m., a review of the facility document titled, “History and Physical,” dated July 22, 2025, at 7:36 p.m., by MD 1, was conducted. The document indicated Patient 17 had a medical history of atrial fibrillation (irregular heartrate), contractures of the upper extremities (a chronic loss of mobility arms, caused by the shortening and stiffening of soft tissues like muscles, tendons, and ligaments) diabetes, neuromuscular disease (a disorder that impacts the nervous system’s ability to control muscles, causing symptoms like muscle weakness, wasting, or spasms), and Stage 3 chronic kidney disease (kidneys have suffered moderate damage and are not filtering waste and fluid like they should, with an estimated glomerular filtration rate (eGFR) between 30 and 59 mL/min. Stage 3 has an eGFR of 30-59. This stage can result in complications like high blood pressure, anemia, and bone disease). Patient 17 was admitted to the facility on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own), and treatment for acute-on-chronic hypoxic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 23, 2025, at 3:25 p.m., a review of the facility document titled, “Discharge Patient,” dated July 30, 2025, at 6:06 p.m., was conducted. The document indicated a telephone order from Nurse practitioner (NP) 1. The document indicated, “...Discharge patient...to hospital [name of Facility B] ER [emergency room]...” On September 23, 2025, at 3:28 p.m., a review of the facility document titled, “Discharge Summary,” dated July 30, 2025, at 9:41 p.m., was conducted. The document indicated that Patient 17 was discharged to [name of Facility B] for higher level of care for the left comminuted humerus fracture. On September 24, 2025, at 2:45 p.m., an interview was conducted with the DQM. The DQM stated, “...They need consent prior to transfer so they can notify the patient or family of the risks and benefits involved with the transfer...we do not have a transfer policy in place...the house supervisor is responsible for arranging transport of the patient...The only thing we have in place is an intrahospital form...this was not done...” On September 24, 2025, at 3:10 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, “...The paperwork is completed, and the house supervisor reports the transfer to [name of chief operating officer (COO)]...Consent is required by the patient...” On September 24, 2025, at 3:45 p.m., an interview was conducted with the house supervisor (HS) 2. The HS 2 stated, “...HLOC [higher level of care] transfer process...he would...get an order to transfer the patient for higher level of care...determine the type of care the patient needs that they are not able to provide. After getting an order...they send the pt to emergency department [ED]...They get an official [name of facility] form that needs to be filled out for ED transport...Necessary transfer packet...” A review of the facility P&P titled, “...Emergency Care,” dated June 2023, was reviewed. The P&P indicated, “...The physician...is consulted when it is determined that patient care needs exceed the services provided...components used to evaluate the effectiveness of the provision of emergency services performed include...complete and accurate transfer agreement...execution of applicable consents based on informed decisions making by responsible party...” 3. On September 22, 2025, at 9:08 a.m., a tour of the facility was conducted. During the tour Patient 20 was observed laying in bed with four side rails (bars on the side of the hospital bed) raised. Patient 20s’ eyes were closed, she was intubated (a breathing tube) connected to a mechanical ventilator. A concurrent interview was conducted with RN 2, who stated four side rails were raised on the bed, and four raised side rails indicate a restraint. She stated she did not have an order for restraints. On September 23, 2025, at 1:21 p.m., a record review was conducted with the Director of Pharmacy (DP). A review of the document titled [Name of Facility] History & Physical for Patient 20 dated August 25, 2025, indicated “...had a motor vehicle collision with a semi-truck on the freeway at highway speeds. She was brought in by ambulance to [Name of outside facility]. Patient was a restrained passenger [SIC] in the emergency room she complains of abdominal [stomach] pain and arrives GCS [Glasgow Coma Scale: a scoring system doctors use to measure how awake and responsive a patient is] 14 [fourteen means the patient is alert and responsive with only a slight change from normal] per [as stated by] EMS [Emergency Medical Services]. She was tachycardic [fast heart rate] in the fields [SIC: at the scene of the emergency]. In the ER she was taken to CT (Computed Tomography: a machine that takes detailed pictures inside the body) scan where her blood pressure dropped. CT abdomen [stomach] identifies atraumatic [sic: a traumatic - causing injury] left sided abdominal wall hernia [a buldge] with protruding bowel [intestines sticking out]. She underwent explore lap [SIC: Exploratory Laparotomy - surgery to explore the inside of the stomach], and partial small bowel removal [removing part of the small intestine]. She was intubated...” There was no documented evidence of orders for restraints or documented evidence of restraints in use. A P&P was reviewed with the DP. The policy indicated “...4 side-rails up on a patient hospital bed are normally considered a restraint...unless the patient...is sedated...if a patient’s condition requires all 4 side rails be raised...the initial order is good for seven (7) days...while side rails are up, document restraint use using required forms...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to employ a method for preventing and controlling the transmission of an infection when staff did not wear appropriate Personal Protective Equipment (PPE) while assisting a patient to conduct oral/mouth self-suctioning. This failure had the potential to expose the staff to potential Hospital Acquired Infection (HAI, an infection that develops in a hospital or other healthcare setting after being admitted for treatment of another condition) and pass it to other vulnerable patients in the facility. Findings: A tour of the facility was conducted on September 22, 2025, at 9:21 a.m., with the Director of Nursing and Clinical Services (DNCS). During the tour Patient 5’s door was observed to have a contact isolation precaution (measures used in healthcare settings to prevent the spread of diseases transmitted by direct or indirect contact with an infected or colonized [one who carries a microorganism on or in their body and has it growing and multiplying without causing any illness or symptoms] patient or their environment) sign on it. The Respiratory Therapist (RT, healthcare professional trained to provide care for patients with breathing and other heart and lung disorders) 1 was observed in Patient 5’s room without a mask, leaning closely towards Patient 5, a vented (mechanical device that breathes for patients who are not able to breathe effectively on their own) patient, who was performing self-mouth suctioning. An interview was conducted on September 22, 2025, at 9:25 a.m., with RT 1. RT 1 stated suction was not working at the time when she was leaning on Patient 5 while he was trying to self-mouth suction. On September 24, 2025, at 12:47 p.m., a concurrent interview and record review was conducted with the Director of Quality Management (DQM). The DQM stated mouth suctioning can generate spraying of respiratory fluids and PPE should be worn. A review of the document titled, “Respiratory Therapist Job Description,” indicated, “Job Summary: Responsible for administering safe and competent respiratory care as ordered per physician...teaching and training...Essential function...Perform effective airway management including oral/nasal airway...Demonstrate safe and appropriate suction techniques...””

“LEADERSHIP RESPONSIBILITIES CFR(s): Standard: Leadership responsibilities (1) The governing body must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 38479 Based on observation, interview, and record review, the facility failed to ensure systems were in place and operational for the tracking, prevention, and control of Hospital Acquired Infections (HAIs, an infection that develops in a hospital or other healthcare setting after being admitted for treatment of another condition) when: 1. For Patient 1, laboratory and nursing staff did not refer a critical QuantiFERON-TB Gold Test (a qualitative indirect test for Mycobacterium tuberculosis infection, an infectious disease) laboratory result to the physician; 2. The facility failed to implement early prevention and control measures to mitigate transmission of potential infection; and 3. The facility failed to provide notification for potential exposure to HAIs for an unknown number of visitors and vendors on July 7, 2025, through August 6, 2025. These failures had the potential to delay identification and control of transmission of the infecting organism, impact the health and treatment of the patients, and may cause delays in the provision of patient care. Findings: On September 22, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility. 1. An interview was conducted on September 22, 2025, at 10:30 a.m., with the Infection Preventionist (IP). The IP stated Patient 1 was admitted to the facility on July 8, 2025, for acute respiratory failure secondary to pneumonia. The IP stated Patient 1 had a fever of unknown origin for a few days, and the Director of Infection Control (DIC) ordered a QuantiFERON-TB Test on July 13, 2025. The IP stated the DIC was not notified until August 6, 2025, of Patient 1’s positive QuantiFERON-TB Test result. An interview was conducted on September 22, 2025, at 1:38 p.m., with the Director of Quality Management (DQM). The DQM stated Patient 1’s QuantiFERON-TB Test was reordered on July 31, 2025, and resulted on August 6, 2025. The DQM stated, laboratory personnel received the result of the QuantiFERON-TB Test on July 17, 2025, and they should have reported it to the nurse and the physician. The DQM stated the result for the initial QuantiFERON-TB test was missed and notification was not done. The DQM further stated the failure to notify the physician for the collection of the QuantiFERON TB test on July 14, 2025, to August 6, 2025, could result in possible exposure to HAIs by the patients, staff, and visitors, and this could delay treatment for the patients. An interview was conducted on September 22, 2025, at 2:45 p.m., with the House Supervisor (HS) 1. The HS 1 stated it was almost 21 days that the QuantiFERON-TB test result was not reported to the physician. The HS 1 stated staff and patients were exposed to Patient 1 who had a positive TB test that resulted on July 17, 2025. A review of the facility policy and procedure titled, “Critical Test Results Communication,” dated June 6, 2023, indicated, “PURPOSE: This procedure establishes guidelines to delineate responsibility and define procedures that improves the effectiveness of communication of critical results of tests...among caregivers...POLICY...ensure proper communication of critical test results. Critical results of tests...are reported to the ordering physician and/or licensed provider in a timely manner to avoid unnecessary delays in the treatment or care of the patient...” 2. On September 23, 2025, at 11:22 a.m., a concurrent interview and record review was conducted with the Laboratory Supervisor (LS) regarding Patient 1’s QuantiFERON-TB test that resulted positive on July 17, 2025. The LS stated she received the QuantiFERON-TB test result on July 17, 2025, and gave it to the nurse to file it on the patient’s chart. The LS stated she overlooked the result that it was positive. The LS stated the result was, “Out of Range and Critical or Alert”. The LS stated this should have been referred to the doctor. The LS stated that if the result was not referred on a timely manner, everyone could be exposed and it would delay treatment to the patients, employees, and visitors. An interview was conducted on September 23, 2025, at 3:30 p.m., with the DNCS. The DNCS stated when she talked to the nursing staff, including the supervisors, no one had received the result of the QuantiFERON-TB test that resulted on July 17, 2025. The DNCS stated the first time they heard of the positive TB test result was when they repeated the test on July 31, 2025. The DNCS stated they never found out there was a positive TB test result in the facility until August 6, 2025. The DNCS stated the delay in the implementation of early prevention and control measures to mitigate transmission of infection from exposure to HAIs was because they wanted to confirm if it was an active TB. The DCNS stated they had to get all the processes in place for notification for testing and follow up before they could implement the tracing and testing for staff and patients. The DNCS stated there was a 12 day delay from August 6 through August 18, 2025, before notification and testing was sent out. The DNCS stated the delay of testing could potentially result in an outbreak or spread of the disease if information was not disseminated in a timely manner. The DNCS stated, as soon as laboratory personnel received the result, they should have notified the nurse and the physician. The DNCS stated laboratory personnel did not follow the policy to ensure proper communication of critical test results and a lot of patients, staff, and visitors were exposed from July 17, 2025, through August 6, 2025, when the positive TB test result was first reported to the facility. On September 24, 2025, at 9:18 a.m., the Chief Operations Officer (COO) and DNCS were interviewed. The COO stated there was a failure to identify and escalate Patient 1’s positive Quantiferon TB test that resulted on July 17, 2025. The COO stated there was approximately 21 days of delay that had caused the potential exposure to patients, staffs, and visitors. 3. On September 22, 2025, at 10:30 a.m., the IP was interviewed regarding notifications of patients, staffs, and visitors to the potential exposure to HAIs organisms. The IP stated the County Health Officer (CHO) will notify visitors and discharged patients. An interview was conducted on September 24, 2025, at 8:59 a.m., with the COO. The COO stated there is a visitor and vendor sign in sheet to do tracking regarding the possible TB exposure in the facility and they will communicate this to the CHO. On September 26, 2025, at 3:16 p.m., the CHO stated visitors with less than 15 minutes of exposure had less chances of exposure and will follow up with the facility for visitors and vendors that went over. A review of the facility policy and procedure titled, “Guideline- Tuberculosis Control Plan,” dated April 2024, indicated, “...Identifying, Evaluating and Initiating Treatment for Patient Who May Have Active MTB (Mycobacterium Tuberculosis infection, serious infectious bacterial disease that mainly affects the lungs. The bacteria that cause TB are spread when an infected person coughs or sneezes)...The most important factors in preventing transmission of MTB are the early identification of patients who may have infectious MTB, prompt implementation of All for such patients, and prompt initiation of effective treatment for those who are likely to have MTB...Public Health Department Reports...all patients with suspected or confirmed MTB should be reported to the appropriate health department immediately for identifying and evaluating MTB contacts to be initiated...””

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 50122 Based on interview, and record review, the facility failed to conduct an MD-to-MD (MD-physician) consultation prior to transfer, for two (Patient 16 & 17) of 24 sample patients. This failure had the potential to cause the patients to have an increase in pain, jeopardized the patient’s health, safety, and well-being, and had the potential to contribute to further complications in health. Findings: On September 23, 2025, at 10:30 a.m., a review of Patient 16’s medical record was conducted with the Radiology manager (RM). 1a. On September 23, 2025, at 10:59 a.m., a review of the facility document titled, “History and Physical,” dated March 26, 2025, at 6:05 p.m., authored by MD 1, was conducted. The document indicated Patient 16 had a medical history of rheumatoid arthritis (a chronic autoimmune disease causing inflammation, pain, and damage to joints and sometimes other organs), systemic lupus erythematosus (a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues and organs), anemia (low blood count), hypertension (high blood pressure), and on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own). Patient 16 was admitted to the facility for acute on chronic respiratory failure (a sudden worsening of a pre-existing chronic respiratory condition). On September 23, 2025, at 11 a.m., a review of the facility document titled, “Change of Condition,” dated July 26, 2025, at 4:30 p.m., was conducted. The document indicated, “...Emergency discharge...Attending physician notified...[name of physician]...Family present...911 was called...” On September 23, 2025, at 11:05 a.m., a review of the facility document titled, “Patient Transfer/Discharge-Change In Level Of Care,” dated July 30, 2025, was conducted. The document indicated, “...Transferring Physician Name...name of NP 1]...” There was no documented evidence of “...Receiving Facility Contact...Title...Phone...” There was no documented evidence of a MD-to-MD consult prior to transfer from Facility A to Facility B. On September 23, 2025, at 11:10 a.m., a review of the facility document titled, “Discharge Summary,” dated July 26, 2025, was conducted. The document indicated, Patient 16 was discharged from the facility to be transferred to a higher level of care facility due to tachycardia (fast heartrate), elevated BP (blood pressure-higher than usual blood pressure), and tachypnea (abnormal, fast breathing). There was no documented evidence of an MD-to-MD consultation prior to transfer from Facility A to Facility B. On September 24, 2025, at 2 p.m., a review of the facility document titled, “Interhospital Patient Transfer Information,” form was reviewed. The document indicated a location to enter the following elements: “...Transfer Form...Transfer To...Physician Certification-Transfer acknowledgement & Consent...Transfer Risks...Transfer Benefits...Signature of Transferring Physician...Signature of Patient...” On September 24, 2025, at 3 p.m. a review of the facility document titled, “Change of condition,” dated July 26, 2025, at 4 p.m., was conducted. The document indicated, “...It was noted that physician to physician communication was not completed appropriately...” 1b. On September 22, 2025, at 3:45 p.m., a review of Patient 17’s medical record was conducted with the RM. The facility document titled, “History and Physical,” dated July 22, 2025, at 7:36 p.m., authored by MD 1, was conducted. The document indicated Patient 17 had a medical history of atrial fibrillation (irregular heartrate), contractures of the upper extremities (a chronic loss of mobility arms, caused by the shortening and stiffening of soft tissues like muscles, tendons, and ligaments) diabetes, neuromuscular disease (a disorder that impacts the nervous system’s ability to control muscles, causing symptoms like muscle weakness, wasting, or spasms), and Stage 3 chronic kidney disease (kidneys have suffered moderate damage and are not filtering waste and fluid like they should, with an estimated glomerular filtration rate (eGFR) between 30 and 59 mL/min. Stage 3 has an eGFR of 30-59. This stage can result in complications like high blood pressure, anemia, and bone disease). Patient 17 was admitted to the facility on a mechanical ventilator (a machine that takes over or assists a patient’s breathing when they cannot breathe adequately on their own), and treatment for acute-on-chronic hypoxic respiratory failure. On September 23, 2025, at 3:25 p.m., a review of the facility document titled, “Discharge Patient,” dated July 30, 2025, at 6:06 p.m., indicated a telephone order from Nurse practitioner (NP) 1. The document indicated, “...Discharge patient...to hospital [name of Facility B] ER [emergency room]...” On September 23, 2025, at 3:28 p.m., a review of the facility document titled, “Discharge Summary,” dated July 30, 2025, at 9:41 p.m., was conducted. The document indicated that Patient 17 was discharged to [name of Facility B] for higher level of care for the left comminuted humerus fracture (displaced fracture of the upper arm). On September 24, 2025, at 2:45 p.m., an interview was conducted with the DQM. The DQM stated, “...It is important for this facility to notify the accepting MD of the information about the patient and care they have received prior to transfer...we do not have a transfer policy in place...The only thing we have in place is an intrahospital form...it was not done...they should have documentation showing they did everything they could prior to the transfer to cover patient information was given prior to transferring to HLOC via Ambulance...” On September 24, 2025, at 3:45 p.m., an interview was conducted with the house supervisor (HS)2. The HS 2 stated, “...HLOC [higher level of care] transfer process...he would...get an order to transfer the patient for higher level of care...determine the type of care the patient needs that they are not able to provide. After getting an order...they send the patient to the emergency department [ED]...They get an official [name of facility] form that needs to be filled out for ED transport...It is required for a peer-to-peer communication...attending physician needs to speak with the ED physician to give endorsement...They coordinate to tell the MD-to-MD at the ED [emergency department]... “ On September 26, 2025, at 1:40 p.m., an electronic message was sent from the Director of Radiology (DOR). The DOR stated, “...I reviewed our policies and consulted with [name of COO] and [name of DQM]. We do not have a discharge policy...” A review of the facility policy and procedure titled, “...Emergency Care,” dated June 2023, was conducted. The P&P indicated, “...The physician supervises the delivery of care...is consulted when it is determined that patient care needs exceed the services provided...evaluate potential transfer or discharge options using capacity and capability information provided by potential receiving facilities...complete an accurate transfer agreement...Ensuring evaluation of capability and capacity of receiving facility prior to transfer...””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to follow their policy and procedures for 12 of 30 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9,13, 15, 28, and 30) when: 1. For Patient 1, a code blue (a medical emergency, specifically a cardiac or respiratory arrest, requiring immediate resuscitation efforts) was not initiated when Patient 1 had no pulse (see A 0398); 2. For Patients 3, 4, and 13, the continuous cardiac monitoring was initiated without a physician’s order (see A 0398); 3. For Patients 1, 2, 5, 6, and 15, the physician’s order for continuous cardiac monitoring did not include diagnosis and parameters (see A 0398); 4. For Patients 1, 2, 8, and 9, the cardiac monitoring strips were not verified by a Registered Nurse (RN) (see A 0398); 5. For Patient 3, there was no evidence that a fall risk re assessment was conducted following a fall (see A 0398); 6. For Patient 3, physician’s order for a 1:1 sitter was not implemented as ordered (see A 0398); 7. For Patients 28, and 30, nutritional assessments were not completed within the required timeframe (see A 0398); 8. For Patient 28, there was no documentation that the nutritional recommendations were implemented (see A 0398); 9. For Patient 28, weekly weights were not obtained as required (see A 0398); 10. For Patient 28, all recommended interventions to support wound healing were not utilized (see A 0398); 11. For Patient 30, there was no documentation of physician notification regarding a change in patient condition (see A 0398); 12. For Patient 30, documentation was incomplete with no record of interventions performed or medications administered during a code blue event (see A 0398); 13. For Patient 30, sedating medication was administered without documented assessment of the Richmond Agitation Sedation Scale (RASS, tool used to assess a patient’s level of sedation, ranging from combativeness [+4] to unarousable sedation [ 5]) score; (see A 0398); and 14. For Patient 30, there was no evidence of a nursing assessment conducted following a change in patient condition (see A 0398). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.”

“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: 45431 Based on observation, interview, and record review, the facility failed to ensure the facility’s policies and procedures (P&P) were implemented, for 12 of 30 sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 13, 15, 28, and 30), when: 1. For Patient 1, a code blue (a medical emergency, specifically a cardiac or respiratory arrest, requiring immediate resuscitation efforts) was not initiated when Patient 1 had no pulse; 2. For Patients 3, 4, and 13, the continuous cardiac monitoring was initiated without a physician’s order; 3. For Patients 1, 2, 5, 6, and 15, the physician’s order for continuous cardiac monitoring did not include diagnosis and parameters; 4. For Patients 1, 2, 8, and 9, the cardiac monitoring strips were not verified by a Registered Nurse (RN); 5. For Patient 3, there was no evidence that a fall risk re assessment was conducted following a fall; 6. For Patient 3, physician’s order for a 1:1 sitter was not implemented as ordered; 7. For Patients 28, and 30, nutritional assessments were not completed within the required timeframe; 8. For Patient 28, there was no documentation that the nutritional recommendations were implemented; 9. For Patient 28, weekly weights were not obtained as required; 10. For Patient 28, all recommended interventions to support wound healing were not utilized; 11. For Patient 30, there was no documentation of notification to the physician regarding a change in patient condition; 12. For Patient 30, documentation was incomplete with no record of interventions performed or medications administered during a code blue event; 13. For Patient 30, sedating medication was administered without documented assessment of the Richmond Agitation Sedation Scale (RASS,tool used to assess a patient’s level of sedation, ranging from combativeness [+4] to unarousable sedation [ 5]) score; (see A 0398); and 14. For Patient 30, there was no evidence of a nursing assessment conducted following a change in patient condition. These failures had the potential to cause a delay in patient care and harm for the patients including death. Findings: 1. A review of Patient 1’s medical record was conducted on April 1, 2025, at 2:23 p.m., with the Radiology Manager (RM). The facility document titled, “Patient registration data,” reflecting April 1, 2025, was reviewed and indicated, “Admit: 12/10/2024 [December 10, 2024]...Diagnosis: ACUTE AND CHR [chronic] RESPIRATORY FAILURE [condition where the lungs are unable to perform adequate gas exchange], UNS [unspecified] W [with] HYPOXIA [insufficient oxygen in the blood]...” A review of the facility document titled, “History and Physical,” dated December 10, 2025, indicated, “...Past medical history...Hypertension [high blood pressure], polycythemia vera[type of blood cancer]...Assessment...Acute hypoxic respiratory failure...COVID [Coronavirus Disease infection of the lungs] pneumonia [lung infection]...Plan... Patient is COVID positive...” A review of the facility document titled, “Physician’s orders,” dated December 10, 2024, indicated, “...Telemetry cardiac monitoring...start 12/10/2024 [December 10, 2025] 18:10 [6:10 p.m.], stop after 3 days...” A review of the facility document titled, “Physician’s order,” dated February 5, 2025, indicated,”...Code status: CPR [cardiopulmonary resuscitation]:no...Life sustaining treatments desired: Antimicrobials [substances that inhibit or kill microorganisms], Artificial feeding and hydration, Blood products, Vasopressors [a drug or other agent which causes the constriction of blood vessels], Anti arrhythmic [class of drugs that are used to suppress abnormally fast rhythms], Hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally]...start today 02/05/2025 [February 5, 2025]...” There was no documented evidence in Patient 1’s medical record of Patient 1’s February 7, 2025, 8 a.m., vital signs. The RM stated the last vital signs for Patient 1 was at 4 a.m., on February 7, 2025. A review of the facility document titled, “Respiratory care,” dated February 7, 2025, indicated, “...07:43 [7:43 a.m.] Pulse oximetry, continuous...Oximeter pulse...116/min [minute]...” A review of the facility document titled, “Compressed Wave Rec.[record],” dated February 7, 2025, indicated the following: On February 7, 2025, at 8:17 a.m., heart rate 67 beats per minute (bpm); On February 7, 2025, at 8:18 a.m., heart rate 63 bpm; On February 7, 2025, at 8:19 a.m., heart rate 65 bpm; On February 7, 2025, at 8:20 a.m., heart rate 60 bpm; On February 7, 2025, at 8:21 a.m., heart rate 48 bpm; On February 7, 2025, at 8:22 a.m., heart rate 47 bpm; On February 7, 2025, at 8:24 a.m., heart rate 37 bpm; On February 7, 2025, at 8:25 a.m., heart rate 40 bpm; On February 7, 2025, at 8:26 a.m., heart rate 28 bpm; On February 7, 2025, at 8:27 a.m., heart rate 0 bpm; On February 7, 2025, at 8:28 a.m., heart rate 30 bpm; On February 7, 2025, at 8:29 a.m., heart rate 30 bpm; On February 7, 2025, at 8:30 a.m., heart rate 34 bpm; On February 7, 2025, at 8:31 a.m., heart rate 33 bpm; On February 7, 2025, at 8:32 a.m., heart rate 27 bpm; On February 7, 2025, at 8:33 a.m., heart rate 16 bpm; On February 7, 2025, at 8:34 a.m., heart rate 16 bpm; On February 7, 2025, at 8:35 a.m., heart rate 0 bpm; On February 7, 2025, at 8:36 a.m., heart rate 0 bpm; On February 7, 2025, at 8:37 a.m., heart rate 0 bpm rapid response (specialized team designed to intervene early when a patient’s condition is deteriorating or at risk of deteriorating) was called; and On February 7, 2025, at 8:42 a.m., heart rate TOD (time of death). A concurrent interview was conducted on April 1, 2025, at 3:45 p.m., with the RM. The RM stated there was no documented evidence in Patient 1’s medical record that a nursing assessment was completed following Patient 1’s change of condition. The RM further stated there was no documented evidence Registry Registered Nurse (RNN) 1, assessed Patient 1, while Patient 1’s heart rate was declining. A review of the facility document titled, “Rapid Response Team and Code H Record,” dated February 7, 2025, indicated, “...Room location...Intensive Care Unit [ICU -a unit that provides the critical care and life support for acutely ill and injured patients] Room A...Time called...0837 [8:37 a.m.]...Event ended...0842 [8:42 a.m.]...Situation/ Reason for call...Asystole...Medications...Epinephrine [medication used for medical emergency](subcutaneous)...0838 [8:38 a.m.]...Other...patient expired pronounced at 0842 [8:42 a.m.]...” A review of the facility document titled, “RESTRAINT CARE PLAN (NON VIOLENT NON SELF DESTRUCTIVE BEHAVIOR,” dated February 7, 2025, indicated, “...Type of Restraint...Mitten...Left Hand...Right Hand...time...8 a.m....RN 30 Minutes Post Restraint Application Safety Check...time..8:30 a.m...” A review of the facility document titled,” Restraint Monitoring (non violent, non self destructive behavior),” dated February 7, 2025, indicated , “...safety checks and monitoring (at least q 2 hours) initialed by RRN1 at 0800 (8 a.m.), 1000 (10 a.m.), 1200 (12 N),1400 (2 p.m.),1600 (4 p.m.) and 1800 (6 p.m.)...” Further review of Patient 1’s medical record indicated there was no documented evidence a code blue was called when Patient 1’s heart rate was 0. The Director of Pharmacy (DOP) stated the Pharmacy usually keeps a copy of a code blue sheet, but there was none for February 7, 2025. A concurrent interview and record review was conducted on April 1, 2025, at 1:33 p.m., with the Monitor Technician (MT). The MT provided her notes on a document titled, “T. Trend Rec (record)”, dated February 7, 2025. The document indicated the following: Patient 1’s Name and medical record number. On February 7, 2025, at 8:15 a.m., HR (heart rate) 82 , blood pressure 68/37 mmHg (millimeter mercury unit of measurement); On February 7, 2025, at 8:16 a.m., HR 69, blood pressure 69/34 mmHg; On February 7, 2025, at 8:21 a.m., HR 45, notified (RN) HR low 40s; On February 7, 2025, at 8:24 a.m., HR 37 MT was notified by (RN) pt (patient) was DNR (do not resuscitate); On February 7, 2025, at 8:27 a.m., HR 0 RN was notified asystole; On February 7, 2025, at 8:28 a.m., HR 30 RN was notified HR picking up; On February 7, 2025, at 8:33 a.m., RN was notified HR low 10’s; On February 7, 2025, at 8:36 a.m., (Name of ICU RN) told MT to call RR (Rapid Response); RR was called; On February 7, 2025, at 8:42 a.m., (Name of MD) was paged TOD. The MT stated RRN 1 was assigned to Patient 1 on February 7, 2025. The MT stated RRN 1 was seated beside her in the ICU nurse’s station and was able to see the monitor, however, RRN1 did not respond to her several notifications of Patient 1’s low heart rate. The MT stated she was informed by RRN 1 that Patient 1 was a DNR. The MT further stated it was ICURN 4 who instructed her to call a rapid response when she learned Patient 1’s code status was DNR with life sustaining measures. An interview was conducted on April 2, 2025, at 9:30 a.m., with the Director of Nursing (DON). The DON stated the facility has no Code Blue Policy but uses the American Heart Association Advance Cardiac Life Support guidelines for patients needing emergency care such as patients without a pulse. A concurrent interview and record review was conducted on April 2, 2025, at 11:53 a.m., with the DON. The facility document titled, “American Heart Association: Adult Cardiac Arrest Circular Algorithm,” dated 2020, was reviewed. The document indicated, “...Drug Therapy ...Epinephrine IV [intravenous[/IO [intraosseous]...1 mg [milligram unit of measurement] every 3 5 minutes...” The DON stated the document did not indicate Epinephrine can be given subcutaneously during a cardiac arrest. An interview was conducted on April 2, 2025, at 1:32 p.m., with ICURN 2. ICURN 2 stated she was not assigned to Patient 1 but witnessed the interaction between MT and RRN 1. ICURN 2 stated she heard MT inform RRN 1 of Patient 1’s low heart rate however, RRN 1 did not respond. ICURN 2 further stated she did not see RRN 1 enter Patient 1’s room to assess Patient 1, nor was there a sense of urgency. ICURN 2 stated she heard ICURN 4 question RRN 1 the reason for the vasopressor (medication that constricts bloodflow) when she (RRN 1) said Patient 1 was a DNR (Do Not Resuscitate). ICURN 2 further stated, “We don’t wait 20 minutes to call the MD [Medical Doctor] during situations like this...” A concurrent interview and review was conducted on April 2, 2025, at 2:15 p.m., with the DON. The facility document titled, “Rapid Response Team and Code H Record,” dated February 7, 2025, was reviewed. The document indicated reason for the rapid response called for Patient 1 was Asystole (no pulse). The DON stated, based on this document a Code Blue should have been called rather than a rapid response. An interview was conducted on April 3, 2025, at 10:08 a.m., with ICURN 3. ICURN 3 stated she heard the MT inform RRN 1 several times about Patient 1’s low heart rate while RRN 1 was busy talking to the dialysis nurse in another patient room. ICURN 3 stated she did not see any sense of urgency from RRN 1, until the rapid response was called. A telephone interview was conducted on April 7, 2025, at 11:26 a.m., with ICURN 4. ICURN 4 stated she was sitting at the ICU nurse’s station when she heard the MT notify RRN 1 of Patient 1’s low heart rate multiple times, but RRN 1 did stand up and check on Patient 1. ICURN 4 stated she heard RRN 1 inform the MT that Patient 1 was a DNR. ICURN 4 also stated, she became suspicious when RRN 1 asked for her help to enter a vasopressor order in the computer, which triggered her to verify Patient 1’s code status. ICURN 4 further stated, when she learned Patient 1 had an order for life sustaining measures, she immediately asked the MT to call for a rapid response team, when the house supervisor checked on the patient (Patient 1), the patient (Patient 1) had already died. A review of the facility document titled, “ICU Staffing Assignment Sheet,” dated February 7, 2025, was conducted. The document indicated RRN 1 was the RN assigned to Patient 1. A review of the facility policy and procedure (P&P) titled, “CORE: Emergency Care,” dated June 2023, was conducted. The P&P indicated, “...When a patient requires emergency intervention which includes resuscitation, current ACLS guidelines are initiated until the time the physician assumes medical direction of the emergent care...” 2a. A review of Patient 3’s medical record was conducted on April 2, 2025, at 2:30 p.m., with the Radiology Manager (RM). A facility document titled, “Patient registration data,” reflecting, April 2, 2025, indicated, “Admit: 02/10/2025 [February 10, 2025]...Diagnosis: OSTEOMYELITIS [a bone infection] UNSPECIFIED...” A facility document titled, “History and Physical,” dated February 10, 2025, indicated, “...Patient...comes to us from [Name of hospital] where he was admitted there around January 29, 2025 for right foot swelling and pain. Was diagnosed with osteomyelitis and diabetic foot underwent a right BKA [below the knee amputation]... PMH [primary medical history]: coronary artery disease [condition where heart arteries are narrowed or blocked]...congestive heart failure [condition where the heart cannot pump enough blood]...” A review of Patient 3’s recorded cardiac rhythm strips (a test that records the electrical activity of the heart) was conducted on April 2, 2025, at 11:10 a.m., with the RM. The recorded cardiac rhythm strip dated March 6, 2025, indicated, “...20:16 [8:16 p.m.] SR [sinus rhythm normal heart rhythm] 84...BBB [Bundle branch block, a block or disruption to the electrical impulse that contracts your heart’s lower chambers], 1° AVB [First degree atrioventricular block, a condition of abnormally slow electrical conduction in the heart]...” The recorded cardiac rhythm strip dated March 13, 2025, indicated, “...19:35 [7:35 p.m.] SR 80...1° AVB...BBB...” The cardiac rhythm strip dated March 15, 2025, indicated, “...20:16 [8:16 p.m.] SR 74...” A concurrent interview and record review of Patient 3’s record was conducted on April 3, 2025, at 1:33 p.m., with the RM. The facility document titled,”Physician’s orders,” were reviewed. The RM stated there was no documented evidence that continuous cardiac monitoring was ordered for Patient 3. 2b. A review of Patient 4’s medical record was conducted on April 3, 2025, with the RM. A facility document titled, “Patient registration data,” reflecting, April 3, 2025, indicated, “Admit: 03/06/2025 [March 6, 2025]...Diagnosis: ACUTE AND CHR [chronic] RESPIRATORY FAILURE [condition where lungs are unable to perform adequate gas exchange], UNS [unspecified] W [with] HYPOXIA [insufficient oxygen in the blood] OR HYPERCAPNIA [too much carbon dioxide in the blood]...” A facility document titled, “History and Physical,” dated February 10, 2025, indicated, “...Patient...comes to us from [Name of hospital] where he was admitted there around January 13, 2025, for abdominal pain hematemesis [vomiting blood] and subsequently weakness and shortness of breath and swallow difficulty...required intubation...have trach [tracheostomy opening in the windpipe]...” A review of Patient 4’s recorded cardiac rhythm strips was conducted on April 3, 2025, at 3 p.m., with the RM. The cardiac rhythm strip dated March 7, 2025, indicated, “...00:14 [12;14 a.m.]...New admit...SR 84...” The recorded cardiac rhythm strip dated March 15, 2025, indicated, “...19:30 [7:30p.m.] SR 87...” A concurrent interview and review of Patient 4’s medical record was conducted on April 3, 2025, at 1:50 p.m., with the RM. The facility document titled, “Physician’s orders,” was reviewed. The RM stated there was no documented evidence in Patient 4’s medical record that continuous cardiac monitoring was ordered. 2c. A tour of the Intensive Care Unit (ICU - unit that provides the critical care and life support for acutely ill and injured patients) was conducted on April 1, 2025, at 8:45 a.m., with the Director of Pharmacy (DOP). A concurrent observation and interview was conducted in the ICU nurse’s station with the Monitor Technician (MT). The MT was observed monitoring multiple patients on a cardiac (heart ) monitor, including Patient 13. The MT stated Patient 13’s cardiac rhythm had been normal. A concurrent observation and interview was conducted on April 1, 2025, at 9:10 a.m., in Patient 13’s room. Patient 13 was observed to be awake, alert, and verbally responsive, sitting in bed connected to a cardiac monitor. Patient 13 stated she has been attached to the cardiac monitor since she was admitted to this facility. A review of Patient 13’s record was conducted on April 2, 2025, at 3:05 p.m., with the RM. A facility document titled, “Patient registration data,” dated April 3, 2025, indicated, “Admit: 01/09/2025 [January 9, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE AND HYPOXIA...” A facility document titled, “History and Physical,” dated January 1, 2025, indicated Patient 13 was admitted to the facility with a diagnosis which include respiratory failure, pneumonia (infection of the lungs) and heart failure ( a condition where the heart does not pump enough blood in the body). A concurrent interview and review of Patient 13’s record was conducted on April 3, 2025, at 3:06 p.m., with the RM. The facility document titled,”Physician’s orders,” was reviewed. The RM stated there was no documented evidence in Patient 13’s medical record that continuous cardiac monitoring was ordered by a physician. An interview was conducted on April 7, 2025, at 8:35 a.m., with the Director of Nursing (DON) and Chief Operating Officer (COO). The DON stated nurses can start patients on continuous cardiac monitoring before calling the physician for an order because it’s a noninvasive procedure. The COO stated there should be a physician’s order for cardiac monitoring on admission or before starting a patient on continuous cardiac monitoring. A review of the facility P&P titled, “CORE: Continuous Cardiac Monitoring (Telemetry),” dated June 2023, was conducted. The P&P indicated, “...Cardiac Monitoring...Is ordered by a physician...” 3a. A review of Patient 1’s record was conducted on April 1, 2025, with the RM. A facility document titled,”Patient registration data,” reflecting, April 1, 2025, indicated, “Admit:12/10/2024 [December 10, 2024]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA...” A facility document titled, “History and Physical,” dated December 10, 2025, indicated, “...Past medical history...Hypertension, polycythemia vera [type of blood cancer]...Assessment...Acute hypoxic respiratory failure...COVID Coronavirus Disease [infection of the lungs] pneumonia [lung infection]...Plan...Patient is COVID positive...” A concurrent interview and review of Patient 1’s record was conducted on April 1, 2025, at 2:40 p.m., with the RM. A facility document titled,”Physician’s orders, dated December 10, 2024, indicated, “...Telemetry cardiac monitoring...start 12/10/2024 [December 10, 2025] 18:10 [6:10 p.m.], stop after 3 days...” The RM stated the order did not indicate diagnosis and alarm parameters. 3b. A review of Patient 2’s medical record was conducted on April 2, 2025, at 10 a.m., with the RM. A facility document titled,”Patient registration data,” reflecting, April 2, 2025, indicated, “Admit: 8/24/2024 [August 24, 2024]...Diagnosis: RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA...” A facility document titled,”History and Physical,” dated August 24, 2024, indicated, “...The patient...came to us from [Name of hospital]...for respiratory distress...sepsis [severe blood infection] pneumonia...PMH [primary medical history] dementia [a condition characterized by progressive or persistent loss of intellectual functioning] and stroke [a loss of blood flow to part of the brain, which damages brain tissue] with weakness in the legs...Heart failure...” A concurrent interview and review of Patient 2’s record was conducted on April 1, 2025, at 2:40 p.m., with the RM. A facility document titled, “Physician’s orders,”dated August 25, 2024 indicated, “...Telemetry cardiac monitoring...start 08/25/2024 [August 25, 2024]...stop after 3 days...renewable...” The RM stated the order did not indicate diagnosis and alarm parameters. 3c. A tour of the ICU was conducted on April 1, 2025, at 8:45 a.m. with the DOP. A concurrent observation and interview was conducted on April 1, 2025, at 9:30 a.m., in Patient 5’s room with ICU Registered Nurse (ICURN 1). Patient 5 was observed to have a tracheostomy connected to a ventilator (a breathing machine) and a cardiac monitor. ICURN 1 stated Patient 5 needed to be on a continous cardiac monitoring due to his current diagnosis. A review of Patient 5’s medical record was conducted on April 3, 2025, at 2:28 p.m., with the RM. A facility document titled,”Patient registration data,” reflecting April 3, 2025, indicated, “Admit: 03/29/2025 [March 29, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA AND HYPERCAPNIA...” A review of a facility document titled, “History and Physical,” dated March 29, 2025, indicated, “...admitted with diagnosis of acute hypoxic respiratory failure, orally intubated, sepsis due to pneumonia and emphysema [a collection of pus that have collected inside a body cavity]...chronic heart failure...” A concurrent interview and review of Patient 5’s medical record was conducted on April 1, 2025, at 2:30 p.m., with the RM. An untitled facility document, dated December 10, 2024, indicated, “...Telemetry cardiac monitoring...start today 03/29/2025 [March 29, 2025], cont. [continuous], stop after 3 days, renewable...” The RM stated the order did not indicate diagnosis and alarm parameters. 3d. A concurrent observation and interview was conducted on April 1, 2025, at 9:35 a.m., in Patient 6’s room with ICURN 1. Patient 6 was observed to have a tracheostomy connected to a ventilator and a cardiac monitor. ICURN 1 stated Patient 6 needed to be on a continuous cardiac monitoring due to her current diagnosis. A review of Patient 6’s medical record was conducted on April 3, 2025, with the RM. A facility document titled, “Patient registration data,” reflecting, April 3, 2025, indicated, “Admit: 03/28/2025 [March 28, 2025]...Diagnosis: PERFORATED INTESTINE(NONTRAUMATIC)...” A review of a facility document titled, “History and Physical,” dated March 29, 2025, indicated, “...admitted with diagnosis of large bowel obstruction with perforation...during hospital stay, patient had new code blue [emergency code indicating medical emergency] along with Afib [atrial fibrillation irregular heartbeat]. Patient was intubated, status post trach on a vent...” A concurrent interview and review of Patient 6’s record was conducted on April 3, 2025, at 2:38 p.m., with the RM. A facility document titled,”Physician’s orders, dated December 10, 2024, indicated, “...Telemetry cardiac monitoring...start today 03/28/2025 [March 28, 2025], cont., stop after 3 days, renewable...” The RM stated the order did not indicate diagnosis and alarm parameters. 3e. A concurrent observation and interview was conducted on April 1, 2025, at 10:45 a.m., in Patient 15’s room. Patient 15 was observed sitting in bed awake, alert, and verbally responsive. Patient 15 was observed to be connected to a cardiac monitor. Patient 15 stated she does not remember how long she has been connected to a monitor. A review of Patient 15’s record was conducted on April 3, 2025, with the RM. A facility document titled, “Patient registration data,” reflecting, April 3, 2025, indicated, “Admit: 03/17/2025 [March 17, 2025]...Diagnosis:RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA...” A review of a facility document titled,”History and Physical,” dated March 29, 2025, indicated, “...admitted with diagnosis of acute hypoxic respiratory failure...history of stroke, CHF and Afib...” A concurrent interview and review of Patient 15’s record was conducted on April 3, 2025, at 3:16 p.m.,with the RM. A facility document titled, “Physician’s orders, dated March 17, 2025, indicated, “...Telemetry cardiac monitoring...start today 03/17/2025 [March 17, 2025], cont., stop after 3 days, renewable...” The RM stated the order did not indicate diagnosis and alarm parameters. A concurrent interview and review was conducted on April 3, 2025, at 3:31 p.m., at the Med (Medical) Surg (Surgical) Telemetry Unit Nurse’s station with the Med Surg Telemetry RN (MSTRN 1). The facility’s document titled, “Physician’s order,” was reviewed. The document indicated, “...Telemetry cardiac monitoring...start today 03/17/2025 [March 17, 2025], cont., stop after 3 days, renewable...” The MSTRN 1 stated diagnosis and alarm parameters were not included in the order. MSTRN 1 further stated, she does not know why Patient 15 is on a continuous cardiac monitoring and she assumes the alarm parameters are already set. A concurrent interview and policy review was conducted on April 3, 2025, at 3:40 p.m., with the DON. The policy titled,”CORE: Continuous Cardiac Monitoring (Telemetry),” dated June 2023, was reviewed. The document indicated, “...Initiation and discontinuation of cardiac monitoring...By a Physician’s order. All orders must state the diagnosis for which the cardiac monitoring is initiated and the alarm parameters...For electronic medical record orders...state the diagnosis...using the “special instructions” under the Telemetry order screen...” The DON stated diagnosis is in the H&P, and the alarm parameters are already set in the machine, so there is no need to write it on the order. 4a. A tour of the ICU was conducted on April 1, 2025, at 8:45 a.m., with the Director of Pharmacy (DOP). A concurrent observation and interview was conducted on April 1, 2025, at 8:50 a.m., in the ICU nurse’s station with the MT. The MT was observed analyzing and interpreting recorded cardiac rhythm strips. The MT stated, the recorded cardiac rhythm strips are printed, analyzed and interpreted by the MT once a shift, when there is an abnormal rhythm, or a change of condition. The MT further stated, once she has analyzed and interpreted the recorded cardiac rhythm strips, she will give it to the RNs for verification. A review of Patient 1’s medical record was conducted on April 1, 2025, with the RM. A facility document titled, “Patient registration data,” reflecting, April 1, 2025, indicated, “Admit: 12/10/2024 [December 10, 2024]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA...” A facility document titled, “History and Physical,” dated December 10, 2025, was reviewed and indicated, “...Past medical history...Hypertension, polycythemia vera [type of blood cancer]...Assessment...Acute hypoxic respiratory failure...COVID [Coronavirus Disease infection of the lungs] pneumonia [lung infection]...Plan...Patient is COVID positive...” A facility document titled, “Physician’s orders,” dated December 10, 2024, indicated, “...Telemetry cardiac monitoring...start 12/10/2024 [December 10, 2024] 18:10 [6:10 p.m.], stop after 3 days...” A review of the facility’s recorded cardiac rhythm strips was conducted on April 2, 2025, at 3:26 p.m. There was no documented evidence verification of the cardiac rhythm interpretation was conducted by an RN on the following shifts: February 7, 2025, day shift (7 a.m. 7 p.m.) 8:15 a.m.; February 6, 2025, night shift (7 p.m. 7 a.m.) 7:25 p.m.; February 4, 2025, day shift 7:21 p.m.; and February 3, 2025, day shift 7:31 a.m. 4b. A review of Patient 2’s medical record was conducted on April 2, 2025, with the RM. A facility document titled, “Patient registration data,” reflecting, April 2, 2025, indicated, “Admit: 8/24/2024 [August 24, 2024]...Diagnosis: RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA...” A facility document titled, “History and Physical,” dated August 24, 2024, indicated, “...patient...came to us from [Name of hospital]...for respiratory distress...sepsis [severe blood infection] pneumonia ...PMH [primary medical history] dementia [a condition characterized by progressive or persistent loss of intellectual functioning] and stroke [a loss of blood flow to part of the brain, which damages brain tissue] with weakness in the legs...Heart failure...” A facility document titled, “Physician’s orders,” dated August 25, 2024, indicated, “...Telemetry cardiac monitoring...start 08/25/2024 [August 25, 2024]...stop after 3 days...renewable...” A review of the facility’s recorded cardiac rhythm strips was conducted on April 2, 2025, at 11:12 a.m. There was no documented evidence verification of the cardiac rhythm interpretation was conducted by an RN on the following shifts: August 27, 2024, day shift (7 a.m. 7 p.m.) 7:32 a.m.; August 27, 2024, night shift (7 p.m. 7 a.m.) 8:10 p.m.; September 1, 2024, night shift 8:40 p.m.; September 3, 2024, day shift 7:31 a.m.; September 4, 2024, day shift 12:53 p.m.; September 9, 2024, night shift 11:38 p.m.; September 10, 2024, day shift 7:02 a.m.; September 12, 2024, night shift 7:15 p.m.; and September 15, 2024, day shift 8:34 a.m. A facility document titled, “Code Blue Sheet,” dated September 9, 2024, indicated, “...Time called: 23:40 [11:40 p.m.]...Summary of events Preceding Code/Precipitating Factors: Bradycardia [slow heart rate]...Cardiac Rhythm change...Initial signs of arrest...apnea [absence of breathing]...absence of pulse...unconsciousness...Initial rhythm...” A facility document titled,”Code Blue Sheet,” dated September 16, 2024, indicated,”...Time called: 7:32 a.m...Summary of events Preceding Code/Precipitating Factors: Cardiac Rhythm change...respiratory distress...Hypotension (low blood pressure)...Initial signs of arrest...absence of pulse...unconsciousness...Initial rhythm...PEA...” 4c. A review of Patient 8’s medical record was conducted on April 3, 2025, with the RM. A facility document titled, “Patient registration data,” reflecting, April 3, 2025, indicated, “Admit: 03/24/2025 [March 24, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE, UNSP, W HYPOXIA...” A facility document titled, “History and Physical,” dated August 24, 2024, indicated, “...Patient...came to us from [Name of hospital]...for altered level of consciousness...She was treated for desaturation of oxygen...Congestive heart failure...sepsis...” A facility document titled, “Physician’s orders,” dated March 24, 2025, indicated, “...Telemetry cardiac monitoring...start 03/24/2025 [March 24, 2025], stop after 3 days...renewable...” A review of the facility’s recorded cardiac rhythm strips was conducted on April 2, 2025, at 8:40 a.m. There was no documented evidence verification of the cardiac rhythm interpretation was conducted by an RN on the following shifts: March 29, 2025, day shift (7 a.m. 7 p.m.) 8: 31 a.m.; March 30, 2025, day shift 8:09 a.m. 4d. A review of Patient 9’s medical record was conducted on April 3, 2025, with the RM. The facility document titled, “Patient registration data,” reflecting, April 3, 2025, was reviewed. The document indicated, “Admit: 03/14/2025 [March 14, 2025]...Diagnosis: ACUTE AND CHRONIC RESPIRATORY FAILURE, UNSP, W HYPOXIA OR HYPERCAPNIA...” A facility document titled, “History and Physical, “dated March 14, 2025, indicated, “...Patient...came at the emergency department [Name of hospital] because of difficulty breathing, acute respiratory failure was intubated...past medical history CVA [cerebrovascular accident- refers to a stroke, which is an interruption of blood flow to the brain]...with right sided deficit...” A facility document titled, “Physician’s orders,” dated March 14, 2025, indicated, “...Telemetry cardiac monitoring...start 03/14/2025 [March 14, 2025], stop after 3 days...renewable...” A review of the facility’s recorded cardiac rhythm strips was conducted on April 2, 2025, at 11:15 a.m. There was no documented evidence of the RN conducting cardiac rhythm interpretation on the following shifts: - March 15, 2025, - night shift (7 p.m. - 7 a.m.)- 8:14 p.m.; - March 17, 2025, - day shift (7 a.m.- 7 p.m.) - 12:44 pm; - March 24, 2025, - night shift - 8:29 p.m.; - March 29, 2025, - day shift - 7:14 a.m.; and - March 30, 2025, - day shift - 8:18 a.m. An interview was conducted on April 2, 2025, at 2:30 p.m., with the DON. The DON stated her expectation is the RNs should verify the MT’s interpretation by signing the cardiac rhythm strip and it was not done for the abovementioned cardiac strips. A review of the P&P titled, “CORE: Continuous Cardiac Monitoring (Telemetry),” dated June 2023, was conducted. The P&P indicated, “...Monitoring, Recording, Interpreting, and Documenting Cardiac Rhythms...A qualified staff member competent in cardiac rhythm interpretation will interpret each strip and measure a recorded rate, rhythm...A qualified and competent RN will verify the strip...” 5. A review of Patient 3’s medical record was conducted on April 2, 2025, with the RM. The facility document titled, “Patient registration data,” reflecting, April 2, 2025, was reviewed. The document indicated, “Admit: 02/10/2025 [February 10, 2025]...Diagnosis: OSTEOMYELITIS [a bone infection] UNSPECIFIED...” A facility document titled, “History and Physical,” dated February 10, 2025, indicated, “...Patient...comes to us from [Name of hospital] where he was admitted there around January 29, 2025, for right foot swelling and pain. Was diagnosed with osteomyelitis and diabetic foot underwent a right BKA [below the knee amputation]...PMH [past medical history]...coronary artery disease...congestive heart failure...” A facility document titled, “Nursing Admission,” dated February 11, 2025, was reviewed and indicated, “...Vital signs, height and weight...height 5 ft [feet -unit of measurement] 11 inc [inches- unit of measurement]...weight 269.5 lbs. [pounds- unit of measurement]...Neurological assessment...Patient is independently oriented to person, place and time...Behavior: alert cooperative...Musculoskeletal assessment: Amputations: below knee[BK][right]...activity level: immobile...Fall Risk screening...Mobility status...no mobility risk factors at this time...mobility status score: 0...” A facility document titled, “Change of condition,” dated, February 18, 2025, written at 11:36 p.m., indicated, “...Patient fall: at 02/18/2025 [February 18, 2025]...05:00[5:00 a.m.] ...Comment: At around 0500 hr. [5:00 a.m.]...found pt [patient] kneeling on his left knee with his head on top of the bed...I called LVN [Licensed Vocational Nurse] [Name] so we can help him back to the bed, unfortunately he was too heavy for us...called HS [House Supervisor Name]...another male nurse from ICU...and help him to go back to bed...” A concurrent interview and review of the facility document titled, “Plan of Care,” dated February 18, 2025, indicated, “...02/28/2025 [February 18, 2025] 02:52 [ 2:52 a.m.]...Risk for falls...reviewed...” The RM stated there was no documented evidence Patient 3’s Plan of Care was updated following the fall. A concurrent interview and review of facility document titled, “Nursing Notes,” dated February 18, 2025, indicated there was no documented evidence Patient 3’s Fall risk screen was completed following the fall. The RM stated Patient 3 should have been re-assessed for fall risk after he had fallen. An interview was conducted on April 7, 2025, at 8:40 a.m., with the DON. The DON stated the fall re-assessment should be done after a fall occurs. A review of the P&P titled, “CORE: Falls Prevention,” dated June 2023, was conducted. The P&P indicated, “...Policy...The policy of [Name of facility] is to ensure the following ...Patients are re-screened for fall risk with a change of condition (i.e. change in condition, after a fall)...” 6. A review of Patient 3’s record was conducted on April 2, 2025, with the RM. The facility document titled, “Patient registration data,” reflected, April 2, 2025, was reviewed. The document indicated, “Admit: 02/10/2025 [February 10, 2025]...Diagnosis: OSTEOMYELITIS [a bone infection] UNSPECIFIED...” A facility document titled, “History and Physical,” dated February 10, 2025, indicated, “...Patient...comes to us from [Name of hospital] where he was admitted there around January 29, 2025, for right foot swelling and pain. Was diagnosed with osteomyelitis and diabetic foot underwent a right BKA [below the knee amputation]...PMH...coronary artery disease ...congestive heart failure...” A facility document titled, “Nursing Admission,” dated February 11, 2025, was reviewed and indicated, “...Vital signs, height and weight ...height 5 ft [feet -unit of measurement]11 inc [inches- unit of measurement]...weight 269.5 lbs. [pounds unit of measurement]...Neurological assessment...Patient is independently oriented to person, place and time...Behavior...alert cooperative...Musculoskeletal assessment: Amputations: below knee [BK] [right]...activity level: immobile...Fall Risk screening...Mobility status...no mobility risk factors at this time ...mobility status score: 0...” A facility document titled, “Change of condition,” dated, February 18, 2025, written at 11:36 p.m., indicated, “...Patient fall: at 02/18/2025 [February 18, 2025]...05:00[5:00 a.m.] ...Comment: At around 0500 hr. [5:00 a.m.]...found pt [patient] kneeling on his left knee with his head on top of the bed...I called LVN [Licensed Vocational Nurse] [Name] so we can help him back to the bed, unfortunately he was too heavy for us...called HS [House Supervisor Name]...another male nurse from ICU...and help him to go back to bed...” A facility document titled, “Change of condition,” dated February 19, 2025, was reviewed and indicated, “...At around 0250 hrs. [2:50 a.m.] CNA [Certified Nurse Assistant] called for help pt [patient] was lying on the floor on top of his stomach, went back to check pt and saw him crawling going to the hallway...Pt placed back to bed safely with multiple staff members using a Hoyer lift ...” A facility document titled, “Change of condition,” dated February 21, 2025, indicated, “...pt found by lvn laying down on the floor by the side of the bed around 2130 [9:30 p.m.]...RN went to the room and saw that pt laying on floor on his stomach...called for more help because patient is heavy (291.5 lbs)...” A facility document titled, “Change of condition,” dated February 21, 2025, was reviewed and indicated, “...pt again found laying on the floor around 1:30 am, house md [medical doctor], supervisor, CCO [Chief Clinical Officer][Name] and DN [Director for Nursing][Name] was also notified that multiple times pt found on the floor...educate him to fall on floor again & [and] again might cause serious injury to self...” A facility document titled, “Change of condition,” dated February 21, 2025, was reviewed and indicated, “...pt found on the floor around 0330 [3:30] a.m...notified primary MD [medical doctor] [Name] and got the orders for 1:1 sitter...” A facility untitled document dated February 21, 2025, was reviewed and indicated, “...1:1 Sitter at bedside (sic)...lack of self-awareness...q [every] shift...start 02/21/2025 [February 21, 2025]...10:00 [10:00 a.m..], stop after 90 days, renewable...” A concurrent interview was conducted on April 3, 2025, at 9 a.m., with the DON. The DON stated the facility does not have a sitter policy or a sitter form for documentation. The DON stated the CNA assigned to be a sitter will document the usual CNA documentation in the EHR (Electronic Health Record). An interview was conducted on April 3, 2025, at 9:01 a.m., with the Certified Nurse Assistant (CNA) 1. CNA 1 stated she is not sure if the facility has a sitter policy. CNA 1 stated if she is a sitter she stays with the patient and documents in the EHR the patient’s behavior every hour. An interview was conducted on April 3, 2025, at 9:06 a.m., with CNA 2. CNA 2 stated he has worked for this facility for 12 years, but is unsure if there is a sitter policy. CNA 2 stated, he sits with the patient 1:1 but sometimes he watches two patients in a room. CNA 2 further stated there used to be a sitter form that they completed but lately it has not been used and he documents his observation in the EHR every 30 minutes. An interview was conducted on April 3, 2025, at 10:01 a.m., with CNA 3. CNA 3 stated there are times she watches two patients in a room even if 1:1 sitter is required. CNA 3 further stated there is no form used while doing 1:1 sitter, and only documents her “normal patient care” in the EHR; nothing specific for the 1:1 sitter. A concurrent interview and record review was conducted on April 3, 2025, at 10:34 a.m., with the RM. The facility document titled, “Nurse’s Notes” dated February 21, 2025, through February 25, 2025, was reviewed. The RM stated there was no documented evidence of sitter documentation by the CNAs for Patient 3. A concurrent interview and record review was conducted on April 7, 2025, at 8:55 a.m., with the DON. The facility document titled, “Med-Surg-Telemetry Daily Assignment Sheet,” dated February 21, 2025, through February 25, 2025, was reviewed. There was no documented evidence a sitter was assigned to Patient 3 on the following shifts: - February 21, 2025, - Night shift (7p.m. - 7a.m.); - February 22, 2025, - Day shift; (7 a.m. - 7 p.m.); - February 22, 2025, - Night shift; - February 23, 2025, - Day shift; - February 23, 2025, - Night shift; - February 24, 2025, - Day shift; - February 24, 2025, - Night shift; and - February 25, 2025, - Day shift. The DON stated all the CNAs working the shift were rotated every four hours to be the sitter for Patient 3 however, it was not reflected on the assignment sheet. 7a. On April 2, 2025, at 10 a.m., a concurrent interview and review of Patient 28’s medical record were conducted with the Director of Pharmacy (DOP). A review of the facility document titled, “HISTORY AND PHYSICAL (H&P),” dated December 12, 2024, was conducted and indicated Patient 28 was admitted to the facility on December 12, 2024, with pneumonia (lung infection), aspiration (inhalation of food or liquid into the lungs), cerebral palsy (condition that causes problems with movement often due to brain damage) with intellectual disability, and contracture (shortening of muscles, tendons, skin that limits movement). A review of the facility document titled, “Nutrition progress note, time span: encounter 12/12/24 [December 12, 2024]...to present...” were reviewed and indicated: - “12/15/24 [December 15, 2024] DIETITIAN INITIAL ASSESSMENT NOTE...ASSESSMENT [examination]...Observed pt [patient] with severe muscle wasting of BUE [Bilateral upper extremities] and BLE [Bilateral lower extremities]. Pt also with severe fat loss of fat overlying ribs and under triceps (muscles located on the back of arm)...Current weight...92.5 lbs [pounds] BMI [Body mass index, a calculation used to assess if someone is within a health weight range]: 15.4 kg [kilogram, unit of measure]/ [per] m2 [meters squared, unit of measure] *underweight...skin condition...DTPI [deep tissue pressure injury]...L [left] medial foot; R [right] plantar [bottom] great toe...Abrasion...R knee...IAD [Incontinence Associated Dermatitis, diaper rash]...Malnutrition status: Pt meets severe malnutrition criteria...pt with severe loss of subcutaneous fat of [sp] fat overlying the rib and triceps and pt with sever muscle wasting on quadriceps [muscles located on the front of the thigh], gastrocnemius [muscle of the calf], and deltoids [shoulder muscle]...Nutrition risk level: HIGH (malnutrition/wounds)...” - “12/26/24 [December 26, 2024]...DIETITIAN FOLLOW UP ASSESSMENT NOTE...ASSESSMENT...Pt continues with severe muscle wasting and sever fat loss...Current weight...93 lbs...BMI 15.5 kg/m2 *underweight... skin condition...DTPI...L medial foot; R plantar great toe...Abrasion...R medial lower leg...IAD...Malnutrition status: Pt continues to meet severe malnutrition criteria...Nutrition risk level: HIGH (malnutrition/wounds)...” - “1/3/25 [January 3, 2025]..DIETITIAN FOLLOW UP ASSESSMENT NOTE...ASSESSMENT...Pt continues with severe muscle wasting and severe fat loss...Current weight...90 lbs...BMI 15 kg/m2 *underweight...skin condition...DTPI...L medial foot; R plantar great toe...Abrasion...R medial lower leg...IAD...Malnutrition status: Pt continues to meet severe malnutrition criteria...Nutrition risk level: HIGH (malnutrition/wounds)...” - “1/16/25 [January 16, 2025]...DIETITIAN BRIEF NOTE...Received communication from wound care coordinator that patient has developed new leg wound...” - “1/18/25 [January 18, 2025]...DIETITIAN FOLLOWUP ASSESSMENT NOTE...ASSESSMENT...Pt continues with severe muscle wasting and severe fat loss...Current weight...98.4 lbs...BMI 16.4 kg/m2 *underweight...skin condition...IAD...Excoriation [abrasion] R [right] buttock; excoriation R ischium [sit bone] Ext [excoriation] to L ischium...Mixed vascular: L dorsal toe; L medial foot; R plantar great toe; L medial malleolus [bony bump located on the outer side of the ankle]...Malnutrition status: Patient continues to meet severe malnutrition criteria...Nutrition risk level: HIGH (malnutrition/wounds)...” - “1/25/25 [January 25, 2025]...DIETITIAN FOLLOW UP ASSESSMENT NOTE...ASSESSMENT...Pt continues with severe muscle wasting and severe fat loss...Current weight...94.5 lbs...BMI 15.7 kg/m2 *underweight...skin condition...IAD...Excoriation R buttock; excoriation R ischium Ext to L ischium...Mixed vascular: L dorsal toe; L medial foot; R plantar great toe; L medial malleolus Malnutrition status: Patient continues to meet severe malnutrition criteria...Nutrition risk level: HIGH (malnutrition/wounds)...” - “2/1/25 [February 1, 2025]...DIETITIAN FOLLOW UP ASSESSMENT NOTE...ASSESSMENT...TF [tube feeding] pump paused d/t [due to] clog. Pt continues with sever muscle wasting and severe fat loss...Current weight...95.62 lbs...BMI 15.7 kg/m2 *underweight...skin condition...IAD...Excoriation R buttock; excoriation R ischium Ext to L ischium...Mixed vascular: L dorsal toe; L medial foot; R plantar great toe; L medial malleolus...Abrasion...R medial malleolus; R knee...Malnutrition status: Patient continues to meet severe malnutrition criteria...Nutrition risk level: HIGH (malnutrition/wounds)...” On April 2, 2025, at 1:45 p.m., an interview and review of Patient 28’s medical record was conducted with the Clinical Nutritional Manager (CNM). The CNM stated, Patient 28 was at a high risk for nutrition status throughout hospitalization and should have been seen every seven days or sooner and this did not occur. The CNM stated the P&P was not followed and this patient should have been assessed by the dietitian more frequently. A review of the P&P titled, “CORE: Interdisciplinary Assessment and Re-assessment,” dated June 2023, was conducted. The P&P indicated, “Nutrition Services...The registered dietitian identifies patients needing further monitoring/evaluation. Examples of patients that may need further monitoring include, but are not limited to patients...Receiving enternal or parenteral nutrition...Having a significant unintentional weight change...Having a pressure injury or wound...Having non-severe or severe malnutrition...Notify and consult with providers regarding patient’s current nutritional status or significant changes in nutritional status...Reassess patient upon significant change of condition in nutritional status...” A review of a facility document titled, “GENERAL STANDARD OF PRACTICE BY PRIORITY/LEVEL OF CARE,” was conducted. The form indicated, RD [Registered dietitian] review for Priority assignment Based on identification of need...High Risk...The following dx [diagnosis]...Starvation-Malnutrition...Wounds...Reassessment 1 x [time] week...3 - [to] 7 days...” 7b. On April 3, 2025, at 2 p.m., a concurrent interview and review of Patient 30’s record was conducted with the DOP. A review of the facility document titled, “HISTORY AND PHYSICAL (H&P),” dated March 20, 2025, was reviewed and indicated Patient 30 was admitted to the facility on March 20, 2024, with respiratory failure (breathing stops), pneumonia, COVID infection, heart failure, end stage renal (kidney) disease on dialysis (treatment that clean the blood when kidney’s aren’t working properly), diabetic vascular disease (damaged blood vessels due to diabetes) and status post respiratory failure and cardiac arrest (heart stops) with residual anoxic encephalopathy (brain damage caused by a lack of oxygen) and metabolic encephalopathy (change in how brain works). A review of the facility document titled, “List of orders for: [Name of Patient 30]” was conducted. It indicated, Physician order “Dietitian consult - enteral nutrition [a way of delivering nutrients directly into the stomach through a tube]: for recommendations on investigation of problem and its etiology [cause], on TF [tube feeding]/ADMISSION.” There was no documented evidence that a nutritional assessment was completed for Patient 30. On April 3, 2025, at 2:45 p.m., a concurrent interview and review of Patient 30’s medical record was conducted with the Chief Clinical Officer (CCO). The CCO stated a nutritional assessment was not completed for Patient 30, and the dietitian should have completed an assessment, and this was not done. A review of the P&P titled, “CORE: Interdisciplinary Assessment and Re-assessment,” dated June 2023, was conducted. The P&P indicated, “Nutrition Services...The registered dietitian completes an assessment within 72 hours of admission and initiates appropriate interventions and goals...Documentation of assessments, care plan updates, nutrition interventions, and nutrition education is completed in the medical record...” 8. On April 2, 2025, at 1:45 p.m., a concurrent interview and review of Patient 28’s medical record was conducted with the CNM. A review of the facility documents titled, “Nutrition progress note, time span: encounter 12/12/24 [December 12, 2024]...to present...” were reviewed and indicated the following interventions and recommendations by the dietitian: -12/15/24 [December 15, 2024] “Diet/Intake...Meeting 84 % [percent] of estimated kcal [caloric] needs and 81% of estimate pro [protein] needs...Water flush: none per chart review...Supplement: None...Recommend formula change...water flushes q4h [every 4 hours] to prevent tube occlusions and meet estimated hydration needs...Juven [a supplement to improve wound healing]...Multivitamin daily for optimized skin integrity...” -12/26/24 [December 26, 2024] “Diet/Intake...Meeting 84% of estimate kcal needs and 81% of estimated pro needs...Water flush: none per chart review...Supplement: None...Recommend formula change...water flushes q4h to prevent tube occlusions and meet estimated hydration needs...” -1/3/25 [January 3, 2025] “Diet/Intake...Meeting 84% of estimate kcal needs and 81% of estimated pro needs...Water flush: none per chart review...Supplement: None...Recommend increasing rate of Jevity [name of tube feeding formula]...water flushes q4h to prevent tube occlusions and meet estimated hydration needs...” -1/16/25 [January 16, 2025] “Recommend daily multivitamin...Juven...Continue Jevity at increased rate...Please add water flush order...Consider vitamin C supplementation if skin worsens...” -1/18/25 [January 18, 2025] “Diet/Intake...Meeting 100% of estimated kcal needs and 100% pro...Water flush: none per chart review...Supplement: None...Recommend...water flushes q4h to prevent tube occlusions and meet estimated hydration needs...” -1/25/25 [January 25, 2025] “Diet/Intake...Meeting 100% of estimated kcal needs and 100% pro...Water flush: none per chart review...Supplement: None...Recommend...water flushes q4h to prevent tube occlusions and meet estimated hydration needs...” -2/1/25 [February 1, 2025] “Diet/Intake...Meeting 100% of estimated kcal needs and 100% pro...Water flush: none per chart review...Supplement: None...Recommend...water flushes q4h to prevent tube occlusions and meet estimated hydration needs...” -2/5/25 [February 5, 2025] “Obtained authorization from [Name of Physician-MD 2] to add Juven BID [twice daily] to diet order. Juven now added...” The CNM stated recommendations are discussed in interdisciplinary care transitions meetings weekly and stated she was not sure why the recommendations were not followed. There was no evidence in the record the physician was notified of the dietitian recommendations. On April 3, 2025, at 9:45 a.m., a concurrent interview and review of Patient 28’s record were conducted with the Wound Care Coordinator (WCC). A facility document titled, “Nurses notes,” dated 2/4/25 [February 4, 2025], was reviewed and indicated Patient 28 developed an unstageable pressure injury (a bed sore, type of pressure ulcer where the wound bed is covered by slough [dead tissue that appears yellow or white that can hinder healing and increase risk of infection] or eschar [dry, thick black or brown layer of dead skin], making it impossible to determine the depth or stage of the wound) to the right buttock. The WCC stated starting the Juven supplement earlier in Patient 28’s hospital stay could have helped the skin improve and possibly prevent the progression of the excoriation to patient’s buttock to become an unstageable wound. The WCC further stated that dietitian will alert the WCC if recommendations are not followed, and this was not done. On April 3, 2025, at 10:10 a.m., a concurrent interview and review of Patient 28’s record was conducted with the RM. The RM stated dietitian recommendations for Jevity change, water flushes and supplements were not followed. RM stated there was no documentation in the record that the physician was notified of dietitian recommendations for Patient 28. On April 3, 2025, at 10:45 a.m., a concurrent interview and review of Patient 28’s record was conducted with the DOP. The DOP stated water flushes were ordered by the physician on February 3, 2025, and none were ordered prior to that. A review of the P&P titled, “CORE: Interdisciplinary Assessment and Re-assessment,” dated June 2023, was conducted. The P&P indicated, “Nutrition Services...The registered dietitian communicates the initiation of interventions to healthcare providers through established communication tools/meetings such as 24 hour nursing report, morning stand-up meeting, nurse’s aide assignment sheet, care plan, ICT [Interdisciplinary Care Transitions] plan/meeting, tray card/ticket, and direct conversations with healthcare providers...Through ongoing monitoring, nutrition interventions are evaluated for effectiveness...Notify and consult with providers regarding patient’s current nutritional status...” 9. On April 3, 2025, at 10:10 a.m., a concurrent interview and review of Patient 28’s medical record was conducted with the RM. A review of an untitled facility document was conducted and indicated Patient 28’s weights were: -December 12, 2024, - 92.5 lbs -December 20, 2024, - 93 lbs -December 27, 2024, - 95.5 lbs -January 3, 2025, - 90 lbs -January 8, 2025, - 98.5 lbs -January 10, 2025, - 98.4 lbs -January 17, 2025, - “sch [scheduled]” -January 24, 2025, - 94.5 lbs -January 31, 2025, - 95.62 lbs -February 6, 2025, - “dc [discharged]” The RM stated all patients are weighed weekly. The RM stated Patient 28 was not weighed on January 17, 2025. The RM stated the facility’s policy was not followed. A review of the P&P titled, “CORE: Weight Measurement,” dated June 2021, was conducted. The P&P indicated, “The policy of [Name of facility] is to ensure proper measure of patient weights...Weight measurement is scheduled as follows...Weight within 24 hr [hour] of admission...Weekly thereafter...” 10. On April 3, 2025, at 10:25 a.m., a concurrent interview and review of Patient 28’s record was conducted with the Wound Care Coordinator (WCC). A review of a facility document titled, “Nursing admission,” dated December 13, 2024, was reviewed and indicated, “Integumentary [skin] assessment...Braden scale [tool used to assess how likely a person is to develop a pressure sore, ranging from 6-23 where lower score indicate higher risk]: 11...moisture: 3, occasionally moist...WCN [wound care nurse] evaluated pt upon admission...Pt has wounds to right knee, left medial foot...deep tissue pressure injury (pressure sore deep within the skin that appears as purple or maroon), right plantar great toe...deep tissue pressure injury...Incontinence associated dermatitis “erythema (redness)/ dermatitis with or without candidiasis (yeast)...perineum (genital area) /buttocks” The WCC stated a weekly wound assessment is completed weekly using BWAT (Bates Jensen Wound Assessment tool, a method used to evaluate and track the status of a wound). Weekly wound assessments reviewed and indicated: -December 17, 2024, - no changes, Braden 12, moisture 3, occasionally moist -December 24, 2024, - no change to prior wounds, developed abrasion to R [right] medial lower leg, Braden 11, moisture 3, occasionally moist -December 31, 2024, - no change to prior wounds, Incontinence associated dermatitis, “denuded/eroded [skin that has lost its top layer appearing raw due to factors such as moisture or friction],” developed new excoriation [skin that is damaged due to prolonged contact with wetness] to R buttock, “acquired after admission...partial thickness skin loss involving epidermis [outermost layer of skin] &/or [and, or] dermis [thick, middle layer of skin beneath epidermis]”, measuring 2 c.m. [centimeter, unit of measure] x [by] 1.5 c.m., Braden, 12, moisture 1, constantly moist -January 7, 2024, - no change to prior wounds, developed new excoriation to R Ischium (sit bone) extending to L ischium measuring 4.5 c.m. x 7 c.m., “acquired after admission...partial thickness skin loss involving epidermis &/or dermis...Per [name of provider, PA], ok to reclassify [change how the wound is classified]” previous wounds [L medial foot, R plantar great toe], as “MIXED VASCULAR [wound, often on lower leg, caused by a combination of problems with both the arteries and veins, leading to poor circulation]” -January 14, 2024, - developed new mixed vascular wound to left medial malleolus [bony bump located on the outer side of the ankle], excoriation to R ischium extending to L ischium measuring 2.5 c.m. x 9 c.m., partial thickness skin loss involving epidermis &/or dermis, Incontinence associated dermatitis, denuded/eroded, measuring 50% of perineum, 50% of buttocks, excoriation to R buttock measuring 2 c.m. x 1 c.m., partial thickness skin loss involving epidermis &/or dermis, Braden 11, moisture 3, occasionally moist -January 21, 2025, - no change to prior wounds, excoriation to R ischium extending to L ischium measuring 4 c.m. x 8 c.m., partial thickness skin loss involving epidermis &/or dermis, excoriation to R Buttock “hospital acquired,” measuring 3 c.m. x 2 c.m., partial thickness skin loss involving epidermis &/or dermis, Braden 11, moisture 3, occasionally moist -February 4, 2025, - “Pressure Injury: R buttock...acquired after admission...unstageable slough and eschar...length 4 c.m....width...4.5 c.m....depth...1 c.m....obscured by necrosis (dead tissue)...Wound declined to UTD [unstageable] from excoriation...” Braden 11, moisture 3, occasionally moist The WCC stated all patients are placed on a “Atmos Air” support surface on admission to help with pressure redistribution. The WCC stated Patient 28 was turned every two hours. The WCC stated the “Skin IQ Microclimate Manager (a mattress cover system that helps to reduce or maintain skin temperature while helping to prevent excess moisture on the skin)” was not available for the facility to utilize. The WCC further stated if the facility had this surface, it would have been utilized for Patient 28 due to incontinence and associated dermatitis and wounds. The WCC stated this surface can help patients with moisture related skin conditions and Patient 28 met the criteria. The WCC stated the “representative has not been in to in-service staff” on the Skin IQ Microclimate Manager yet. On April 2, 2025, at 12:10 p.m., an interview was conducted with the DON. The DON stated although the facility P&P stated to use the “Skin IQ Microclimate Manager” for patients with moisture associated skin damage, “this is a corporate policy for all [Name of Facility] Hospitals” and this facility did not have this system available for patients. A review of P&P titled, “Core Support Surfaces,” dated June 2022, was conducted. The P&P, indicated, “The Wound Care Team or designee determines when patients meet criteria for advanced specialty surfaces based on assessment and characteristics of the support surface...Patients are placed on Enterprise Frame with AtmosAir support surface upon admission...Clinical considerations for use...Atmos Air Support Surface...The standard for all patients upon admission. The first line of prevention and treatment...Skin IQ Microclimate Manager...Meets criteria for Enterprise frame and AtmosAir...Braden moisture subscale of 1 [one] or 2 [two] or actively being treated for moisture associated skin damage. 11. On April 3, 2025, at 2 p.m., a concurrent interview and review of Patient 30’s record was conducted with the DOP. A review of the facility document titled, “HISTORY AND PHYSICAL (H&P),” dated March 20, 2025, was conducted and indicated Patient 30 was admitted to the facility’s Intensive Care Unit (ICU, unit for critically ill patients ) on March 20, 2024 with respiratory failure (breathing stops), pneumonia, COVID infection, heart failure, end stage renal (kidney) disease on dialysis (treatment that clean the blood when kidney’s aren’t working properly), diabetic vascular disease (damaged blood vessels due to diabetes) and status post respiratory failure and cardiac arrest (heart stops) with residual anoxic encephalopathy (brain damage caused by a lack of oxygen) and metabolic encephalopathy (change in how brain works). The patient was with an ET (Endotracheal tube, a flexible tube inserted into the windpipe through the mouth to help a person breath) tube on a ventilator (machine that assists with breathing). A review of facility document titled, “Change of condition,” dated March 24, 2025, at 4:11 a.m., indicated, “...patient pulled his EET resp [respiratory] tech [technician] inform at 03/23/20205 [March 23, 20205] 22:00 [10 p.m.]...no signs of distress as of now post extubation [removal of breathing tube]...” There was no documented evidence in Patient 30’s medical record a physician was notified of this change in condition. A review of facility document titled, “Change of condition,” dated March 24, 2025, at 8:39 a.m., indicated, “...called for code re-intubation at 03/24/2025 [March 24, 2025] 04:20 [4:20 a.m.]...Treatment initiated: intubation [procedure where an ET tube is placed to assist a patient with breathing on a ventilator]...Levophed [medication used to treat life threatening low blood pressure] drip [infusion]...Dopamine [medication used to treat low blood pressure] drip...Epinephrine [emergency medication used to treat life threatening conditions] iv [intravenous] push...patient resuscitation done with no good result lost his vitals [sp] signs [measurements that indicate how well body is functioning] and pronounced dead at 5:20 a.m....Patient was intubated at 04:20 [4:20 a.m.] by DR [Name of Doctor- MD 1)...” On April 4, 2025, at 9 a.m., a concurrent interview and record review was conducted with the DOP and the RM. Both the DOP and the RM stated the change of condition on March 24, 2025, at 4:11 a.m., when Patient 30 pulled out his ET tube, should have been reported to the patient’s physician and family and this was not done per facility policy. On April 4, 2025, at 11 a.m., an interview was conducted with MD 1. MD 1 stated he works the night shift at the facility and did not receive notification that Patient 30 had self-extubated himself. MD 1 further stated that he was notified by the respiratory therapist that the patient was not doing well and to go see the patient. MD 1 stated he re-intubated the patient without difficulty and a few minutes later, the patient lost his pulse, and a code blue (hospital emergency code signaling a life-threatening situation) was called. MD 1 stated the patient was a chemical code (when a patient does not want compressions but allows medications should the heart stop). MD 1 stated Patient 30 did not respond to medications and expired. On April 4, 2025, at 2:15 p.m., an interview was conducted with Patient 30’s Primary Physician (MD 2). MD 2 stated when Patient 30 self-extubated himself, a physician should have been notified to get new orders. MD 2 stated he was surprised to find out the following day that Patient 30 had expired as he had not been notified of the patient’s death. A review of the P&P titled, “CORE: Interdisciplinary Assessment and Re-assessment,” dated June 2023, was conducted. The P&P indicated, “...Reporting/Notification of a Change of Condition...An acute change in condition is a clinically important change from a patient’s established and documented baseline...Notification Responsibilities When an Assessment Reveals a Change or Suspected Change in Condition...The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient’s primary physician or designee using appropriate channels and chain of command for assuring that there is physician response...Document change of condition, notification and interventions in the medical record...” 12. On April 4, 2025, at 9 a.m., a concurrent interview and review of Patient 30’s medical record was conducted with the DOP. The facility document titled, Change of Condition, dated March 24, 2025, at 3:50 a.m., indicated “...ABG [Arterial blood gases, blood test that measures levels of oxygen and carbon dioxide in the blood] was obtained...showed [Name of MD 1]. MD 1 chose to reintubate patient...no complications...Patient placed back on vent [ventilator]...no pulse found...Code blue lasted approximately 40 min [minutes]. Pt was pronounced, vent was removed from patient...” A review of facility document titled, “Change of condition,” dated March 24, 2025, at 8:39 a.m., indicated, “...called for code re-intubation at 03/24/2025 [March 24, 2025] 04:20 [4:20 a.m.]...Treatment initiated: intubation [procedure where an ET tube is placed to assist a patient with breathing on a ventilator]...Levophed [medication used to treat life threatening low blood pressure] drip [infusion]...Dopamine [medication used to treat low blood pressure] drip...Epinephrine [emergency medication used to treat life threatening conditions] iv [intravenous] push...patient resuscitation done with no good result lost his vitals [sp] signs [measurements that indicate how well body is functioning] and pronounced dead at 5:20 a.m....Patient was intubated at 04:20 [4:20 a.m.] by [Name of Doctor- MD 1)...” Further review of Patient 30’s medical record indicated there was no documented evidence of the code blue sheet. The DOP stated there should have been a code sheet in the record documenting all medications administered and interventions performed during the code blue event. The DOP further stated that Levophed, Dopamine, and Epinephrine were removed from the Pyxis [automated medication dispensing system] but not documented on the Medication Administration Record. The DOP stated the policy was not followed. A review of the P&P titled, “CORE: Resuscitative Services for Specialty Units,” dated June 2023, was conducted. The P&P indicated, “...Documentation...Events (including the arrival of emergency personnel) are documented in the patient’s medical record. Documentation may include but is not limited to...Code team record sheet...” A review of the P&P titled, “CORE: Administration of Medications via Injection,” dated June 2022, was reviewed. The P&P indicated, “...The individual administering the medication(s) must document after administration in the patient’s medical record...” 13. On April 3, 2025, at 2 p.m., a concurrent interview and review of Patient 30’s medical record was conducted with the DOP. The facility document titled, “Controlled Substance/ Sedative infusion Flowsheet,” dated March 23, 2025, indicated Patient 30 was on a Dexmedetomidine (medication administered for sedation while on the ventilator) infusion. Patient 30’s RASS (Richmond Agitation-Sedation Scale, tool used to assess a patient’s level of sedation, ranging from combativeness [+4] to unarousable sedation [-5]) score: -3:30 p.m., -2 Light sedation -5 p.m., -2 Light sedation -7 p.m., -2 Light sedation -9 p.m., -2 Light sedation -11 p.m., no documentation -1 a.m., no documentation -3 a.m., no documentation The DOP stated the RASS score is documented every two hours when a patient is on a Dexmedetomidine infusion. The DOP stated there was no documentation on March 4, 2025, at 11 p.m., 1 a.m., and 3 a.m.. The DOP further stated the policy was not followed. Patient 30 was no longer on the ventilator during this time. A review of P&P titled “CORE: Controlled Substance/Sedative and PCA [Patient Controlled Analgesia [type of pain management that lets a patient decide when to take a dose of pain medicine],” dated June 2021, was conducted. The P&P indicated, “...Documentation...The nurse on duty will document appropriate monitoring parameters...Monitoring...Pain level, sedation level (Richmond Agitation Sedation Scale), vital signs, respiratory rate, and dosing parameters outlined on the respective flowsheet will be monitored and documented every 15 minutes on initiation for the first hour and then at least every two hours and as needed...” 14. On April 4, 2025, at 9 a.m., a concurrent interview and review of Patient 30’s medical record was conducted with the DOP. A facility document titled, “Change of Condition,” dated March 23, 2025, at 10 p.m., indicated “...RN [Registered Nurse] called RT [Respiratory Therapy] department, stated pt [patient] had self-extubated. Pt was stable satting [Oxygen saturation, amount of oxygen in the blood] 100% on room air...nasal cannula was placed on patient...” The facility document titled, “Controlled Substance/ Sedative infusion Flowsheet,” dated March 23, 2025, indicated the patient continued on a Dexmedetomidine (medication administered for sedation) infusion following the self extubation. There was no documented evidence in Patient 30’s medical record that a nursing assessment was completed following the change of condition for Patient 30. The DOP stated there was no documentation that the Dexmedetomidine infusion, used to sedate the patient, was discontinued following the self extubation when the patient was no longer on the ventilator. Patient 30 later required re-intubation and had a cardiac arrest and expired. On April 4, 2025, at 2:15 p.m., an interview was conducted with MD 2. MD 2 stated a Dexmedetomidine infusion is common when a patient is on the ventilator and helps with agitation and keeps patients from pulling at lines, also Dexmedetomidine is administered when a patient is weaning (coming off) from the ventilator to avoid bucking the vent (a situation where a patient on mechanical ventilation exhibits signs of distress because their breathing efforts are not synchronized with the ventilator’s settings). MD 2 stated Dexmedetomidine is a sedating medication and would be stopped once the patient self-extubates, Dexmedetomidine “can knock people out” causing them to stop breathing. Other medication could be ordered for agitation if necessary. MD 2 stated Dexmedetomidine can lead to Hypoxia which can then cause cardiac arrest. A review of the P&P titled, “CORE: Interdisciplinary Assessment and Re-assessment,” dated June 2023, was conducted. The P&P indicated “...Patient reassessment is based on but not limited to the following...to evaluate patient response to care, treatment and services...to respond to a significant change in status and/or diagnosis or condition...All nursing assessment(s)/reassessments are recorded in the patient medical record by a licensed nurse...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 47071 Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P), for two of 31 sample patients (Patients 4 and 18), when Patients 4, and 18’s soft wrist restraints were not monitored every two hours. These failures had the potential to impact the health and treatment of the patients and may cause harm to the patient. Findings: 1. On January 27, 2025, at 9 a.m., a tour of the Medical/Surgical unit was conducted with the Interim Director of Quality Management (DQM). During the tour of the Medical/Surgical Unit with the DQM, in Patient 4’s room, Patient 4 was observed with soft wrist restraints on both wrists. During a concurrent interview on January 27, 2025, at 9:45 a.m., the Licensed Vocational Nurse (LVN) 1 stated the soft wrist restraints were placed on Patient 4’s wrists because Patient 4 was pulling the trach (surgical opening in the trachea (windpipe) to provide an airway for breathing) and tubing and nasogastric tube (NGT, a feeding tube). A review of Patient 4’s medical record was conducted on January 27, 2025, at 2:15 p.m., with the Education Manager (EM). The facility document titled, “History and Physical” dated December 26, 2024, indicated, “...Date of Admission: December 26, 2024...Diagnosis...Acute and Chronic Respiratory failure, unspecified with hypoxia [not enough oxygen to the body] or hypercapnia [excessive carbon dioxide in the blood]. The facility document titled, “[Facility Name] Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior).” The document indicated, “...Restraint Episode Began: 1/20/25 [January 20, 2025] Episode Day # [number] 7 [seven]...Safety Checks and Monitoring (at least Q [every] 2 [two] hours)...Daily Assessment to Determine Need for Restraint(s)...timed 08:00 a.m....dated 1/26/25 [January 26, 2025].” There was no documented evidence the RN completed the Daily Assessment to determine the need for restraint(s) and signed the Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior). During further review of Patient 4’s medical record, the facility document titled, “[Facility Name] Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior)” indicated, “...Restraint Episode Began: Episode Day # [number]...Safety Checks and Monitoring (at least Q 2 hours)...Range of motion offered/provided...food/fluids offered/provided...Toileting offered/provided...Dignity/comfort/hygiene maintained...managed safety/no injury...mental status unchanged...skin integrity unchanged...temporary release during care giving...circulatory status of restrained extremities unchanged RN ONLY...Pain managed per policy RN ONLY...08 [8 a.m.] signed...10 [10 a.m.] signed...Daily Assessment to Determine Need for Restraint(s)...RN signature...” There was no documented evidence of the RN Episode Began date, identified episode number, assessed the patient every two hours, and completed the daily assessment from 12 p.m. to 2 p.m., to determine need for restraints. An interview was conducted on January 27, 2025, at 2:17 p.m., with RN 1. RN 1 stated she did not complete the 2 hour assessment and document per the facility policy. RN 1 further stated she should have completed the assessment. An interview was conducted on January 27, 2025, at 2:30 p.m., with the EM. The EM stated the nurse did not assess the patient and document the assessment every two hours. The EM stated there is no documentation the nurse monitored the patient between 12 p.m. and 2 p.m. The EM further stated the nurse is to visibly assess the patient every two hours. 2. A tour of the Medical Surgical Unit was conducted on January 27, 2025, at 9:30 a.m., with the Director of Radiology (DOR). During the tour of the Medical surgical Unit, in Patient 18’s room, Patient 18 was observed having bilateral wrist restraints on. The DOR stated Patient 18 had been pulling on the tubes and lines, and needed the restraints for safety. On January 27, 2025, at 2:45 p.m., a review of Patient 18’s record was conducted with the DOR. The facility document titled, “History and Physical ( H&P)”, dated January 15, 2025, indicated Patient 18 was admitted on January 15, 2025, for Acute and Chronic Respiratory Failure with hypoxia or hypercapnia. Patient 18 had a medical history of diabetes (a chronic disease that occurs when the body can’t produce or use insulin properly), acute renal failure (a sudden decrease in kidney function) with hemodialysis (a medical procedure that filters waste products and excess fluid from the blood when the kidneys are no longer able to do so), and hypertension (elevated blood pressure). On January 27, 2025, at 3:15 p.m., a review of the facility document titled, “Restraint Care Plan,” indicated, “Type of Restraint - limb/soft...location...left wrist...right wrist...restraint initiation...risk of injury to self due to inability to understand or remain oriented...disturbing monitoring equipment or necessary treatment modality (i.e. Pulling at Lines/Tubes/Drains)...lack of safety awareness/doesn’t seek assistance...unsuccessful attempts to redirect behavior...” The document further indicated a signature from the physician on January 27, 2025, at 8 a.m. On January 27, 2025, at 3:30 p.m., a review of the facility document titled, “Safety Checks and Monitoring,” dated January 27, 2025, was conducted, and there was no documented evidence Patient 18’s restraint assessment was conducted at 12 p.m. and 2 p.m. On January 27, 2025, at 3:35 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she should have assessed and documented the restraints. She further indicated she did not complete the documentation for 12 p.m. and 2 p.m. On January 27, 2025, at 4 p.m., an interview was conducted with the House Supervisor (HS). The HS stated, “...the documentation and assessment should have been completed with today’s information at the time of assessment and it was not done...” On January 28, 2025, a review of the facility’s P&P titled, “Core: Physical Restraints [Violent and Non-Violent Behavior] and seclusion,” dated June 2023, was conducted. The policy indicated, “...Ongoing safety checks & [and] monitoring at least every two hours or as noted on the designated forms by the patient’s clinical team of the patient’s response to the restraint, including any condition changes...visually observe the patient at least every 2 hours for safety needs....all documentation of the patient’s status should be in real time...””

“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: 47071 Based on observation, interview and record review, the facility failed to follow their policies and procedures (P&P), for six of 31 patients (Patients 2, 3, 6, 7, 10 and 31) when: 1. For Patient 10, did not receive a CHG bath daily, 2. For Patient 10, tracheostomy care was not completed, 3. For Patient 2, foley catheter care was not provided once per shift, 4. For Patient 2 and 3, central line tubing was not changed, 5. For Patient 31, facility did not ensure proper personal protective equipment was worn while providing patient care; 6. For Patient 6, staff did not maintained a sterile field for a sterile procedure, 7. For Patient 7, facility failed to notify provider when an occult blood lab was canceled. The cumulative effects of these failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care. Findings: 1. On January 29, 2025, at 1:24 p.m., Patient 10’s medical record was reviewed with the Director of Radiology (DOR). The facility document titled, “History and Physical,” dated December 7, 2024, was reviewed and indicated Patient 10 was admitted for Acute (less than 6 months) and Chronic (longer than 6 months) Respiratory failure, unspecified with hypoxia (not enough oxygen to the body) or hypercapnia (excessive carbon dioxide in the blood). A review of the facility’s untitled, and undated document was conducted on January 29, 2025, at 2:05 p.m., with the DOR. It indicated Patient 10 did not receive a chlorhexidine bath (CHG, special bath to prevent infection) on the below dates and shifts: December 8, 2025, a.m. (6:30 a.m. to 7:00 p.m.) and p.m.(7:00 p.m. to 6:30 a.m.) shifts, December 9, 2025, a.m. and p.m. shifts, December 10, 2025, a.m. and p.m. shifts, December 15, 2025, a.m. and p.m. shifts, December 17, 2025, a.m. and p.m. shifts, December 26, 2025, a.m. and p.m. shifts; and January 3, 2025, a.m. and p.m. shifts. The DOR indicated, there was no documented evidence a CHG bath was given to Patient 10 on the dated and shift listed above. An interview was conducted on January 30, 2025, at 9:40 a.m., with the Infection Prevention (IP). The IP stated the facility does not have a policy for giving the patient a CHG bath. The facility uses a tool for guidelines or suggestions for the use of a CHG Bath. The IP further stated currently the CHG bath is given daily to every patient to reduce the Multidrug-Resistant Organisms (MDRO, a drug resistant microorganism) transmission. The IP stated the nurses will document the CHG bath in the electronic medical record under the hygiene section. A review of the facility’s resource titled, “Procedure-Chlorhexidine Bathing and Decolonization,” dated June 2023 was conducted. It indicated, “...CHG bathing should be considered part of the hospital’s risk reduction strategy in infection prevention...CHG bathing as part of quality improvement...Patient’s plan of care is updated to reflect the CHG bath...” 2. On January 29, 2025, at 1:24 p.m., Patient 10’s medical record was reviewed with the DOR. The facility document titled, “History and Physical,” dated December 7, 2024 indicated Patient 10 was admitted for Acute (less than 6 months) and Chronic (longer than 6 months) Respiratory failure, unspecified with hypoxia (not enough oxygen to the body) or hypercapnia (excessive carbon dioxide in the blood).Acute and Chronic Respiratory failure, unspecified with hypoxia or hypercapnia. A review of the facility document titled, “Flowsheet’s,” dated December 27, 2024, was conducted. The document indicated, “...Physician orders...Tracheostomy Care...Start 12/8/24 [December 8, 2024], 7:01 a.m. q [every] 12 h [hour]...” A concurrent interview was conducted with the DOR. The DOR stated there was no documented evidence Patient 10 received tracheostomy care on the following dates and shifts: December 28, 2024, a.m., (6:30 a.m. to 7:00 p.m.) and p.m. (7:00 p.m. to 6:30 a.m.) shifts, December 29, 2024, a.m. shift, January 6, 2025, a.m. shift; and January 11, 2025, a.m. shift. An interview with the Respiratory Therapy Manager (RTM) on January 30, 2025, at 10:52 a.m., was conducted. The RTM stated there is currently no policy in place for providing respiratory care. The practice of the facility is to perform respiratory care/Tracheostomy care once per shift. The Respiratory Therapist (RT) is expected to document the care provided. The RTM further stated, if the RT did not document the care, it was not done. An interview with the Chief Operating Officer (COO) on January 30, 2025, at 11:03 a.m., was conducted. The COO stated they do not have a policy for tracheostomy care. The tracheostomy care is part of the scope of practice just like nursing care. The RT should know when and how to perform the care. 3. On January 28, at 2:20 p.m., Patient 2’s medical record was reviewed with the Educator Manager (EM). The facility document titled, “History and Physical,” dated December 7, 2024, indicated Patient 2 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia. A facility document titled, “Kardex,” dated January 28, 2025, was reviewed. The document indicated, “...foley catheter [tube inserted in the bladder]...start 12/9/2024 (December 9, 2024)...days to date...50...Present on admission...” An untitled facility document, dated January 28, 2025, was reviewed. The document indicated, “...Foley catheter...16FR [french, size of catheter]...Start 12/9/2024 (December 9, 2024) at 8:16 (8:16 a.m.)...” An untitled, facility document, dated January 1, 2025, was reviewed. The document indicated no foley catheter care was provided to Patient 2 on the below dates and shifts: December 28, 2024, a.m., (7 a.m. to 7:30 p.m.) and p.m., (7:30 p.m. to the 7 a.m.) shifts; and January 1, 2025, for a.m., and p.m., shifts. A concurrent interview was conducted with the EM. The EM stated there was no documented evidence Patient 2 received foley catheter care on the dates and shifts listed above. The EM further stated foley catheter care is required once a shift or every 12 hours. The EM further stated that if the nurses did not document the foley catheter care, it was not done. A review of the facility Policy and Procedure titled, “Core: Indwelling Urinary Catheter Standards and Practice,” dated June 2022, was conducted. The document indicated, “...The insertion of an indwelling urinary catheter requires a physician order...All patients admitted to the hospital with an existing indwelling urinary catheter will be assessed...Patients with urinary catheter will be assessed daily...” 4 a. A tour of the Medical/Surgical unit was conducted with the Interim Director of Quality Management (DQM) on January 27, 2025, at 9 a.m. During the tour, while in Patient 2’s room, Patient 2’s Intravenous (IV, administering in the veins) tubing was observed with a pink sticker that indicated to change on Sunday and was dated January 25, 2025. A concurrent interview was conducted on January 27, 2025, at 9:12 a.m., with Registered Nurse (RN) 2. RN 2 stated the IV tubing that is used for the Total Parenteral Nutrition (TPN, providing all the necessary nutrients directly into the bloodstream through a catheter) should be changed each time the TPN is changed. RN 2 further stated the IV tubing should have been changed on Sunday, and tubing for a central line is changed daily. On January 28, 2025, at 2:20 p.m., Patient 2’s medical record was reviewed with the EM. The facility document titled, “History and Physical,” dated December 7, 2024, was reviewed. The document indicated, Patient 2 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia. A facility document titled “History and Physical,” dated December 7, 2024, indicated,”...history and physical performed...impression...14...TPN dependent...continue TPN...” A facility document titled, “Kardex,” dated January 28, 2025, was reviewed. The document indicated, “...CV Line [Central venous catheter, thin flexible tube inserted into a large vein]..RT [Right] upper arm PICC [peripherally inserted central catheter] line...present on admission...” b. A tour of the Medical/Surgical unit was conducted with the Interim Director of Quality Management (DQM) on January 27, 2025, at 9 a.m. During the tour, while in Patient 3’s room, Patient 3’s Intravenous (IV, administering in the veins) tubing was observed with a pink sticker that indicated to change on Sunday and was dated January 25, 2025. A concurrent interview was conducted on January 27, 2025, at 9:22 a.m., with the DQM. The DQM stated the IV tubing used for Total Parenteral Nutrition (TPN, providing all the necessary nutrients directly into the bloodstream through a catheter) should be changed each time the TPN is changed. The DQM further stated the IV tubing should have been changed on Sunday. On January 29, 2025, at 9:33 a.m., Patient 3’s medical record was reviewed with the DQM. The facility document titled, “History and Physical,” dated January 12, 2025, was reviewed. The document indicated, Patient 3 was admitted for unspecified anemia (low red blood cell count) with a history of liver cirrhosis (scarring of the liver), hypertension (elevated blood pressure), concerns of Gastrointestinal (stomach) bleed. A facility document titled, “IV administration set (tubing) change,” dated August 19, 2024, was reviewed. The document indicated, “...Change administration sets, including in-line and add-on filters used for parenteral nutrition (with or without lipids), at least every 24 hours. Change the set with each new parenteral nutrition container...” 5. During a tour of Patient 31’s room, on January 27, 2025, at 9:30 a.m., Registered Nurse (RN) 3 was observed in Patient 31’s room with no gloves on. Registered Nurse (RN) 3 was observed in Patient 31’s room pulling the curtain between bed A and bed B, and around bed A, and began to work on the dialysis machine. A concurrent interview was conducted with RN 3. RN 3 stated he was aware he was in an isolation room. RN 3 stated Patient 31 is in contact isolation. RN 3 stated he removed his gloves and did not put new ones on when closing the curtains. RN 3 further stated he should have put new gloves on and should keep gloves on while in Patient 31’s room. An interview with the DQM on January 27, 2024, at 9:35 a.m., was conducted. The DQM stated Patient 31 is on contact isolation and the nurse should have gloves on while in the room. On January 29, 2025, at 9:03 a.m., Patient 31’s medical record was reviewed with the DQM. The facility document titled, “History and Physical,” dated January 12, 2025, was reviewed. The document indicated, Patient 31 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia, sepsis (life threatening infection) secondary to Extended spectrum Beta-Lactamase (ESBL, an enzyme that makes bacteria resistant to some antibiotics), and MRSA (Methicillin Resistant Staphylococcus Aureus). A facility Policy and Procedure titled, “Procedure-Donning and Doffing Personal Protective Equipment,” dated June 2022, was reviewed. The document indicated, “...Personal Protective Equipment (PPE) when there is a potential for contamination from the skin-to-skin contact...PPE will be donned (put on) upon entering the patients room...PPE will be doffed (removed) upon exiting the patients room...” 6. During the tour of the Medical Surgical unit on January 27, 2025, at 9: 55 a.m., conducted with the DQM, RN 1 was observed in Patient 6’s contact isolation room preparing for a central line dressing change. RN 1 placed the central line dressing change kit on the foot of Patient 6’s bed. RN 1 began to open the package and pulled out two green packages. RN 1 began to open both green packages and place on the foot of the bed. RN 1 pulled out white folded package and chlora prep pad. RN 1 opened the sterile package and put on the gloves and touched the outside of the package and the front of her PPE gown with the sterile gloves. RN 1, with sterile gloves on, grabbed the chlora prep pad and the towel, shook the towel with the sterile gloves on, then RN 1 shook the prep towel two times and walked to the head of Patient 6’s bed. RN 1 shook the towel again and put it on the patient’s chest. RN 1 set down the chlora prep pad and proceeded to begin the process of removing the previous central line dressing on the patient. When asked about shaking the towel and contaminating the gloves, RN 1 stated she would get new gloves. When asked about the sterile field, RN 1 stated she had broken the sterile field and contaminated her gloves and would start over with a new kit. The House Supervisor (HS) put on PPE and came into the room to assist RN 1 with the central line dressing change. The HS brought in a new Central line dressing kit and pack of size 7.5 sterile gloves. RN 1 began to open the new sterile package and again broke sterility by touching her gloves with her PPE. On January 27, 2025, at 10:15 a.m., an interview with the HS was conducted. The HS stated RN 1 broke the sterile field and she came into Patient 6’s room to help guide and educate the nurse with the central line dressing change. The HS redirected RN 1 during the central line dressing change multiple times. On January 28, 2025, at 9:30 a.m., Patient 6’s medical record was reviewed with the DQM. The facility document titled, “History and Physical,” was reviewed. The document indicated, Patient 6 was admitted to the facility for acute or chronic respiratory failure, unspecified with hypoxia or hypercapnia and ESBL in the urine. On January 30, 2025, at 2:10 p.m., an interview with the Director of Nursing Clinical Services (DNCS) was conducted. The DNCS stated it is expected for the nurses to maintain the sterile field while performing the sterile procedure of central line dressing changes. The DNCS further stated the nurse is expected to clean the area where they plan to work to ensure they are working on a clean surface. A facility Policy and Procedure titled, “[Facility Name] Core: Central Line Placement, Maintenance and Dressing Change,” dated June 2023, was reviewed. The document indicated, “...the procedure for central line dressing changes will be performed under strict aseptic technique (sterile gloves and mask)...” 7. On January 30, 2025, a review of Patient 7’s record was conducted with Director of Pharmacy (DOP). A review of the facility document, titled, “History and Physical,” dated December 26, 2024, indicated Patient 7 was admitted for Respiratory failure, unspecified with hypoxia or hypercapnia, On January 30, 2025, a review of the facility untitled document, dated December 26, 2024, at 1:47 a.m., indicated an order was placed for a stool specimen for occult blood. On January 30, 2025, a review of the facility document titled, “Laboratory Results,” dated January 5, 2025, at 10:47 a.m., indicated the occult blood lab was not done and cancelled on January 8, 2025, at 11:35 p.m., by lab. On January 30, 2025, an interview was conducted with the Chief Operating Officer (COO). The COO stated, “...there was no note placed by lab as to why the test was cancelled. It was not caught by medical or nursing staff. The physician or RN should have been notified and the test should have been reordered. There should have been a phone call and documentation to the RN of why it was cancelled. Policy was not followed...” On January 30, 2025, a review of the facility document titled, “Criteria For Acceptance of Microbiology Specimens,” dated August 2, 2022, indicated, “Guidelines for Rejection of Specimens...Specimen without requisition/order: Call the nursing station and have a requisition sent to the laboratory or ordered...If there are questions about the order, the nurse must clarify with the physician before the specimen is processed...Specimen unlabeled or mislabeled...Reject specimen. Call the nursing station and have a new specimen collected and sent, along with a new requisition...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 42512 Based on interview and record review, the facility failed to ensure patient rights were maintained when: 1. For Patient 9, the facility failed to ensure the grievance process was implemented (see A-0118). 2. For Patient 1, the facility failed to provide care in a safe setting when facility policy and procedures were not followed for an invasive bedside procedure (see A-0144). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 42512 Based on observation, interviews, and record review, the facility failed to follow their policy and procedures when: 1. For Patient 25, a pacing detection error on their cardiac (heart) monitor was not reported to the physician (see A-0398). 2. For Patient 26, a new bundle branch block (a condition in which there’s a delay or blockage along the pathway that electrical impulses travel to make the heartbeat) was not reported to the physician (see A-0398). 3. For Patient 1, the facility did not perform a time out prior to an invasive procedure, did not document the start and end of the procedure, and a post procedure assessment (see A-0398). The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 34933 Based on interview and record review, the facility failed to ensure the grievance process was implemented, for one of 31 sample patients (Patient 9), in accordance with the facility’s policy and procedure (P&P). This failure had the potential to cause harm and delay of care to the patient. A review of Patient 9’s record was conducted on November 19, 2024, at 10 a.m., with the Radiology Manager (RM). A review of the facility document titled, “History and Physical,” dated September 27, 2024, was reviewed. The document indicated Patient 9 was admitted to the facility on September 26, 2024, with a diagnoses of end-stage renal disease (End Stage Renal Disease-irreversible kidney failure) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), obesity, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure). A review of the facility document titled, “Change of condition,” dated October 3, 2024, indicated, “...family member also stated that Patient 9’s roommate yells and makes it difficult for him to sleep at night while here at the hospital, so if possible could he move to another patient room? DNCS [Director of Nursing and Clinical Services] communicated that due to the hospital census and infection control practices, it is not possible at this time. But, DNCS let family member know that future efforts will be made to accommodate this request...” An interview was conducted on November 20, 2024, at 10:40 a.m., with the Chief Operating Officer (COO). The COO indicated, all formal grievances are entered in the Event Reporting System (ERS) and a letter is sent out regarding the complaint. The COO was unable to show documentation of the complaint in the ERS system. An interview was conducted on November 21, 2024, at 1:25 p.m., with the DNCS. The DNCS indicated she spoke to the family regarding the request for a room change and does not remember if she documented follow up in the ERS system. The DNCS indicated the facility typically resolves complaints within 3-5 business days without it being escalated to the quality department. The DNCS stated she was unaware if this issue was resolved. A review of the facility’s policy and procedure titled, “Procedure-Patient Complaint and Grievance Process,” dated June 2022, indicated, “...Intake and Initial Handling of a Complaint/Grievance. When reasonably possible, the person who receives a complaint should address and resolve it...Initiate an investigation if it has not already been started, including interviews of individuals with information about the issue (patient, family, staff, etc.) Initiate the complaint and Grievance entry into the Event Reporting System...Every effort should be made to complete entries by end of the shift. Communicate the status of the investigation to the patient and/or individual who reported the issue...””

“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: 42512 Based on interview and record review the facility failed to provide care in a safe setting for two of 30 sampled patients, (Patient 1, 26), when hospital policy and procedures were not followed for an invasive bedside procedure, and when Patient 26’s hyperkalemia [medical condition where too much potassium is in the blood] was not treated properly. These failures had the potential to result in an invasive procedure being performed on the wrong patient, wrong procedure and had the potential to cause harm or death to the patient. Findings: On November 18, 2024, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate facility reported incidents and complaints. 1. On November 18, 2024, at 10:08 a.m., a review of Patient 1’s record was conducted. The “History and Physical,” dated September 30, 2024, at 4:59 p.m., indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses of multi substance abuse, morbid obesity, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure). Review of a facility document titled, “General Surgery Consult,” dated October 2, 2024, at 7:54 a.m., was reviewed. The document indicated, “...PLEASE PUT QC [Quinton Catheter] HD [Hemodialysis -Life saving treatment for kidney failure] CATHETER IN...Timeframe: Urgent - 48 hrs...” Review of a facility document titled, “PROCEDURE CHECKLIST...INVASIVE PROCEDURES WITHOUT SEDATION,” was reviewed. There was no documented evidence the facility completed this form for Patient 1’s procedure on October 4, 2024. Review of a facility document for Patient 1 titled, “Operative/PROCEDURE Report,” dated October 4, 2024, was reviewed. The document indicated, “...ANESTHESIA: Local...DESCRIPTION OF PROCEDURE: The patient was placed on the bed...A 13 cm [centimeter - unit of measurement] Quinton catheter was threaded over the guidewire...The catheter was anchored in place with two interrupted 2-0 nylon sutures...and a postprocedure [sic] chest x-ray was ordered. There was no documented evidence of the time out, start of procedure or end of procedure. There was no documented evidence care provided during the procedure was completed. There was no documented evidence patient’s vital signs were assessed during the procedure. There was no documented evidence there was a handoff report to the unit nurse at the conclusion of the procedure. There was no documented evidence post-procedure assessment was completed. Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...HD catheter placement...at 10/04/2024 [October 4, 2024] 17:00 [5 p.m.] Comment: Pt transfer to OR for HD catheter placement. Vital sign [sic] are BP [blood pressure] 112/62, HR [heart rate] 82, Resp. [respirations] 20, Temp [temperature] 98.2...” Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...Oxygen Desaturation...at...17:40 [5:40 p.m.]...” Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...Patient had a rapid response 1742 [5:42 p.m.] led to code blue 1745 [5:45 p.m.]...comment...After HD placement, patient wheeled back to patient room where she was observed to be struggling to breath...Rapid response called and ambubagging started...code blue called...CPR initiated but no ROSC [Return of spontaneous circulation]...Patient pronounced by [Name of MD 4] at 1809 [6:09 p.m.]...” Review of Patient 1’s document titled, “Chest 1 View portable,” indicated, “...DATE OF EXAM: 10/04/2024 [October 4, 2024] 17:52 [5:52 p.m.]...CLINICAL INDICATORS: verify tube/line placement, renal dialysis catheter...Signed Date: 10/04/2024 18:26 [6:26 p.m.]. Facility document titled, “Discharge Summary,” for Patient 1 indicated, “...[Patient 1] is scheduled for the temporary hemodialysis catheter replacement...underwent the procedure on October 4th...postop chest x-ray reportedly okay with no pneumothorax...Please note...the chest x-ray was...for postop dialysis catheter placement but she developed a good [sic] blue it was done during the code...Soon after the procedure she went back to her room and she developed desaturation and eventually coded and expired...the cause of death at this point is probable pulmonary embolisms...” Facility document titled, “RAPID RESPONSE TEAM AND CODE H RECORD,” indicated, “...Reason for Call: HR less than 50...O2 sat [oxygen saturation]...43...Vital Signs [VS] on arrival: Time 1742 [5:42 p.m.]...HR 12, BP 63/33, SPO2 [Peripheral Oxygen Saturation] 40, Temp 98...Repeat VS: Time: 1745 [5:45 p.m.] HR 0, BP N/A...Outcome: Code Blue called...” Facility document titled, “CODE BLUE FLOWSHEET,” indicated, “...Time Code Called: 1745 [5:45 p.m.]...Xray done 1752 [5:52 p.m.] Pronounced by Physician (P) 2...Expired...Time Pronounced 18:09 [6:09 p.m.]...” On November 19, 2024, at 8:55 a.m., an interview was conducted with the Registered Nurse (RN) 5. RN 5 stated she was dealing with another patient and was not aware of why Patient 1 was moved to the OR for a bedside procedure. RN 5 stated she took Patient 1’s vitals prior to Patient 1 being moved. RN 5 stated the House Supervisor (HS) moved Patient 1 to the OR. RN 5 stated at the time of the procedure there was no OR staff available. She further stated when the procedure was a bedside procedure the RN or the HS will assist in the procedure. RN 5 stated she was not aware of when Patient 1 returned from the OR, and she did not assess the patient when they returned. On November 19, 2024, at 9:26 a.m., an interview was conducted with the House Supervisor (HS). The HS stated Patient 1 was scheduled to have a bedside procedure for a hemodialysis catheter placement. The HS stated Physician (P) 1 requested to have the procedure in a larger room. The HS additionally stated staff should have documented the time Patient 1 was moved to the OR. During continued interview, the HS stated she should have completed the “PROCEDURE CHECKLIST” throughout the procedure, and she did not, and that there was no documented evidence a “timeout” was completed prior to start of procedure as per the policy. The HS stated there was also no documentation of post procedure vitals being taken for Patient 1. During further interview, the HS stated the on-call X-ray technician should have been called prior to the procedure to verify placement, and rule out perforation or bleeding, immediatly following th procedure. The HS stated that when the Licensed Vocational Nurse (LVN) 1, and CNA 1 were cleaning Patient 1 following the procedure, Patient 1 stated she was having difficulty breathing so, LVN 1 called a rapid response. The HS stated she came to assess Patient 1, and upon assessment, Patient 1 did not have a pulse so a Code Blue was called and CPR started at 5:45 p.m. The HS stated Physician 1 had already left the building and she (HS) called her to come back during the code. The HS stated she was on the phone with P 2, and P 2 requested for an X-ray to be completed during the code blue. The HS stated Patient 1 did not achieve ROSC (return of spontaneous circulation, resumption of a sustained heart rhythm after cardiac arrest) and Patient 1 was pronounced deceased at 1809 (6:09 p.m.). On November 19, 2024, at 10:02 a.m., an interview was conducted with LVN 1. LVN 1 stated no one was documenting anything in the OR room. LVN 1 stated the on-call X-ray tech was called while patient was in the OR room, but the HS requested Patient 1 to be moved to her room before the X-ray tech arrived. LVN 1 stated Patient 1 had a bowel movement and needed to be cleaned. She stated after cleaning Patient 1, she started thrashing around and was having trouble breathing, oxygen on the monitor started to fall, and a code rapid was called. She stated the rapid response was then converted to a code blue. On November 20, 2024, at 3 p.m., an interview was conducted with P 1. P 1 stated there is a form that is filled out prior to a bedside procedure but was not sure who filled it out. P 1 stated they could not recall who was in the OR during the procedure on Patient 1. P 1 stated she did not recall if there was a timeout for this procedure. P 1 stated they were not sure where the timeout would be documented. On November 20, 2024, at 3:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the HS asked her to stay in the OR to help P 1 with the procedure. CNA 1 stated she handed Tegaderm (transparent medical dressing) and 4x4 sponge pads to P 1. CNA 1 stated Patient 1 stated she had difficulty breathing during procedure in the OR room. CNA 1 stated P 1 left the facility prior to the X-ray. CNA 1 stated Patient 1 had a bowel movement and after being cleaned up, Patient 1 started thrashing around stating she was having difficulty breathing. CNA 1 stated a code rapid was called, and then shortly after a code blue was called. CNA 1 stated after the code blue was called, she exited the room and was asked to call P 1 so they could return to the facility. CNA 1 stated no staff was documenting anything while the procedure was being performed. A review of the policy and procedure (P&P) titled, “Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation,” dated June 2022, was conducted. The P&P indicated, “...verification of the patient’s identification and completion of all patient safety procedures including site marking and time out procedures must be performed prior to every inpatient and outpatient invasive procedures with or without sedation...Complete and accurate documentation as outlined here is required for all invasive procedures with our without sedation...Postoperative documentation records the patient’s vital signs...any unusual events...Nursing and/or surgical personnel are to maintain a log of all bedside and non-bedside operative or invasive procedures...The following steps are required before any procedure may proceed:...Pre-procedure checklist...Time out completed...Note: No procedure may proceed if the above required steps are not followed. Any physician, nurse, licensed therapist involved in the procedure may halt the procedure until the required steps are completed...Perform all “Timeout” procedures as outlined on the forms. One designated team member ensures that a final verification of the correct patient, procedure, site, and as applicable...During the Procedure/Post Procedure...Document all care provided on the appropriate forms...At the conclusion of the procedure, the procedure nurse provides a complete “handoff” communication to the unit nurse. The hand off after a procedure should include at least the following: patient’s vital signs prior to and after the conclusion of the procedure...Invasive Procedures without Sedation (Local Anesthesia only)...Invasive procedures without sedation - this includes both pre-procedure checklist and post-procedure assessment...” A review of the P&P titled, “PATIENT’S RIGHTS AND RESPONSIBILITIES,” undated, indicated, “...the expectation that understanding and observation of the rights will result in more effective patient care and in promotion of the confidence and trust which must exist between the patient, the physician...name of facility has responsibilities and duties of its own to the patient...The right to considerate and respectful care...” 2. On November 20, 2024, at 10:59 a.m., Patient 26’s medical record was reviewed with CARN. The facility document titled “Inpatient Admission Face Sheet” undated, indicated, “...Admit date: 09/06/2024 [September 6, 2024]...Reason for visit: Respiratory Failure [a medical condition where the lungs are unable to adequately provide oxygen to the blood or remove carbon dioxide from it, leading to a lack of oxygen in the body’s tissues and potentially dangerous levels of carbon dioxide in the bloodstream]...” Review of a facility document titled, “History and Physical,” indicated, “...Past medical History: atrial fibrillation [a type of arrhythmia, or irregular heartbeat, that occurs when the electrical signals in the heart’s upper chambers fire rapidly and irregularly], and chronic kidney disease stage II...” The facility’s untitled document dated September 20, 2024, indicated, “...Basic metabolic panel partial result: potassium [an electrolyte and mineral found in the blood that helps the heartbeat regularly, muscles work properly, and cells, nerves and muscles function properly] 6.3 mmol/L [Unit of measurement -Millimoles per litre] CRITICAL [dangerous] HIGH...called comment Critical result[s] called to and read back by: k [potassium]= [Name of Registered Nurse ][Registered Nurse 1]...” The facility’s untitled document dated September 20, 2024, indicated, “...Change of condition...critical value [specify]: K [potassium]+ 6.3 at 09/20/2024 [September 20, 2024] 09:56:00 [9:56 a.m.]...Attending physician notified: [Name of Physician] [ Doctor of Medicine [MD] 1]...comment: left message with [Name of Physician] awaiting call back. Treatment initiated: Kayexalate [a medicine used to treat high levels of potassium in the blood] ordered with follow up K+ level at 1430...” The facility untitled document dated September 20, 2024, indicated, “...physician orders...[telephone], 09/20, 2024 [September 20, 2024]10:30 [10:30 a.m.]...potassium, serum: start 09/20/2024 [September 20, 2024] 14:30 [2:30 p.m.] x 1, not renewable, ancil [ancillary-department that provides support] dept to draw...Read back verification: yes...” The facility’s untitled document dated September 20, 2024, indicated, “...Physician orders...[Name of RN 2] September 20, 2024 [telephone], 09/20/2024 [September 20, 2024] 10:44...sodium polystyrene sulfonate [a medicine used to treat high levels of potassium in the blood] : PO susp, 60 g [unit of measurement - grams]*** k+ 6.3**** start today [09/20/24] [September 20, 2024] , x1, not renewable Read back verification: yes...” The facility’s untitled document dated September 20, 2024, indicated, “...sodium polystyrene sulfonate: PO sus, 60 g...DOSE: Sodium Polystyrene sulfonate 60 GM-240 ml [milliliters-unit of measurement] September 20, 2024 10:52...administered by...[ Name of RN] [RN 2]...” There was no documented evidence of any other ordered treatment regarding Patient 26’s critical serum potassium level. The facility’s untitled document dated September 20, 2024, indicated, “...Monitor observations: 09/20/2024 [September 20, 2024] 20:00 [8 p.m.]...cardiac rhythm [heart rhythm]: normal sinus rhythm [normal heart rhythm], w/ [with] BBB [bundle branch block -a condition that occurs when the electrical signals that make the heartbeat are delayed or blocked]...QRS [the time it takes for an electrical signal to spread through the heart’s ventricles] interval: 0.12 sec [seconds]...” An interview was conducted on November 21, 2024, at 2:51 p.m., with the CARN. The CARN stated there was no change of condition nurses’ notes referring the BBB to a doctor or doctors’ orders for the BBB documented in Patient 26’s medical records. CARN stated the nurse should have referred to the doctor regarding the BBB. She further stated, “they [doctors] can’t treat patients if they don’t have information regarding the patient’s condition.” The CARN further stated, the facility does not have a policy or procedure for treatment of hyperkalemia. Review of a facility untitled document dated September 21, 2024, indicated, “... [ Name of RN 3] 09/21/24 [September 21, 2024] 01:59 [1:59 a.m.]...oxygen desaturation [a decrease in the level of oxygen saturation in the blood]: at 09/21/2024 [September 21, 2024] 1:50 [1:50 a.m.]... Comment: patient had O2 sat [oxygen saturation-the percentage of oxygen in the blood]. below 90% RT [respiratory therapist] change NC (nasal cannula-a medical device that provides supplemental oxygen to a patient through two prongs that fit into the nostrils) to venti mask (a medical device that delivers a specific concentration of oxygen to a patient) at 40% O2 (oxygen). It got up to 93%. RT did ABG (arterial blood gas-a medical test that measures the levels of oxygen and carbon dioxide in your blood) stat result available at RT labs. Called HS (House Supervisor) MD [Doctor of Medicine 2] [Name of Physician] saw ABG result ordered to do Hiflow [oxygen therapy that delivers oxygen, through nasal prongs, at higher-than-normal flow rates of traditional oxygen therapy] and chest X-ray in AM. Will continue to monitor...Comment: at 0540 (5:40 a.m.) Pt. patient[sic], cardiac rhythm change to bradycardia [slow heart rate], reassessed pt. He was still desating [a drop in oxygen levels in the blood] to 86%. Call rapid response [a program that aims to quickly identify and treat patients who are at risk of clinical deterioration]/ code blue [a patient is experiencing a life-threatening medical emergency, typically a cardiac arrest or respiratory failure]...Continue with code blue but patient was pronounced at 0635 (6:35 a.m.) hr [hour]...” Review of a facility untitled document dated September 21, 2024, indicated, “...laboratory results...potassium, serum...8.2mmol/L...Called comment Critical result [s] K called to and read back by: [Name of RN 4]: 09/21/2024 [September 21, 2024], 07:29 (7:29 a.m.)...slightly hemolized...” Review of a facility document titled, “Expiration Summary,” dated September 21, 2024, indicated, “...Date of expiration: September 21, 2024...Causes of death...Acute cardiopulmonary arrest...” An interview was conducted on November 21, 2024, at 2:16 p.m., with MD 1. MD 1 stated the process for treating patients with high serum potassium levels include Kayexalate and EKG [Electrocardiogram- test that measures the electrical activity of the heart]. EKG to identify any EKG changes. She further stated if serum potassium is higher than 6, treatment includes insulin, Dextrose 50 Water 50, calcium, kayexalate and sodium bicarbonate if patient has EKG change. MD 1 stated high serum potassium is not safe for patients because “it causes cardiac arrhythmias (an irregular heartbeat that can cause the heart to beat too fast, too slow, or with an irregular rhythm) and cardiac arrest (sudden, sometimes temporary, cessation [stopping] of function of the heart).””

“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: 50304 Based on observation, interviews, and record review, the facility failed to follow their policy and procedures when: 1. For Patient 25, a pacing detection error on the cardiac (heart) monitor was not reported to the physician; 2. For Patient 26, a new bundle branch block (a condition in which there’s a delay or blockage along the pathway that electrical impulses travel to make the heartbeat) was not reported to the physician; and 3. For Patient 1, the facility did not perform a time out (an immediate pause by the medical team to confirm the correct patient, procedure, and site) prior to an invasive procedure, did not document the start and end times of the procedure, and did not document a post procedure assessment. These failures had the potential to place patients’ medical condition at risk for injury or death, and for the potential for the wrong procedure to be conducted. Findings: 1. On November 20, 2024, at 10:06 a.m., Patient 25’s medical record was reviewed with the Clinical Analyst Registered Nurse (CARN). Review of the facility document titled “Inpatient Admission Face Sheet” undated, indicated, “...Admit date: 09/28/2024 [September 28, 2024]...Reason for visit: Acute and Chronic Respiratory Failure...” Review of a facility document titled, “History and Physical,” dated 10/03/2024 [October 3, 2024], indicated, “...History and Physical...patient has a history of pacemaker history of CVA [stroke, medical condition that occurs when blood flow to the brain is suddenly interrupted], diabetes mellitus [a chronic metabolic disease that occurs when the body can’t control its blood sugar levels], congestive heart failure...” On November 20, 2024, at 11:34 a.m., a tour of Patient 25’s room was conducted with the Chief Operating Officer (COO). Patient 25’s cardiac monitor was observed showing a silenced alarm. The COO stated the monitor showed alarm silenced because of the pacing (the process of delivering electrical impulses to the heart to stimulate a contraction) detection error on the cardiac monitor. During continued observation the alarm silenced image was observed to automatically show after the pacing detection error appeared when the COO unplugged and plugged the cable connected to the cardiac monitor. On November 20, 2024, at 11:44 a.m., an observation and concurrent interview was conducted in Patient 25’s room with the Intensive Care Unit Registered Nurse (ICU RN) 1. Patient 25 was observed unconscious and connected to the ventilator (a machine that helps patients breathe by mechanically pushing air into their lungs when they are unable to). Observation of the cardiac (heart) monitor on Patient 25 showed a pacing detection error. ICU RN 1 stated she could see the pacing detection error on Patient 25’s monitor, and that she had checked the leads and patient, and everything was working fine. ICU RN 1 stated she did not call the physician to report the error message. On November 20, 2024, at 1:47 p.m., an interview with ICU RN 2 was conducted. ICU RN 2 stated if she saw a pacing detection error on the monitor, she would check the patient and the monitor. She further stated there might be something wrong, “it may be the monitor, or it may be the pacemaker.” She stated the pacemaker makes the patient’s heartbeat. If the pacemaker is not functioning properly, it would affect the patient’s heart. On November 20, 2024, at 2:12 p.m., an interview with Biomed Technician (BT) was done. BT stated he contacted (Name of Company) tech support, and they evaluated the unit. He further stated the monitor is 100 % functional. A review of facility policy titled, “CORE: Continuous Cardiac monitoring (Telemetry),” dated, June 2023, indicated, “...the nurse assigned to the patient responds immediately if any of the following occurs...any observed change in the patient’s cardiac rhythm...” A review of facility policy titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated, August, 2023, indicated, “...Patients are re-evaluated by a licensed nurse [RN, LPN/LVN-according to state specific practice acts] at a minimum every 12 hour shift-based on level of care...to respond to a significant change in status and/or diagnosis or condition...Reporting/Notification of a change in condition...changes in the condition of the patient are determined by assessments...the nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient’s primary physician or designee using appropriate channels and chain of command for assuring that there is physician response...” 2. On November 20, 2024, at 10:59 a.m., Patient 26’s medical record was reviewed with CARN. The facility document titled “Inpatient Admission Face Sheet” undated, indicated, “...Admit date: 09/06/2024 [September 6, 2024]...Reason for visit: Respiratory Failure...” Review of a facility document titled, “History and Physical,” indicated, “...Past medical History: atrial fibrillation [a type of arrhythmia, or irregular heartbeat, that occurs when the electrical signals in the heart’s upper chambers fire rapidly and irregularly], and chronic kidney disease stage II...” On November 20, 2024, at 9:43 a.m., an interview and concurrent record review of Patient 26’s recorded rhythm strips (a test that records the electrical activity of the heart) dated September 20, 2024, was conducted with the House Supervisor (HS). The untitled document, dated September 20, 2024, indicated, “...September 20, 2024, 07:20 (7:20 a.m.)...SR (sinus rhythm) -67 c [with] BBB [Bundle Branch Block-a condition that occurs when the electrical signals that make the heart beat are delayed or blocked]...” HS stated the monitor technician watches the rhythms for patients in the telemetry unit and refers the reading to the nurses. She further stated, the nurse assigned to the patient verifies the strip and calls the doctor for any changes. She stated, “we want to be proactive and catch anything that may need treatment or to get some treatment to prevent a more serious condition.” On November 21, 2024, at 2:51 p.m., an interview and concurrent record review of Patient 26’s recorded rhythm strip, dated September 20, 2024, was conducted with CARN. The document indicated, “...Monitor observations: 09/20/2024 [September 20, 2024] 20:00 (8 p.m.)...cardiac rhythm: normal sinus rhythm, w/ BBB...QRS [the time it takes for an electrical signal to spread through the heart’s ventricles] interval: 0.12 sec [seconds]...” The CARN stated, “there are no change of condition nurse’s notes or doctors’ orders for the BBB” documented in Patient 26’s medical records. The CARN further stated the nurse should have referred the BBB to the doctor and that “they (doctors) can’t treat patients if they don’t have information regarding the patient’s condition.” A review of facility policy titled, “CORE: Continuous Cardiac monitoring (Telemetry),” dated, June 2023, indicated, “...the nurse assigned to the patient responds immediately if any of the following occurs...any observed change in the patient’s cardiac rhythm...” A review of facility policy titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated, August, 2023, indicated, “...Patients are re-evaluated by a licensed nurse [RN, LPN/LVN-according to state specific practice acts] at a minimum every 12 hour shift-based on level of care...to respond to a significant change in status and/or diagnosis or condition...Reporting/Notification of a change in condition...changes in the condition of the patient are determined by assessments...the nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient’s primary physician or designee using appropriate channels and chain of command for assuring that there is physician response...” 3. On November 18, 2024, at 10:08 a.m., a review of Patient 1’s record was conducted. The “History and Physical,” dated September 30, 2024, at 4:59 p.m., indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses of multi substance abuse, morbid obesity, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure). Review of a facility document titled, “General Surgery Consult,” dated October 2, 2024, at 7:54 a.m., was reviewed. The document indicated, “...PLEASE PUT QC [Quinton Catheter] HD [Hemodialysis -Life saving treatment for kidney failure] CATHETER IN...Timeframe: Urgent - 48 hrs...” Review of a facility document titled, “PROCEDURE CHECKLIST...INVASIVE PROCEDURES WITHOUT SEDATION,” was reviewed. There was no documented evidence the facility completed this form for Patient 1’s procedure on October 4, 2024. Review of a facility document for Patient 1 titled, “Operative/PROCEDURE Report,” dated October 4, 2024, was reviewed. The document indicated, “...ANESTHESIA: Local...DESCRIPTION OF PROCEDURE: The patient was placed on the bed...A 13 cm [centimeter - unit of measurement] Quinton catheter was threaded over the guidewire...The catheter was anchored in place with two interrupted 2-0 nylon sutures...and a postprocedure [sic] chest x-ray was ordered. There was no documented evidence of the time out, start of procedure or end of procedure. There was no documented evidence care provided during the procedure was completed. There was no documented evidence patient’s vital signs were assessed during the procedure. There was no documented evidence there was a handoff report to the unit nurse at the conclusion of the procedure. There was no documented evidence post-procedure assessment was completed. Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...HD catheter placement...at 10/04/2024 [October 4, 2024] 17:00 [5 p.m.] Comment: Pt transfer to OR for HD catheter placement. Vital sign [sic] are BP [blood pressure] 112/62, HR [heart rate] 82, Resp. [respirations] 20, Temp [temperature] 98.2...” Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...Oxygen Desaturation...at...17:40 [5:40 p.m.]...” Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...Patient had a rapid response 1742 [5:42 p.m.] led to code blue 1745 [5:45 p.m.]...comment...After HD placement, patient wheeled back to patient room where she was observed to be struggling to breath...Rapid response called and ambubagging started...code blue called...CPR initiated but no ROSC [Return of spontaneous circulation]...Patient pronounced by [Name of MD 4] at 1809 [6:09 p.m.]...” Review of Patient 1’s document titled, “Chest 1 View portable,” indicated, “...DATE OF EXAM: 10/04/2024 [October 4, 2024] 17:52 [5:52 p.m.]...CLINICAL INDICATORS: verify tube/line placement, renal dialysis catheter...Signed Date: 10/04/2024 18:26 [6:26 p.m.]. Facility document titled, “Discharge Summary,” for Patient 1 indicated, “...[Patient 1] is scheduled for the temporary hemodialysis catheter replacement...underwent the procedure on October 4th...postop chest x-ray reportedly okay with no pneumothorax...Please note...the chest x-ray was...for postop dialysis catheter placement but she developed a good [sic] blue it was done during the code...Soon after the procedure she went back to her room and she developed desaturation and eventually coded and expired...the cause of death at this point is probable pulmonary embolisms...” Facility document titled, “RAPID RESPONSE TEAM AND CODE H RECORD,” indicated, “...Reason for Call: HR less than 50...O2 sat [oxygen saturation]...43...Vital Signs [VS] on arrival: Time 1742 [5:42 p.m.]...HR 12, BP 63/33, SPO2 [Peripheral Oxygen Saturation] 40, Temp 98...Repeat VS: Time: 1745 [5:45 p.m.] HR 0, BP N/A...Outcome: Code Blue called...” Facility document titled, “CODE BLUE FLOWSHEET,” indicated, “...Time Code Called: 1745 [5:45 p.m.]...Xray done 1752 [5:52 p.m.] Pronounced by Physician (P) 2...Expired...Time Pronounced 18:09 [6:09 p.m.]...” On November 19, 2024, at 8:55 a.m., an interview was conducted with the Registered Nurse (RN) 5. RN 5 stated she was dealing with another patient and was not aware of why Patient 1 was moved to the OR for a bedside procedure. RN 5 stated she took Patient 1’s vitals prior to Patient 1 being moved. RN 5 stated the House Supervisor (HS) moved Patient 1 to the OR. RN 5 stated at the time of the procedure there was no OR staff available. She further stated when the procedure was a bedside procedure the RN or the HS will assist in the procedure. RN 5 stated she was not aware of when Patient 1 returned from the OR, and she did not assess the patient when they returned. On November 19, 2024, at 9:26 a.m., an interview was conducted with the House Supervisor (HS). The HS stated Patient 1 was scheduled to have a bedside procedure for a hemodialysis catheter placement. The HS stated Physician (P) 1 requested to have the procedure in a larger room. The HS additionally stated staff should have documented the time Patient 1 was moved to the OR. During continued interview, the HS stated she should have completed the “PROCEDURE CHECKLIST” throughout the procedure, and she did not, and that there was no documented evidence a “timeout” was completed prior to start of procedure as per the policy. The HS stated there was also no documentation of post procedure vitals being taken for Patient 1. During further interview, the HS stated the on-call X-ray technician should have been called prior to the procedure to verify placement, and rule out perforation or bleeding, immediatly following th procedure. The HS stated that when the Licensed Vocational Nurse (LVN) 1, and CNA 1 were cleaning Patient 1 following the procedure, Patient 1 stated she was having difficulty breathing so, LVN 1 called a rapid response. The HS stated she came to assess Patient 1, and upon assessment, Patient 1 did not have a pulse so a Code Blue was called and CPR started at 5:45 p.m. The HS stated Physician 1 had already left the building and she (HS) called her to come back during the code. The HS stated she was on the phone with P 2, and P 2 requested for an X-ray to be completed during the code blue. The HS stated Patient 1 did not achieve ROSC (return of spontaneous circulation, resumption of a sustained heart rhythm after cardiac arrest) and Patient 1 was pronounced deceased at 1809 (6:09 p.m.). On November 19, 2024, at 10:02 a.m., an interview was conducted with LVN 1. LVN 1 stated no one was documenting anything in the OR room. LVN 1 stated the on-call X-ray tech was called while patient was in the OR room, but the HS requested Patient 1 to be moved to her room before the X-ray tech arrived. LVN 1 stated Patient 1 had a bowel movement and needed to be cleaned. She stated after cleaning Patient 1, she started thrashing around and was having trouble breathing, oxygen on the monitor started to fall, and a code rapid was called. She stated the rapid response was then converted to a code blue. On November 20, 2024, at 3 p.m., an interview was conducted with P 1. P 1 stated there is a form that is filled out prior to a bedside procedure but was not sure who filled it out. P 1 stated they could not recall who was in the OR during the procedure on Patient 1. P 1 stated she did not recall if there was a timeout for this procedure. P 1 stated they were not sure where the timeout would be documented. On November 20, 2024, at 3:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the HS asked her to stay in the OR to help P 1 with the procedure. CNA 1 stated she handed Tegaderm (transparent medical dressing) and 4x4 sponge pads to P 1. CNA 1 stated Patient 1 stated she had difficulty breathing during procedure in the OR room. CNA 1 stated P 1 left the facility prior to the X-ray. CNA 1 stated Patient 1 had a bowel movement and after being cleaned up, Patient 1 started thrashing around stating she was having difficulty breathing. CNA 1 stated a code rapid was called, and then shortly after a code blue was called. CNA 1 stated after the code blue was called, she exited the room and was asked to call P 1 so they could return to the facility. CNA 1 stated no staff was documenting anything while the procedure was being performed. A review of the policy and procedure (P&P) titled, “Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation,” dated June 2022, was conducted. The P&P indicated, “...verification of the patient’s identification and completion of all patient safety procedures including site marking and time out procedures must be performed prior to every inpatient and outpatient invasive procedures with or without sedation...Complete and accurate documentation as outlined here is required for all invasive procedures with our without sedation...Postoperative documentation records the patient’s vital signs...any unusual events...Nursing and/or surgical personnel are to maintain a log of all bedside and non-bedside operative or invasive procedures...The following steps are required before any procedure may proceed:...Pre-procedure checklist...Time out completed...Note: No procedure may proceed if the above required steps are not followed. Any physician, nurse, licensed therapist involved in the procedure may halt the procedure until the required steps are completed...Perform all “Timeout” procedures as outlined on the forms. One designated team member ensures that a final verification of the correct patient, procedure, site, and as applicable...During the Procedure/Post Procedure...Document all care provided on the appropriate forms...At the conclusion of the procedure, the procedure nurse provides a complete “handoff” communication to the unit nurse. The hand off after a procedure should include at least the following: patient’s vital signs prior to and after the conclusion of the procedure...Invasive Procedures without Sedation (Local Anesthesia only)...Invasive procedures without sedation - this includes both pre-procedure checklist and post-procedure assessment...” A review of the P&P titled, “PATIENT’S RIGHTS AND RESPONSIBILITIES,” undated, indicated, “...the expectation that understanding and observation of the rights will result in more effective patient care and in promotion of the confidence and trust which must exist between the patient, the physician...name of facility has responsibilities and duties of its own to the patient...The right to considerate and respectful care...””

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 48562 Based on interview and record review, the facility failed to develop and implement a policy on the prevention of transmission of infections, within the hospital for one of 30 patient’s (Patient 17), when Patient 17 developed a hospital acquired infection. Based on interview and record review, the facility failed to prevent the transmission of infections within the hospital for one patient (Patient 17), when the patient developed a hospital acquired infection. This failure led to Patient 17 developing Candida Auris (C. Auris; a type of yeast that can cause severe illness and spreads among patients in healthcare facilities) fungemia (a systemic infection that occurs when fungi or yeast are present in the blood) and had the potential to further impact the patient’s health. Findings: On November 18, 2024, an unannounced complaint validation survey was conducted at the facility. On November 19, 2024, at 10 a.m., a review of Patient 17’s medical record was conducted with the Resource Chief Operating Officer (RCOO). The facility document titled “History and Physical” dated July 24, 2024, indicated Patient 17 was admitted to the facility on July 24, 2024. An untitled facility document indicated a blood culture was collected from Patient 17 on July 25, 2024, “...Preliminary result...blood culture...no growth after 24 hours...” An untitled facility document indicated a Candida Auris screen was collected from Patient 17’s axilla/groin on July 25, 2024, “...Final result...Candida Auris screen...detected...” The facility document titled, “Operative/Procedure Report,” dated August 7, 2024, indicated “...Removal of right internal jugular vein tunneled hemodialysis catheter...” The facility document titled “Progress Note,” dated August 8, 2024, indicated “Assessment: HD cath removal indicated; done yesterday; cath tip sent for cx...patient needs new HD cath ASAP [as soon as possible]...patient is C auris colonized; contact precautions are in place...” The facility document titled, “Operative/Procedure Report,” dated August 9, 2024, indicated “...Right internal jugular vein Quinton hemodialysis catheter placement under ultrasound guidance...” An untitled facility document indicated a blood culture was collected on August 22, 2024, “...Final result...blood culture...Candida auris has been isolated...” The facility document titled “Progress Note,” dated August 28, 2024, indicated “Assessment: C auris fungemia...must schedule HD cath removal...cath to be left out for at least 48 hrs [hours] before replacement of new HD quinton cath...” An untitled facility document indicated a catheter tip culture was collected on August 28, 2024, “...Final result...source: dialysis catheter...Candida auris has been isolated...” The facility document titled “Progress Note,” dated August 30, 2024, indicated “Subjective...C auris fungemia dx’d [diagnosed]...HD cath tip cx [culture] c/w [consistent with] this cath as the source of fungemia...WBC 14...” The facility document titled “Progress Note,” dated September 4, 2024, indicated “WBC 15.2...Assessment: Sepsis...W/ [work] up pos [positive] for fungemia...C auris isolated...HD cath [hemodialysis catheter] out on 8/28 [August 28, 2024]...” The facility document titled “Discharge Summary,” dated September 8, 2024, indicated “...WBC 23.9...Impression...acute hypoxic respiratory failure...sepsis with shock...severe abdominal distension...candida auris fungemia- line sepsis...multiple pressure wounds unstageable...partially dislodged G tube likely not in stomach...large ascites-most likely G tube feed...to be transferred to [name of facility] for surgical evaluation of abdomen...” On November 21, 2024, at 11:15 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated all patients are tested for C. auris upon admission to the facility. The IP stated a patient is considered colonized with C. auris when there is a positive culture result of the axilla (Armpit) and or groin. The IP stated if C. auris is present in the blood, sputum, or wounds it would be considered a clinical positive versus colonized. The IP stated they would consult with the infectious disease doctor (ID) to determine if the patient required treatment or not. The IP further stated that a positive C. auris culture in the blood three days after the patient’s admission would be considered hospital acquired. A review of an untitled facility document was conducted on November 21, 2024, at 11:30 a.m., with the IP. The document indicated between August 1, 2024, and November 21, 2024, the facility had 19 patients with hospital acquired C. Auris infections cultured after three days of the patient’s admission. On November 21, 2024, at 2 p.m., during an interview with the IP she stated the facility does not have specific policies for infection control at this time. The IP stated infection control policies were changed to guidelines/procedures only.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 42512 Based on interview and record review the facility failed to implement their policy and procedure for one of 30 sampled patients, (Patient 1), for an invasive bedside procedure. These failures had the potential to result in an invasive procedure being performed on the wrong patient, wrong procedure, and had the potential to cause harm or death to the patient. Findings: On November 18, 2024, at 10:08 a.m., a review of Patient 1’s record was conducted. The “History and Physical,” dated September 30, 2024, at 4:59 p.m., indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses of multi substance abuse, morbid obesity, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure). Review of a facility document titled, “General Surgery Consult,” dated October 2, 2024, at 7:54 a.m., was reviewed. The document indicated, “...PLEASE PUT QC [Quinton Catheter] HD [Hemodialysis -Life saving treatment for kidney failure] CATHETER IN...Timeframe: Urgent - 48 hrs...” Review of a facility document titled, “PROCEDURE CHECKLIST...INVASIVE PROCEDURES WITHOUT SEDATION,” was reviewed. There was no documented evidence the facility completed this form for Patient 1’s procedure on October 4, 2024. Review of a facility document for Patient 1 titled, “Operative/PROCEDURE Report,” dated October 4, 2024, was reviewed. The document indicated, “...ANESTHESIA: Local...DESCRIPTION OF PROCEDURE: The patient was placed on the bed...A 13 cm [centimeter - unit of measurement] Quinton catheter was threaded over the guidewire...The catheter was anchored in place with two interrupted 2-0 nylon sutures...and a postprocedure [sic] chest x-ray was ordered. There was no documented evidence of the time out, start of procedure or end of procedure. There was no documented evidence care provided during the procedure was completed. There was no documented evidence patient’s vital signs were assessed during the procedure. There was no documented evidence there was a handoff report to the unit nurse at the conclusion of the procedure. There was no documented evidence post-procedure assessment was completed. Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...HD catheter placement...at 10/04/2024 [October 4, 2024] 17:00 [5 p.m.] Comment: Pt transfer to OR for HD catheter placement. Vital sign [sic] are BP [blood pressure] 112/62, HR [heart rate] 82, Resp. [respirations] 20, Temp [temperature] 98.2...” Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...Oxygen Desaturation...at...17:40 [5:40 p.m.]...” Review of a facility document for Patient 1 titled, “Change of Condition,” indicated, “...Other change of condition...Patient had a rapid response 1742 [5:42 p.m.] led to code blue 1745 [5:45 p.m.]...comment...After HD placement, patient wheeled back to patient room where she was observed to be struggling to breath...Rapid response called and ambubagging started...code blue called...CPR initiated but no ROSC [Return of spontaneous circulation]...Patient pronounced by [Name of MD 4] at 1809 [6:09 p.m.]...” Review of Patient 1’s document titled, “Chest 1 View portable,” indicated, “...DATE OF EXAM: 10/04/2024 [October 4, 2024] 17:52 [5:52 p.m.]...CLINICAL INDICATORS: verify tube/line placement, renal dialysis catheter...Signed Date: 10/04/2024 18:26 [6:26 p.m.]. Facility document titled, “Discharge Summary,” for Patient 1 indicated, “...[Patient 1] is scheduled for the temporary hemodialysis catheter replacement...underwent the procedure on October 4th...postop chest x-ray reportedly okay with no pneumothorax...Please note...the chest x-ray was...for postop dialysis catheter placement but she developed a good [sic] blue it was done during the code...Soon after the procedure she went back to her room and she developed desaturation and eventually coded and expired...the cause of death at this point is probable pulmonary embolisms...” Facility document titled, “RAPID RESPONSE TEAM AND CODE H RECORD,” indicated, “...Reason for Call: HR less than 50...O2 sat [oxygen saturation]...43...Vital Signs [VS] on arrival: Time 1742 [5:42 p.m.]...HR 12, BP 63/33, SPO2 [Peripheral Oxygen Saturation] 40, Temp 98...Repeat VS: Time: 1745 [5:45 p.m.] HR 0, BP N/A...Outcome: Code Blue called...” Facility document titled, “CODE BLUE FLOWSHEET,” indicated, “...Time Code Called: 1745 [5:45 p.m.]...Xray done 1752 [5:52 p.m.] Pronounced by Physician (P) 2...Expired...Time Pronounced 18:09 [6:09 p.m.]...” On November 19, 2024, at 8:55 a.m., an interview was conducted with the Registered Nurse (RN) 5. RN 5 stated she was dealing with another patient and was not aware of why Patient 1 was moved to the OR for a bedside procedure. RN 5 stated she took Patient 1’s vitals prior to Patient 1 being moved. RN 5 stated the House Supervisor (HS) moved Patient 1 to the OR. RN 5 stated at the time of the procedure there was no OR staff available. She further stated when the procedure was a bedside procedure the RN or the HS will assist in the procedure. RN 5 stated she was not aware of when Patient 1 returned from the OR, and she did not assess the patient when they returned. On November 19, 2024, at 9:26 a.m., an interview was conducted with the House Supervisor (HS). The HS stated Patient 1 was scheduled to have a bedside procedure for a hemodialysis catheter placement. The HS stated Physician (P) 1 requested to have the procedure in a larger room. The HS additionally stated staff should have documented the time Patient 1 was moved to the OR. During continued interview, the HS stated she should have completed the “PROCEDURE CHECKLIST” throughout the procedure, and she did not, and that there was no documented evidence a “timeout” was completed prior to start of procedure as per the policy. The HS stated there was also no documentation of post procedure vitals being taken for Patient 1. During further interview, the HS stated the on-call X-ray technician should have been called prior to the procedure to verify placement, and rule out perforation or bleeding, immediately following th procedure. The HS stated that when the Licensed Vocational Nurse (LVN) 1, and CNA 1 were cleaning Patient 1 following the procedure, Patient 1 stated she was having difficulty breathing so, LVN 1 called a rapid response. The HS stated she came to assess Patient 1, and upon assessment, Patient 1 did not have a pulse so a Code Blue was called and CPR started at 5:45 p.m. The HS stated Physician 1 had already left the building and she (HS) called her to come back during the code. The HS stated she was on the phone with P 2, and P 2 requested for an X-ray to be completed during the code blue. The HS stated Patient 1 did not achieve ROSC (return of spontaneous circulation, resumption of a sustained heart rhythm after cardiac arrest) and Patient 1 was pronounced deceased at 1809 (6:09 p.m.). On November 19, 2024, at 10:02 a.m., an interview was conducted with LVN 1. LVN 1 stated no one was documenting anything in the OR room. LVN 1 stated the on-call X-ray tech was called while patient was in the OR room, but the HS requested Patient 1 to be moved to her room before the X-ray tech arrived. LVN 1 stated Patient 1 had a bowel movement and needed to be cleaned. She stated after cleaning Patient 1, she started thrashing around and was having trouble breathing, oxygen on the monitor started to fall, and a code rapid was called. She stated the rapid response was then converted to a code blue. On November 20, 2024, at 3 p.m., an interview was conducted with P 1. P 1 stated there is a form that is filled out prior to a bedside procedure but was not sure who filled it out. P 1 stated they could not recall who was in the OR during the procedure on Patient 1. P 1 stated she did not recall if there was a timeout for this procedure. P 1 stated they were not sure where the timeout would be documented. On November 20, 2024, at 3:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the HS asked her to stay in the OR to help P 1 with the procedure. CNA 1 stated she handed Tegaderm (transparent medical dressing) and 4x4 sponge pads to P 1. CNA 1 stated Patient 1 stated she had difficulty breathing during procedure in the OR room. CNA 1 stated P 1 left the facility prior to the X-ray. CNA 1 stated Patient 1 had a bowel movement and after being cleaned up, Patient 1 started thrashing around stating she was having difficulty breathing. CNA 1 stated a code rapid was called, and then shortly after a code blue was called. CNA 1 stated after the code blue was called, she exited the room and was asked to call P 1 so they could return to the facility. CNA 1 stated no staff was documenting anything while the procedure was being performed. A review of the policy and procedure (P&P) titled, “Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation,” dated June 2022, was conducted. The P&P indicated, “...verification of the patient’s identification and completion of all patient safety procedures including site marking and time out procedures must be performed prior to every inpatient and outpatient invasive procedures with or without sedation...Complete and accurate documentation as outlined here is required for all invasive procedures with our without sedation...Postoperative documentation records the patient’s vital signs...any unusual events...Nursing and/or surgical personnel are to maintain a log of all bedside and non-bedside operative or invasive procedures...The following steps are required before any procedure may proceed:...Pre-procedure checklist...Time out completed...Note: No procedure may proceed if the above required steps are not followed. Any physician, nurse, licensed therapist involved in the procedure may halt the procedure until the required steps are completed...Perform all “Timeout” procedures as outlined on the forms. One designated team member ensures that a final verification of the correct patient, procedure, site, and as applicable...During the Procedure/Post Procedure...Document all care provided on the appropriate forms...At the conclusion of the procedure, the procedure nurse provides a complete “handoff” communication to the unit nurse. The hand off after a procedure should include at least the following: patient’s vital signs prior to and after the conclusion of the procedure...Invasive Procedures without Sedation (Local Anesthesia only)...Invasive procedures without sedation - this includes both pre-procedure checklist and post-procedure assessment...””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47071 Based on observation, interview and record review, the facility failed to ensure nursing staff followed standards of practice for patient care, when: 1. For Patients 2, 4, 5, 17, 18, 19, and 21, oral care was not provided every six hours (Refer to A0144); 2. For Patients 1 and 4, Percutaneous Endoscopic Gastrostomy (PEG- feeding tube) assessments were not completed every shift (Refer to A0144); 3. For Patient 1, a midline catheter (a device used to infuse medications) was not re-assessed for necessity after four weeks (Refer to A144); 4. For Patient’s 1 and 2, a midline catheter (a device used to infuse medication) site was not assessed daily and dressing changes were not performed every seven days (Refer to A 0144); 5. For Patient 8, the hemodialysis catheter (flexible tube inserted into a vein in the neck, chest, or upper leg for dialysis) was used to infuse medication (Refer to A0144); 6. For Patient 21, the Central Venous site was not assessed daily, and dressing changes were not performed every seven days (Refer to A0144); 7. For Patients 4 and 21, the Sepsis Management (involves a combination, appropriate treatment, and control of the source of infection) was not activated timely (Refer to A0144); 8. For Patient 4, vital signs were not done every two hours as required in the Intensive Care Unit (Refer to A0144); 9. For Patient 4, abdominal distention was not reported to the physician (Refer to A0144); 10. For Patient 21, nail care was not provided (Refer to A0144); 12. For Patient 8, soft wrist restraints were initiated without a physician’s order (Refer to A0168); 13. For Patient 10, an ongoing assessment for restraints was not conducted (Refer to A0174). The cumulative effects of these systemic failures resulted in the facility’s inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Patient’s Rights was met. On September 19, 2024, at 3:39 p.m., the survey team identified significant concerns in the facility’s Medical Surgical Telemetry (MSTU) and Intensive Care Unit ICU). Due to the seriousness of the situation, an IJ was called in the presence of the hospital’s Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director for Quality (RDQ), Director for Nursing Clinical Services (DNCS), and Director for Quality (DQ). The facility’s CEO, COO, DNCS, RDQ, and QD were verbally notified regarding the concerns of the facility’s failure to ensure patients receive care in a safe setting. On September 20, 2024, at 9:39 a.m., the COO provided a Corrective Action Plan (CAP). The CAP was found to not be acceptable. On September 23, 2024, at 2:42 p.m., the COO provided a revised CAP. The CAP indicated the following: 1. The Nursing Leadership team reviewed the following policies on September 19, 2024, and no modifications were recommended. a. H-PC 04-015 Oral Hygiene for Airway Assisted Patients; b. H-PC 04-009 Routine Bathing; c. H-PC 05-006 Administration of Enteral Nutrition; d. H-PC 05-010 Mid line Catheter Site Placement, Maintenance and Dressing Change; e. H-PC 03-007 Sepsis: Early Recognition and Management; f. H-PC 02-001 Interdisciplinary Assessment and Re-Assessment; and g. H-IM 01-001 General Documentation Guidelines; 2. All patients were assessed by nursing for the need of oral care, perineal care (pericare, the practice of washing the genital and anal areas of the body) and bathing needs. Care was provided to patients identified as needing oral care, peri care or bathing. Medical records were reviewed by clinical leadership to verify the current worklist includes oral care, peri care and bathing. Any missing elements were added onto the worklist within the electronic medical record for nurses, certified nursing assistant (CNA) and/or respiratory therapist (RT). Bathing and/or pericare to occur daily (by CNA, LVN, RN) and as needed for patients who are soiled, incontinent or upon patient request. For patients who are hemodynamically unstable based on RN assessment, bathing may be paused until hemodynamic status improves. Oral care to occur daily (by CNA, LVN, RN, RT) and as needed or upon patient request. For patients with artificial airway or patients receiving continuous BiPAP (bilevel positive airway pressure, a noninvasive breathing machine that helps people breathe by delivering pressurized air through a mask) therapy by mask, oral care will occur at six-hour intervals (by Nursing, and Respiratory Therapy); 3. All patient records with current physician orders for lactate (a chemical produced in the body when cells break down food for energy, high levels of which could indicate low levels of oxygen in the blood and sepsis [a life threatening infection]) laboratory specimen collection associated with a positive sepsis protocol meeting SIRS (Systemic Inflammatory Response Syndrome, criteria used to identify the body’s defense response to harmful stressors) criteria were verified and placed on the worklist for collection every six hours. Additionally, a sepsis screening was completed on each patient to ensure that any early signs of sepsis were identified and sepsis protocol activated, including lab orders, as appropriate; 4. All patients with midlines (a long, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) were reviewed for the date of insertion. The physician was contacted for an order to replace midline with an insertion date greater than 30 days. All patients with line dressing were assessed for intact dressings as well as labeled with date and time. The dressings were changed as appropriate; 5. Education began with nursing (RN, LVN, CNAs, RTs) that were on duty. The remaining staff will be trained within 30 days of acceptance of plan. Any required staff that have not completed the training within the 30 days will not work until training has been completed. The education included: a. Interdisciplinary assessment and reassessment policy (policy H-PC-02-001); b. Change of condition to include notification of provider and instructions for completing documentation in Protouch (an electronic medical record used by the facility); c. A change of condition is anything that is not anticipated or is an unexpected change from previous status. A change of condition includes changes in status, such as a transfer to a higher or lower level of care, change in GI status, early signs and symptoms of sepsis and abnormal vital signs; d. Vital sign requirements for Intensive Care Unit (unit for critically ill patients) level patients; and e. Proper assessment of gastrointestinal (refers to the organs that process food and liquids) status includes abdominal assessment and percutaneous endoscopic gastrostomy (PEG, a feeding tube through the stomach wall and skin) tube or gastrostomy (G tube, an artificial opening in the stomach) tube assessment every shift. On September 23, 2024, at 2:51 p.m., the CAP was reviewed and accepted, and the DNCS and the DQM were notified. On September 24, 2024, at 9:30 a.m., through observations, interviews, and record review, the CAP was verified onsite to have been fully implemented. On September 24 , 2024, at 10:25 a.m., the IJ was removed in the presence of the DNCS and the DQ.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 47071 Based on interview and record review, the facility failed to ensure qualified and competent Registered Nurses (RN’s) were assigned to provide care for patient’s in the Medical/ Surgical/Telemetry Unit, and Intensive Care Unit (ICU, a unit for critically ill patients) requiring cardiac monitoring (continuous or intermittent monitoring of the heart’s activity to assess a patient’s condition). Additionally, the facility failed to follow their policies and procedures on weight management and waste disposal when: 1. 62 of 66 RN’s (RN’s 1 to 9, 11 to 14, 16, 18, and 20 to 66) did not complete a cardiac arrhythmia (irregular heart rate and rhythm) interpretation course for the certification required to care for patients requiring cardiac monitoring, and who were providing care for patients placed on a cardiac monitor (a device which shows the heart rate and rhythm on a monitor with a capability of printing them on strips) (Refer to A0397); 2. 44 of 66 RN’s (RN’s 2 to 9, 11 to 13, 20, 21, 25 to 41, 46, 50, 53, 55 to 59, and 61 to 66) did not complete the cardiac rhythm interpretation test required to care for patients requiring cardiac monitoring, and who were providing care for patients on the cardiac monitor (Refer to A0397); 3. Two RN’s (RNs 2 and 50), who were providing care to patients in the ICU, had no ICU competency validation and unit orientation completed (Refer to A0397); 4. Six of eight Nursing and House supervisors (NSRN 58, 59, 60, 61, 62, and 65) who are responsible to oversee all the units in the facility during a shift, and who take over the care of patients in the ICU when the ICU RN responds to emergency situations, had no ICU nursing orientation or competency (Refer to A0397); 5. The Director of Nursing Clinical Services (DNCS) did not meet the qualification for the position based on the DNCS job description (Refer to A0397); 6. For Patient 29 and 30 who were on enteral feeding were not re-weighed after a significant weight loss/gain (Refer to A0398); and 7. The facility did not ensure sharps were properly stored or disposed of (Refer to A0398). The cumulative effects of these systemic failures resulted in the facility’s inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Nursing Services were met. On September 18, 2024, at 1:12 p.m., the survey team identified significant concerns in the facility’s Medical Surgical Telemetry (MSTU) and Intensive Care Unit (ICU). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation which had the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director for Quality (RDQ), Director for Nursing Clinical Services (DNCS), Director for Quality (DQ), and Clinical Analyst (CA). The facility’s CEO, COO, DNCS, RDQ, and QD were verbally notified regarding the concerns of the facility’s failure to ensure qualified and competent Registered Nurses (RNs), for 62 of 66 RNs, were assigned to provide care to patients requiring cardiac monitoring. On September 20, 2024, at 9:39 a.m., the COO provided a Corrective Action Plan (CAP). The CAP was found to not be acceptable. On September 20, 2024, at 3:28 p.m., the COO provided a revised CAP. The CAP indicated the following: 1. The Nursing Leadership team reviewed the facility policy and procedure titled, “Continuous Cardiac Monitoring H-PC 7-015,” and no modifications to policy were recommended. 2. All RN files were reviewed by the Nursing Leadership to develop a list of RN team members who have taken a course in cardiac interpretation and have passed the (name of facility) cardiac rhythm interpretation test. 3. All patients currently on continuous cardiac monitoring were assessed by a competent Registered Nurse (RN) with evidence of cardiac rhythm interpretation competency. Rhythm interpretation, vital signs and plan of care reviewed with bedside nurse. Documentation of rhythm interpretation, vital signs, and any interventions are to be documented in the change of condition and will continue to be charted under change of condition for a period of 30 days. 4. All Patients with continued cardiac monitoring will be assessed each shift by a competent Registered Nurse (RN) with evidence of cardiac rhythm interpretation competency by a) rhythm interpretation, vital signs and plan of care, b) review with bedside nurse and c) assessment and interventions as indicated until education can be completed to obtain the sufficient number of licensed nurses with competency in cardiac rhythm interpretation. 5. At least 2 RNs, with the support of a Nursing Supervisor who are competent in cardiac interpretation, will be assigned to continually monitor and provide interpretation of cardiac status of all patients requiring cardiac monitoring. This process will continue until a sufficient number of RNs, based on the number of patients with continuous cardiac monitoring, have completed the competency for cardiac rhythm interpretation; and 6. A Lippincott [a publisher of medical and nursing books] based education plan was identified. Initial implementation of education and testing began to ensure qualified and competent licensed nurses are assigned to provide care to patients requiring cardiac monitoring. On September 20, 2024, at 4:10 p.m., the CAP for the IJ was reviewed and accepted. The DNCS and the Director of Quality Management (DQM) were notified. On September 23, 2024, at 11:40 a.m., through observations, interviews, and record review, the CAP was verified onsite to have been fully implemented. On September 23, 2024, at 1:10 p.m., the IJ was removed in the presence of the COO, the DNCS, and the DQ.”

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 47071 Based on interview and record review, facility failed to ensure the grievance process was implemented, for one of 31 sample patients (Patient 18), in accordance with the facility’s policy and procedure (P&P). This failure had the potential to cause harm and delay of care to the patient. Findings: A review of Patient 18’s record was conducted on September 19, 2024, at 10:40 a.m., with the Clinical Analyst (CA). A facility document titled, “History and Physical,” dated July 19, 2024, at 12:32 a.m., was reviewed. The document indicated Patient 18 was admitted to the facility on July 17, 2024, with diagnoses which included acute (occuring for less than six months) and chronic (occuring for more than six months) respiratory failure (difficulty breathing) with hypoxia (not enough oxygen in the body) or hypercapnia (too much carbon dioxide in the blood) and inhalation injury (damage to the respiratory system or lungs caused by breathing in toxic substances, extreme heat, or other irritants) sustained in a house fire. On September 18, 2024, at 11:48 a.m., an interview was conducted with the Director of Quality Management (DQM). The DQM stated RN 56 is a house supervisor who works at the facility on weekends. The DQM stated RN 56 gave out his personal email which is not part of the policy. The DQM stated the staff member can take a grievance and put it in the event reporting system and the policy is for that person to attempt to solve the concern. The DQM stated, if the staff are unable to solve the concern, they are to escalate the concern up the chain of command (a ladder of authority where those in charge of an organization). The DQM further stated if the name of the complainant is not on the list, then she did not receive the grievance. On September 22, 2024, at 6:31 a.m., an interview was conducted with RN 56. RN 56 stated he did sit with the family to discuss their concerns. RN 56 stated he gave out his personal email address because the facility computers were down at that time and his personal email was working. RN 56 stated he sent the complaintant’s email to his supervisor. RN 56 further stated he did not enter the grievance in the Event Reporting System (system used by the facility to report patients’ grievances) in accordance with the facility’s P&P. The facility was unable to provide documentation the complaint was entered in the Event Reporting System in accordance with the facility’s P&P. A review of facility P&P titled, “Procedure-Patient Complaint and Grievance Process,” dated June 2022, was conducted. The P&P indicated, “...When reasonably possible, the person who receives a complaint should address and resolve it...It is the supervisor’s responsibility to handle unresolved complaints or grievances promptly and effectively...Initiate an initial investigation if it has not already been started, including interviews of individuals with information about the issue...Initiate the complaint and grievance entry in to the Event Reporting System...Every effort should be made to complete entries by end of the shift...Escalate (if the complaint is not resolved immediately)...every issue, concern, or expression of dissatisfaction that you cannot resolve should be escalated to a supervisor, manager, or administrator...””

“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: 47071 J) Based on observation, interview, and record review the facility failed to follow their policies and procedures for 11 of 31 patients (Patients 1, 2, 4, 5, 8, 16, 17, 18, 19, 20, and 22) when: 1. For Patients 2, 4, 5, 17, 18, 19, 20, and 22, oral care was not provided every six hours; 2. For Patients 1, 2, 4, 7, 16, and 17, Percutaneous Endoscopic Gastrostomy (PEG- feeding tube) assessments were not completed every shift; 3. For Patient 1’s midline catheter (a device used to infuse medications) was not re-assessed for necessity after four weeks; 4. For Patients 1, and 2, midline catheter sites were not assessed daily, and dressings were not changed every seven days; 5. Patient 8’s hemodialysis catheter (flexible tube inserted into a vein in the neck, chest, or upper leg for dialysis) was used to infuse medication; 6. For Patient 17 and 22’s Central Venous Catheter (thin flexible tube inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart) site was not assessed daily and dressing changes were not done every seven days; 7. For Patient 4, the Sepsis Management (involves a combination, appropriate treatment, and control of the source of infection) was not activated timely; 8. Patient 4, an Intensive Care Unit (ICU) patient, vitals signs were not done every two hours; 9. Patient 4’s abdominal distention was not reported to the physician; 10. Patient 22 was not provided nail care; 11. Patients 19, and 20’s PEG Feeding container and water flush was not labeled; 12. Patient 16’s change of condition was not reported to the physician; and 13. Patient 18 was not provided a daily bath. These failures had the potential to cause infection, delay patient care, and cause patient harm or death. Findings: 1a. On September 16, 2024, at 8:47 a.m., a tour of the facility was conducted with the Director of Nursing Clinical Services (DNCS) and Director Quality Management (DQM). During the tour of Patient 2’s room, Patient 2’s mouth was observed with dried mucus on the teeth, white residue around the mouth, and dry flakey lips. An interview was conducted on September 16, 2024, at 11:12 a.m., with Registered Nurse (RN) 4. RN 4 stated oral care is done every shift and when needed. RN 4 stated it is a shared responsibility of Nursing staff and Respiratory Therapy staff. RN 4 further stated Patient 2 needed oral care to be done. A review of Patient 2’s medical record was conducted on September 17, 2024, at 1:10 p.m., with the Education Manager (EM). The facility document titled, “History and Physical”, dated, August 24, 2024, indicated, “...DATE OF ADMISSION: August 24, 2024... A/P [Assessment/Plan]: Chronic with acute respiratory failure [condition that makes it difficult to breath] which is multifocal from pneumonia [lung infection], Congestive heart failure [heart can’t pump enough blood], and aspiration...” The facility document titled, “Oral Care”, dated September 11, 2024, through September 18, 2024, was reviewed with the EM, and indicated oral care was not performed every six hours per the facility policy. An interview was conducted with the EM on September 17, 2024, at 1:30 p.m. The EM stated oral care should be done every six hours per the facility policy. b. A review of Patient 4’s medical record was conducted on September 18, 2024, at 10:30 a.m., with the Rancho Director of Quality (RDQ). The facility document titled, “History and Physical” dated February 23, 2024, indicated, Patient 4 was admitted to the facility on February 22, 2024, with a diagnosis of Acute hypoxic respiratory failure (condition where there is not enough oxygen in the blood), Status epilepticus (prolonged seizure), and status post trach (tracheostomy - opening in the neck) and on a ventilator. The facility document titled “Oral Care” dated February 22, 2024, through February 27, 2024, indicated: - February 22, 2024, - no documented evidence oral care was provided; - February 23, 2024, - documentation showed oral care was provided once at 4:24 a.m.; - February 24, 2024, - documentation showed care was provided at 3:36 a.m., 3 p.m., and 10:56 p.m.; - February 25, 2024, - documentation showed oral care was provided at 4: 59 a.m.; - February 26, 2024, - documentation showed oral care was provided at 5:53 p.m., and 8:22 p.m.; and - February 27, 2024, - there was no documented evidence that oral care was provided. An interview was conducted on September 18, 2024, at 11:00 a.m., with the RDQ. The RDQ stated oral care was not provided for Patient 4, per the facility policy. c. A review of Patient 5’s medical record was conducted on September 18, 2024, at 3:05 p.m., with the RDQ. The facility document titled “HISTORY AND PHYSICAL”, dated June 17, 2024, indicated, Patient 5 was admitted to the facility on June 16, 2024, with a diagnosis of respiratory failure with hypoxia (not enough oxygen in the brain) and pneumonia (infection of the lungs). The facility document titled, “Oral care” dated June 23, 2024, through June 30, 2024, indicated oral care was not provided for Patient 5 every six hours. An interview was conducted on September 18, 2024, at 3:35 p.m., with the RDQ. The RDQ stated oral care was not provided for Patient 5 every six hours per facility policy. d. A review of Patient 17’s medical record was conducted on September 17, 2024 at 2:08 p.m.., with the CA. A facility document titled, “History and Physical,” dated April 29, 2024, at 10:58 a.m. was reviewed. The document indicated Patient 16 was admitted April 28, 2024, with a diagnosis of respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood). The facility document titled “Oral Care” dated April 29 through May 6, 2024, indicated oral care was not provided every 6 hours. An interview was conducted on September 17, 2024, at 3:15 p.m., with the CA. CA stated the RN and the Respiratory Therapist are to complete oral care every 6 hours. The CA stated the staff did not follow the hospital policy. e. A review of Patient 18’s medical record was conducted on September 18, 2024, at 1:59 p.m. with the CA. The facility document titled, “History and Physical,” dated July 18, 2024, at 12:32 a.m., was reviewed. The document indicated Patient 18 was admitted to the facility on July 17, 2024, with a diagnosis of acute and chronic respiratory failure unspecified with hypoxia or hypercapnia, and inhalation injury sustained in a house fire. The facility document titled, “Nurses Notes Provide Oral Care-Registered Nurse [RN]Work List,” dated July 17, 2024, to August 27, 2024, indicated Patient 18 did not receive oral care every six hours per the facility policy. An interview was conducted on September 18, 2024, at 2:05 p.m., with the CA. The CA stated the RN and the RT are to complete oral care every six hours. The CA stated the staff did not follow the facility’s policy. f. A review of Patient 19’s medical record was conducted on September 19, 2024, at 10:32 a.m., with the CA. The facility document titled, “History and Physical,” dated August 30, 2024, at 8:53 p.m., indicated Patient 19 was admitted to the facility on August 29, 2024, with a diagnosis of respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood). There was no documented evidence Patient 19 was provided oral care by the Respiratory Therapist (RT) on: August 30, 2024, no documentation of oral care by RT; August 31, 2024, no documentation of oral care by RT; September 1, 2024, no documentation of oral care by RT; and September 2, 2024, no documentation of oral care by RT. An interview was conducted on September 19, 2024, at 3:23 p.m., with the CA. CA stated oral care should have been performed every six hours by the RN and the RT. CA further stated there is no documentation the RT completed the oral care. An interview was conducted on September 19, 2024, at 3:25 p.m., with RT 2. RT 2 stated the order set in the computer should include oral care. If it is on the work list, they have to clear the workload. RT 2 stated the RT should have performed oral care every six hours. The RT 2 further stated if it is not found in the documentation, then the RT did not complete the oral care. g. On September 16, 2024, at 9:35 a.m., Patient 20 was observed lying in bed. Patient 20s mouth was observed to be dry with a thick tan matter on the teeth, gums, and lips. On September 16, 2024, at 9:41 a.m., an interview was conducted with the DQM. The DQM stated oral care is to be completed every six hours by the RN and RT. The DQM stated based on Patient 20’s mouth, she did not think it is good oral care. A review of Patient 20’s medical record was conducted on September 20, 2024, at 9:19 a.m., with the CA. The facility document titled, “History and Physical,” dated September 8, 2024, at 7:12 p.m., indicated Patient 20 was admitted to the facility on September 7, 2024, with a diagnosis of Acute (less than 6 months) and chronic (greater than 6 months) respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood). h. On September 16, 2024, at 10:37 a.m., an observation of Patient 22’s room was conducted with the DNCS, DQM and RN 5. Patient 22’s mouth was observed to be dry with cracked lips and thick white build up on teeth. RN 5 stated he was Patient 22’s nurse for the day, and did not know when the last time Patient 22 had oral care performed. A review of Patient 22’s medical record was conducted on September 23, 2024, at 2 p.m., with the CA. The facility document titled, “History and Physical,” dated August 18, 2024, at 5:40 p.m., indicated Patient 22 was admitted to the facility on August 17, 2024, with a diagnosis of acute (under 6 months) respiratory failure unspecified with hypoxia ( not enough oxygen in the brain) or hypercapnia (too much carbon dioxide ion the blood). The facility document titled, “Nurses Notes Provide Oral Care-Registered Nurse [RN] Work List,” dated September 16, 2024, to September 19, 2024, indicated Patient 22 did not receive oral care every six hours per the facility policy. An interview was conducted on September 23, 2024, at 2:10 p.m., with the CA. CA stated the RN, and the RT are to complete oral care every six hours. CA stated the staff did not follow the facility’s policy. A review of the facility P&P titled, “Core: Oral Hygiene for Airway Assisted Patients,” dated June 2021, indicated,”...A combined Respiratory Therapy and Nursing approach will allow for oral hygiene scheduled at 6-hour intervals in order to maintain an oral environment free from bacteria often associated with Ventilator associated pneumonia (respiratory disorder)...” 2 a. A review of Patient 16’s medical record was conducted on September 17, 2024, at 11:40 a.m., with the CA. The facility document titled, “History and Physical,” dated February 14, 2024, at 7:15 p.m., indicated Patient 16 was admitted to the facility on February 13, 2024, with a diagnosis of respiratory failure unspecified with hypoxia (not enough blood in the brain) or hypercapnia (too much carbon dioxide in the blood). The facility document titled, “Nurses Notes” dated February 13, 2024, through February 15, 2024, contained no documented evidence Patient 16’s percutaneous endoscopic gastrostomy (PEG-feeding tube through the stomach) feeding tube was completely assessed, and no dressing change was performed for the PEG tube, on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.). An interview was conducted on September 17, 2024, at 11:50 a.m., with the CA. CA stated she was unable to find documentation Patient 16’s PEG tube was assessed for February 13, 2024, through February 15, 2024. CA stated the PEG tube should be assessed once every shift and as needed. An interview was conducted on September 17, 2024, at 1:47 p.m., with the EM. EM stated the PEG tubes are to be assessed once a shift for the feeding infusion, and dressing changes. An interview was conducted on September 17, 2024, at 1:50 p.m., with the DQM. DQM stated there is no policy for the PEG tube assessment and cleaning. The DQM stated they currently use the “Gastrostomy” information from their online resource as the procedure for the facility. b. On September 16, 2024, a tour of the facility was conducted with the DNCS and DQM. On September 16, 2024, at 10:25 a.m., in Patient 1’s room, Patient 1 was observed to be sitting in bed and had a PEG tube in the left upper abdominal quadrant with feeding infusing. A review of Patient 1’s medical record was conducted on September 17, 2024 at 10:50 a.m., with EM. The facility document titled,” History and Physical” indicated, Patient 1 was admitted to the facility on May 18, 2024, with a diagnosis of acute hypoxic respiratory failure, opiate (pain medication) drug overdose and pneumonia. The facility’s untitled document dated August 25, 2024, indicated, “...*** okay to use G tube*** Verified by KUB [kidney, ureter, and bladder - procedure to scan the kidneys and stomach] x1, start 08/25/2024 [August 25, 2024] 08:20 [8:20 a.m.]...” Patient 1’s PEG feeding tube assessments dated September 10, 2024, through September 16, 2024, indicated: - September 10, 2024, no documented evidence Patient 1’s PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.) - September 11, 2024, there was no documented evidence Patient 1’s PEG feeding tube was assessed on the day shift (7a.m.-7p.m.) - September 12, 2024, there was no documented evidence Patient 1’s PEG feeding tube was assessed on the day shift (7a.m.-7p.m.) - September 13, 2024, there was no documented evidence Patient 1’s PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.) - September 14, 2024, there was no documented evidence Patient 1’s PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.) - September 15, 2024, there was no documented evidence Patient 1’s PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and - September 16, 2024, there was no documented evidence Patient 1’s PEG feeding tube was assessed on day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.). An interview was conducted on September 17, 2024, at 11:02 a.m., with the EM. The EM stated PEG feeding tube assessments should be done by the RN’s every shift. c. On September 16, 2024, at 11:10 a.m., Patient 2 was observed lying in bed with a PEG tube in his left upper abdominal quadrant. A review of Patient 2’s medical record was conducted on September 17, 2024, at 1:10 p.m., with the EM. The facility document titled, “History and Physical”, dated August 25, 2024, indicated Patient 2 was admitted to the facility on August 25, 2024, with a diagnosis of chronic with acute respiratory failure, renal failure, and diabetic vascular disease. The facility document titled, “Nursing Admission” dated August 25, 2024, indicated Patient 2 had a PEG feeding tube located in the left upper abdominal quadrant. Patient 2’s Peg feeding tube assessments dated September 10, 2024, through September 16, 2024, indicated: - September 10, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) - September 11, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift; - September 12, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift; - September 13, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on day (7a.m. top 7p.m.) and night (7p.m. to 7 a.m.) shift; - September 14, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on day (7a.m. to 7p.m.) and night (7p.m. to 7 a.m.) shift; - September 15, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on day (7a.m. to 7p.m.) and night (7p.m. to 7 a.m.) shift; and - September 16, 2024, no documented evidence Patient 2’s PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift. An interview was conducted on September 17, 2024, at 1:20 p.m., with the EM. EM stated PEG assessments should be done by the RNs every shift. d. A review of Patient 4’s medical record was conducted on September 18, 2024, at 10:30 a.m., with the RDQ. The facility document titled, “History and Physical” dated February 23, 2024, indicated Patient 4 was admitted to the facility on February 22, 2024, with a diagnosis of Acute hypoxic respiratory failure (condition where there is not enough oxygen in the blood) and Status epilepticus (prolonged seizure). The facility document titled, “Physician orders”, dated February 22, 2024, indicated, “...VERIFY TUBE PLACEMENT AND PATENCY...Start 02/23/2024 [February 23, 2024] 10:00 [10:00 a.m.]...q[every]...(10 22)...” Patient 4’s PEG feeding tube assessments dated February 22, 2024, through February 26, 2024, indicated: - February 22, 2024, no documented evidence Patient 4’s PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift; and - February 24, 2024, no documented evidence Patient 4’s PEG feeding tube was assessed on the night (7p.m. to 7 a.m.) shift. An interview was conducted on September 18, 2024, at 1:49 p.m., with the RQD. RQD stated the expectation is for the PEG assessments to be done by the RNs every shift, however, that was not done for Patient 4. e. On September 16, 2024, at 11:39 a.m., in Patient 7’s room, Patient 7 was observed sitting in bed with a PEG tube in the left upper abdominal quadrant, with feeding infusing. A review of Patient 7’s medical record was conducted on September 19, 2024, at 10:21 a.m., with the RDQ. The facility document titled, “ HISTORY AND PHYSICAL” dated July 3, 2024, indicated, “DATE OF ADMISSION: July 2, 2024...IMPRESSION...Acute on chronic hypoxic respiratory failure, status post trach [tracheostomy: incision on the windpipe] on a vent [ventilator- machine to help breath]...Dysphagia [difficulty swallowing] with PEG tube dependent...” The facility’s untitled document, dated July 2, 2024, indicated, “...VERIFY TUBE PLACEMENT AND PATENCY q [every] shift, (10, 12), start 07/03/2024 [July 3,2024] 10:00 [a.m.], stop after 90 days, renewable...” Patient 7’s Peg feeding tube assessments dated from September 1, 2024, through September 15, 2024, indicated; - September 1, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 2, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 3, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 4, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 5, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift; - September 6, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift; - September 7, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 8, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 9, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift; - September 10, 2024, no documented evidence patient 7’s PEG feeding tube was assessed on night (7 p.m. to 7 a.m.) shift; - September 11, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 12, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; - September 13, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift; - September 14, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; and - September 15, 2024, no documented evidence Patient 7’s PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift. An interview was conducted on September 19, 2024, at 10:45 a.m., with the RDQ. The RDQ stated PEG tube assessments should be done every shift but were not done for Patient 7. f. A review of Patient 17’s medical record was conducted on September 17, 2024, at 2:40 p.m., with the CA. The facility document titled, “History and Physical,” dated April 29, 2024, at 10:58 a.m., indicated Patient 17 was admitted to the facility on April 29, 2024, with a diagnosis of respiratory failure unspecified with hypoxia or hypercapnia. - May 2, 2024, no documented evidence Patient 17’s PEG feeding tube was assessed on the night (7 p.m. to 7 a.m.) shift; - May 3, 2024, no documented evidence Patient 17’s PEG feeding tube was assessed on the day (7a.m. to 7 p.m.) shift; - May 5, 2024, no documented evidence Patient 17’s PEG feeding tube was assessed on the day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shifts; and - May 6, 2024, no documented evidence Patient 17’s PEG feeding tube was assessed on the day (7a.m. to 7 p.m.) shift. An interview was conducted on September 17, 2024, at 2:45 p.m., with the CA. CA stated Patient 17’s PEG tube should have been assessed once every shift and as needed. CA stated the staff did not follow the facility policy. A review of the facility’s P&P titled, “Core: Administration of Enteral Nutrition,” dated June 2023, indicated, “...Assess for GI intolerance to enteral tube feeding by assessing for abdominal distention, monitoring for complaints of abdominal pain, and observing for passage of flatus and stool every shift and PRN...” A review of facility document titled, “Gastrostomy” dated October 9, 2023, indicated,”...Monitor the gastrostomy site for signs of skin irritation and infection...Wash the area around the tube daily with soap and water or normal saline solution...Keep the gastrostomy site clean and dry...Changing the Dressing...Change your dressing daily or whenever it’s wet or soiled...clean...the skin around the tube with mild soap and warm water...” 3. A tour of the Medical Surgical Telemetry Unit (MSTU) was conducted on September 16, 2023, at 9:55 a.m., with the DNCS and DQM. During the tour, in Patient 1’s room, Patient 1 was observed sitting in bed, with a midline catheter (a long, flexible tube inserted into a vein in the upper arm to administer medication) in the left upper arm. An interview was conducted on September 16, 2024, at 1:30 p.m., with RN4. RN4 stated Patient 1’s midline is being used to infuse medications. A review of Patient 1’s medical record was conducted on September 17, 2024, at 10:50 a.m., with the EM. The facility document titled, “History and Physical” dated May 19, 2024, indicated Patient 1 was admitted to the facility on May 18, 2024, with a diagnosis of acute hypoxic respiratory failure, opiate drug overdose and pneumonia. The facility document titled, “Orders” dated June 26, 2024, indicated, “...Midline catheter insertion: x1, start 06/26/2024 [June 26, 2024] 15:34 [3:34 p.m.]...” An interview was conducted with the DNCS on September 17, 2024, at 1:13 p.m. The DNCS stated she is not sure when a midline catheter should be discontinued. A concurrent interview and record review was conducted on September 19, 2024, at 7:40 a.m., with the Chief Operation Officer (COO). The facility education board was reviewed. Education board information indicated, “INS Infusion Nursing Society Selecting a Standards for Infusion Care...Infusion Therapy Device Selection...Peripheral...Therapy Duration...>4 weeks consider PICC (Peripherally Inserted Central Catheter) or non-tunneled (short tracked catheter)...” The COO stated he is not an expert on midline catheters so he does not know when a midline should be changed or discontinued. 4.a. On September 16, 2024, at 10:25 a.m., in Patient 1’s room, Patient 1 was observed sitting in bed, with a midline catheter in Patient 1’s left upper arm. An interview was conducted on September 16, 2024, at 1:30 p.m. with RN 4. RN 4 stated the midline is being used to infuse medications. A review of Patient 1’s medical record was conducted on September 17, 2024, at 10:50 a.m., with the EM, The facility document titled, “ History and Physical” dated May 19, 2024, indicated Patient 1 was admitted to the facility on May 18, 2024, with a diagnosis of acute hypoxic, respiratory failure, opiate drug overdose and pneumonia. The facility document titled, “Orders” dated June 26, 2024, indicated, “...Midline catheter insertion: x1, start 06/26/2024 [June 26,2024] 15:34 [3:34 p.m.]...” During a concurrent interview, the EM stated there was no documented evidence that the midline was changed or discontinued. The facility document titled, “ Intravenous Lines” dated September 10, 2024, through September 15, 2024, had no documented evidence Patient 1’s midline catheter dressing was changed every seven days. EM stated midline line dressing should be changed every seven (7) seven days per policy. The facility document titled, “Nurses Notes: Peripheral Venous line: left upper arm, 5 fr [French] midline ..”, dated September 10, 2024, through September 15, 2024, had no documented evidence Patient 1’s midline catheter was assessed on September 13, 2024, nor September 14, 2024. An interview was conducted on September 17, 2024, at 10:55 a.m., with the EM. EM stated there was no documented evidence Patient 1’s midline catheter was changed or discontinued. EM stated midline catheter dressings should be changed every seven days, and assessed daily per the facility policy. b. On September 16, 2024, at 11:10 a.m., in Patient 2’s room, Patient 2 was observed sitting in bed with a midline catheter in Patient 2’s right upper arm. A review of Patient 2’s medical record was conducted on September 17, 2024, at 1:10 p.m., with the EM. The facility document titled, “History and Physical”, dated August 25, 2024, indicated Patient 2 was admitted to the facility on August 25, 2024, with a diagnosis of chronic with acute respiratory failure, renal failure, (kidney disease) and diabetic vascular disease (diabetes (high blood sugar) caused blockages). The facility document titled, “Orders” dated June 26, 2024, indicated, “Change midline dressing: q [every] 7d [days], (10), start 09/01/2024 [September 1, 2024] 10:00 (a.m.), stop after 90 days, renewable...”. The facility document titled, “Intravenous Lines” dated September 8, 2024, through September 17, 2024, had no documented evidence Patient 2’s midline dressing was changed. The EM stated midline line dressing should be changed every seven (7) seven days per policy. The facility document titled, “Intravenous Lines” dated September 10, 2024, through September 17, 2024, had no documented evidence Patient 2’s midline catheter was assessed on September 13, 2024, and September 16, 2024. An interview was conducted on September 16, 2024, at 11:25 a.m., with the EM. EM stated midline line dressings should be changed every seven days and midline catheter sites should be assessed daily per facility policy. A review of facility’s policy and procedure (P&P) titled, “Midline Catheter Site Placement, Maintenance and Dressing Change”, dated June 2023, indicated, “...Policy: the policy of [Name of Facility] is to ensure the following...Midline catheter should be utilized for anticipative infusion therapy provided for 1-4 weeks...Ongoing daily assessment and with dressing change of IV [intravenous, within a vein] sites. Assess for complications (signs of infection and/or pain of site) and measurement as indicated...Midline catheter site care and dressing changes will be performed every seven days...” A review of the Infusion Therapy Standards of Practice ninth (9th) Edition (2024), indicated, “Section Five: Vascular Access Device Selection...VASCULAR ACCESS DEVICE PLANNING AND SITE SELECTION... INS [Infusion Nursing Society] categorizes 3 types of PIVCs [Peripheral intravenous catheters]...Midline peripheral catheter...Standard...The appropriate vascular access device (VAD), peripheral or central, is selected based on the prescribed therapy or treatment regimen, anticipated duration of therapy...General Information for Vascular Access Device and Site Selection...Anticipated duration of therapy...(5-14 days): Insert a midline catheter in hospitalized adult patients when all the above elements indicate peripherally compatible therapy...(>15 days) Consider insertion of a peripherally inserted central catheter [PICC - catheter use for long term medication treatment]...” 5. A tour of the ICU was conducted on September 16, 2024, at 8:47 a.m., with the DNCS. During the tour on September 16, 2024, at 9:12 a.m., in Patient 8’s room, Patient 8 was observed in bed with Total Parenteral Nutrition (TPN- a method of feeding that provides nutrients to a patient intravenous [through the vein]) infusing using Patient 8’s hemodialysis (treatment for kidney failure) catheter in Patient 8’s right groin. An interview was conducted on September 16, 2024, at 9:15 a.m., with the DNCS. DNCS stated the hemodialysis catheter has a triple lumen, wherein one lumen can be used for infusing the TPN. An interview was conducted on September 16, 2024, at 11:15 p.m., with Physician 1. Physician 1 stated hemodialysis catheters should not be used for medication infusion. An interview was conducted on September 16, 2024, at 1:25 p.m., with Dialysis Nurse (DN). The DN stated, hemodialysis catheters should not be used for infusing any medications unless it is an emergency. A review of Patient 8’s medical record was conducted on September 20, 2024, at 9:23 a.m., with the RDQ. The facility document titled, “History and Physical”, dated September 14, 2024, indicated Patient 8 was admitted to the facility on September 14, 2024, with a diagnosis of Chronic hypoxic respiratory failure and acute pulmonary embolism. The untitled facility document indicated, “...Amino Acid [molecules that combine to form protein] 4.25%/dextrose [fluid with sugar]5%...2000 ml [milliliters, unit of measurement]...50ml/hr. cont....start date 09/16/2024 [September 16, 2024]...Stop date...09/20/2024 [September 20, 2024]...” The facility document titled “Orders” had no documented evidence of a physician’s order to use Patient 8’s hemodialysis catheter for TPN infusion. A review of the P&P titled, “CORE: Hemodialysis Catheter Care and Maintenance”, dated June 2022, indicated, “...Policy...It is the policy of [Name of Facility] to ensure the following...The hemodialysis catheter is not used for routine administration of parenteral [intravenous solution] except upon physician or other authorized prescriber’s written order...” 6. a. A review of Patient 17’s medical record was conducted on September 17, 2024, at 2:08 pm., with the CA. The facility document titled, “History and Physical,” dated April 29, 2024, indicated Patient 17 was admitted to the facility on April 28, 2024, with a diagnosis of respiratory failure unspecified with hypoxia, or hypercapnia. The facility documents titled, “Central Venous [CV] Line” dated May 3, 2024, through May 5, 2024, indicated no documented evidence Patient 17’s CV dressing was changed. The facility documents titled, “Central Venous Line” dated May 5, 2024, through May 10, 2024, indicated no documented evidence Patient 17’s CV dressing was changed. The facility documents titled, “Central Venous Line” dated May 11, 2024, through May 14, 2024, indicated no documented evidence Patient 17’s CV dressing was changed. An interview was conducted on September 17, 2024, at 2:21 p.m., with the CA. CA stated Patient 17’s CV line dressing should have been changed every seven days and the nurse should have documented the dressing change if it was completed. CA stated there was no documentation of Patient 17’s CV line dressing was change. b. Observations in Patient 22’s room were conducted on September 16, 19, and 23, 2024. Patient 22 was observed lying in bed with a Central line in the left upper arm with a dressing dated September 9, 2024. A review of Patient 22’s medical record was conducted on September 19, 2024, at 2:00 p.m., with the CA. The facility document titled, “History and Physical,” dated August 18, 2024, indicated Patient 22 was admitted to the facility on August 17, 2024, with a diagnosis of acute respiratory failure unspecified with hypoxia or hypercapnia. The facility document titled, “List of Orders”, dated September 23, 2024, indicated, “...Central line necessity order...start 08/18/24 [August 18, 2024] at 09:00 [9:00 a.m.] daily...stop after 45 days...renewable...” The facility document titled, “Intravenous Lines” dated September 13, 2024, through September 23, 2024, had no documented evidence Patient 22’s central line dressing was changed. An interview was conducted on September 19, 2024, at 9:50 a.m., with the DNCS. DNCS stated Patient 22’s central line dressing should be changed every seven days. DNCS further stated Patient 22’s central line dressing should have been changed on or before September 16, 2024. A review of the facility’s P&P titled, “CORE: Central line placement maintenance and dressing change”, dated June 2023, indicated, “...Central vascular access device (CAVD) and PICC site care and dressing changes will be performed every seven days...Perform site care and dressing changes as soon as possible if dressing integrity becomes compromised...” 7. A review of Patient 4’s medical record was conducted on September 18, 2024, at 10:30 a.m., with the RDQ. The facility document titled, “History and Physical” dated February 23, 2024, indicated, Patient 4 was admitted to the facility on February 22, 2024, with a diagnosis of Acute hypoxic respiratory failure (condition where there is not enough oxygen in the blood) and Status epilepticus (prolonged seizure). The facility document titled, “Vital Signs [temperature (T), pulse (P), respiration (R), and blood pressure (BP)] /I & O [Intake and Output] /Unit labs” dated September 25, 2024, through September 27, 2024, indicated: a. On September 25, 2024: - 12 a.m. - T: 97.3 F, P: 60, R:19, BP:137/62 mmHg; - 2 a.m. - no vital signs documented; - 4 a.m. - T:97.3 F, P:96, R:21, BP:164/91 mmHg; - 8:16 a.m. - T: 97.1 F, P:100, R:22, BP:125/67 mmHg; - 10 a.m. - no vital signs documented; - 11:17a.m. - T: 97.2 F, P: 104, R: 24, BP:141/46 mmHg; - 2 p.m. - no vital signs documented; - 3:16 p.m. - T: 97.2 F, P: 108, R: 24, BP: 96/45 mmHg; - 6 p.m. - no vital signs documented; - 8:15 p.m. - T: 97 F, P: 96, R: 27, BP: 87/47 mmHg; - 10 p.m. - no vital signs documented; and - 12 a.m. - no vital signs documented On September 26, 2024: - 4:45 a.m. - T: 97.1 F, P: 104, R: 27, BP: 115/56 mmHg; - 8:06 a.m. - T 98.8 F, P: 106, R: 30, BP: 108/53 mmHg; - 9:07 a.m. - T: 98.6 F, P: 108, R: 39, BP: 96/52 mmHg; - 9:33 a.m. - T: 98.6 F, P: 108, R: 31, BP: 96/52 mmHg; - 10:04 a.m. - T: 98.6 F, P: 104, R: 40, BP: 112/51 mmHg; - 11:37 a.m.- T: 99.8 F, P: 104, R: 31, BP: 104/44 mmHg; - 12:22 a.m. - T:99.8 F, P: 99, R: 31, BP: 105/50 mmHg; - 1:13 p.m. - T: 99.8 F, P: 99, R:31, BP: 111/48 mmHg; - 2:06 p.m. - T: 99.4 F, P:1 08, R: 29, BP: 108/54 mmHg; - 3:22 p.m. - T: 99.9 F, P: 112, R: 28, BP: 107/55 mmHg; - 5:17 p.m. - T: 100 F, P: 101, R: 29, BP: 90/56 mmHg; - 6:09 p.m. - T: 101.4 F, P: 105, R: 27, BP: 81/45 mmHg; - 7:02 p.m. - T: 100.2 F, P: 119, R: 28, BP: 104/53 mmHg; and - 8:53 p.m. - T: 102.8 F, P: 120, RR: 26 , BP: 110/28 mmHg. On September 27, 2024: - 12:17 a.m. - T: 101.9 F, P: 120, R:26, BP: 110/28 mmHg - 4:04 a.m. - T: 103.3 F, P: 110, R: 26 BP: 100/47 mmHg The facility’s untitled document dated February 26, 2024, indicated, “Laboratory exam...Blood Count Complete w/[with] Auto Diff (CBC) COLLECTED RESULT Specimen Collection: 02/26/2024 [February 26, 2024] 00:03 [12:03 a.m.] Test Reported: 02/26/24 [February 26, 2024] 10:42 [a.m.] WBC [White Blood Count] 25.21 10*3/uL [microliter- unit of measurement] HIGH (3.6-11.2)”. The facility’s untitled document dated February 26, 2024, indicated, “...Lactic acid [a chemical produced by the body when it breaks down carbohydrates for energy, especially when oxygen levels are low] unit performed...Specimen collection 02/26/2024 [February 26, 2024] 15:20 [3:20 p.m.]...Blood sample source venous: 8.5 mmol/L H (0.70-2.50)...” The facility document titled, “Physician’s orders”, dated February 26, 2024, indicated, “...Lactic acid - unit performed: *** Until Lactic Acid is less than 2.0*** Start 02/26/2024 [February 26, 2024] 1800 [6:00 p.m.], q [every] 6h [hours] (00 [12 a.m.], (6.12,18)...” There was no documented evidence a lactic acid draw was performed on February 26, 2024, at 6:00 p.m., 12:00 a.m., and September 27, 2024, at 6:00 a.m. The facility’s untitled document dated February 27, 2024, indicated, “...Lactic acid- unit performed: Draw q [every] 6h [hour] till level is less than 2.0...02/27/2024 [February 27, 2024] 2:07 [a.m.]...Blood Sample source venous: 9.8 mmol/L H (0.70-2.50)...rvb [report verbal back] [name of registered nurse] 0213 [2:13 a.m.] on critical result...” There was no documented evidence the critical lab result was reported to a physician. The facility’s document titled, “Change of Condition” dated February 27, 2024, indicated physician was not notified of the critical value for lactic acid of 9.8 at 4:35 a.m. The facility document titled, “Vital signs / I&O/ unit labs” dated February 26, 2024, indicated, “...18:09 [6:09 p.m.] Oral temp:101.4, Oximeter pulse 105/min, Vent rate setting: 27, BP supine: 81/45 mmHg...” A review of Patient 4’s facility document titled, “Discharge Summary” dated February 27, 2024, indicated, “... Patient was admitted on February 22, 2024...Date of death is February 27, 2024...The cause of death is going to be septic shock...” An interview was conducted on September 18, 2024, at 10:45 a.m., with the RDQ. The RDQ stated Patient 4’s vital signs should have been documented every two hours, and abnormal vital signs should have been reported to the physician immediately. RDQ further stated Patient 4’s lactic acid should have been drawn every six hours per physician’s order, and the lactic acid result should have been reported immediately to the physician. An interview was conducted on September 19, 2024, at 1:50 p.m., with RN 2. RN 2 stated if it is not documented that I notified the physician, then I didn’t report it. A review of the facility’s policy and procedure titled, “CORE: Sepsis: Early Recognition and Management” dated June 2022, indicated, “...Policy...A positive sepsis screen for suspicious sepsis occurs with a. A “yes” response to 2 or more Systemic Inflammatory response [SIRS - body’s overwhelming response to a stressor such as an infection] criteria AND b. A “yes” response to history or signs/symptoms of a new infection. NOTE: A “ yes” response is required for both parts of the assessment. 4. Rapid assessment criteria: a. Systemic Inflammatory Response Syndrome (SIRS) - two or more must be present i. Temperature >100.4 F or < 96.8F...Heart rate >90 (beats per minute)...Respiratory rate > 20 breaths per minute (or higher than baseline)...WBC >12,000 cells/uL or >4,000 cells/uL...DEFINITIONS...Time Zero: when the patient first meets one of the SIRS indicators...Sepsis bundle: Measure lactate level...Re-measure lactate every 2 -4 [hours], if the initial lactate level is elevated (>2 mmol/L)...” 8. A review of Patient 4’s medical record was conducted on September 18, 2024, at 10:30 a.m. with the RDQ. The facility document titled, “Vital Signs” dated September 25, 2024, through September 27, 2024, indicated: On September 25, 2024: - 2 a.m. - no documented evidence of Patient 4’s vital signs; - 6 a.m. - no documented evidence of Patient 4’s vital signs; - 10 a.m. - no documented evidence of Patient 4’s vital signs; - 2 p.m. - no documented evidence of Patient 4’s vital signs; - 6 p.m. - no documented evidence of Patient 4’s vital signs; - 10 p.m. - no documented evidence of Patient 4’s vital signs; - 12 a.m. - no documented evidence of Patient 4’s vital signs; On September 26, 2024: - 2 a.m. - no documented evidence of Patient 4’s vital signs; - 6 a.m. - no documented evidence of Patient 4’s vital signs; - 10 p.m. - no documented evidence of Patient 4’s vital signs; c. September 27, 2024: - 2 a.m. - no documented evidence of Patient 4’s vital signs; and - 6 a.m. - no documented evidence of Patient 4’s vital signs; An interview was conducted on September 18,2024, at 10:35 a.m. with the RDQ. The RDQ stated Patient 4’s vital signs were not taken every 2 hours. A review of the P&P titled, “CORE: Interdisciplinary Assessment and Re-Assessment”, dated June 2023, indicated, “...Procedure...Physician’s orders routine vital signs will be interpreted by nursing personnel as follows...Intensive Care Unit...Every 2 hours...” 9. A review of Patient 4’s medical record was conducted on September 18, 2024, at 10 a.m., with the RDQ. The facility document titled, “History and Physical” dated February 23, 2024, indicated Patient 4 was admitted to the facility for Acute hypoxic respiratory failure and Status epilepticus (prolonged seizure). The facility document titled, “GI [Gastro Intestinal] Assessment “ dated September 26, 2024, indicated, “...DAY SHIFT - Abdomen soft, rounded, obese, distended tenderness in both left quadrant bowel sound...” An interview was conducted on September 19, 2024, at 1:43 p.m., with RN 2. RN 2 stated she did not report Patient 4’s abdominal distention as a change of condition to the physician. RN 2 further stated, “ If it was not documented then I didn’t report it.” A review of the facility’s P&P titled,” CORE: Administration of Enteral Nutrition”, dated June 2023, indicated, “...Assess for GI[Gastrointestinal] intolerance to enteral tube feedings by assessing for abdominal distention, monitoring for complaints of abdominal pain, and observing for passage of flatus and stool every shift and PRN [pro re nata - as needed)...” 10. During a tour on September 16, 2024, at 10:45 a.m., with the DNCS, in Patient 22’s room, Patient 22 was observed to have long unkept fingernails with dark matter under the nails. An interview was conducted on September 16, 2024, at 11 a.m., with RN 5. RN 5 stated he was Patient 22’s nurse that day and did not know when the last time Patient 22 had nail care done. RN 5 further stated he does not know the nail care policy for the facility. An interview was conducted on September 16, 2024, at 11:10 a.m., with the DQM. The DQM stated staff do not cut the patients nails at the facility. The DNCS stated the facility does not have a policy on nail trimming however, they currently utilize on-line resources as the practice for nail care. A tour was conducted of Patient 22’s room on September 22, 2024, at 6:12 a.m. Patient 22 was observed to have long unkept fingernails with dark matter under the nails. A tour was conducted of Patient 22’s room on September 23, 2024, at 9:12 a.m., with the DNCS. Patient 22 was observed to have long unkept fingernails with dark matter under the nails. At this time the DNCS stated Patient 22’s nails were not clean. A review of Patient 22’s medical record was conducted on September 23, 2024, at 2:00 p.m., with the CA. A facility document titled, “History and Physical,” dated August 18, 2024, was reviewed. The document indicated Patient 22 was admitted to the facility on August 17, 2024, with a diagnosis of acute (under 6 months) respiratory failure unspecified with hypoxia or hypercapnia. A review of the facility’s education resource, titled, “Nail Care,” dated May 20, 2024, indicated,”...Nail care is an essential component of personal hygiene...procedure reviews nail care for the fingernails...equipment...clean towel...orange stick or other appropriate tool... optional...basin...emery board...nail clipper...use orange stick...to remove dirt from beneath each nail...use emery board as needed to smooth any rough edges...This procedure has been reviewed by the Academy of Medical-Surgical Nurses (AMSN)...” 11.a. A tour of the Intensive Care Unit (ICU) was conducted on September 16, 2024, at 9:30 a.m., with the DQM. During the tour, in Patient 19’s room, Patient 19 was observed to have a tube feeding [Brand Name] 1.8 cal. (type of liquid feeding) and water bag (flush) running at 30 ml/hr. (milliliters per hour, unit of measurement) not labeled with the patient name, date and time. An interview was conducted on September, 16, 2024, at 9:40 a.m., with the DQM. The DQM stated there should be a patients sticker labeling the water and tube feeding to identify the patient and the time and date the feeding was started. The water flush bag should also be labeled. A review of Patient 19’s medical record was conducted on September 16, 2024 at 1 p.m., with the CA. A facility document titled, “History and Physical,” dated August 30, 2024, at 8:53 p.m., indicated Patient 19 was admitted to the facility on August 29, 2024, with a diagnosis of respiratory failure unspecified with hypoxia or hypercapnia. b. A tour of the ICU was conducted on September 16, 2024, at 9:40 a.m., with the DQM. In Patient 20’s room, Patient 20’s feeding tube feeding was observed infusing [Brand Name] 1.2 cal and bag of water for flush, was running at 50ml/hr, and was not labeled with the Patient 20’s name, date, or time. At this time the DQM stated the tube feeding and water flush bag should be labeled with the patients name, date and time the feeding started. A review of Patient 20’s medical record was conducted on September 20, 2024, at 9:19 a.m., with the CA. The facility document titled, “History and Physical,” dated September 8, 2024, indicated Patient 20 was admitted to the facility on September 7, 2024, with a diagnosis of Acute (less than 6 months) and chronic (greater than 6 months) respiratory failure unspecified with hypoxia or hypercapnia. A review of the facility P&P titled, “Core: Administration of Enteral Nutrition,” dated June 2023, indicated, “...Label formula bag with two patient identifiers, feeding rate, and hang date and time...Label flush bag with date and content...water...normal saline...” 12. A review of Patient 16’s medical record was conducted on September 17, 2024, at 11:30 a.m., with the CA. A facility document titled, “History and Physical,” dated February 15, 2024, indicated Patient 16 was admitted to the facility on February 13, 2024, with a diagnosis of respiratory failure unspecified with hypoxia or hypercapnia. Review of facility document titled “Vital signs”, indicated Patient 16’s blood pressure was taken by the Certified Nursing Assistant (CNA) at 3:15 p.m., and was 80/54. There was no documented evidence Patient 16’s blood pressure was reported, or a Change of Condition (COC) was created. On September 17, 2024, at 11:40 a.m., an interview with the CA was conducted. The CA stated after review of the computerized charting she did not see any notes from the day nurse (7a.m.- 7 p.m.) relating to the low blood pressure. The CA stated the only notes were from the nurse for the night (7p.m.- 7 a.m.) shift. A review of facility’s P&P titled, “CORE: Interdisciplinary Assessment and RE-Assessment”, dated June 2022, indicated, “...Reporting/Notification of a change of Condition...systolic Blood Pressure (B/P) <80 or >180 sustained...” 13. A review of Patient 18’s medical record was conducted on September 18, 2024, at 10:32 a.m., with the CA. A facility document titled, “History and Physical,” dated July 19, 2024, at 12:32 a.m., indicated Patient 17 was admitted to the facility on July 17, 2024, with a diagnosis of Acute (less than 6 months) and chronic (greater than 6 months) respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood), Inhalation injury sustained in a house fire. The facility document titled “Nursing notes” dated July 17, 2024, through July 39, 2024, was indicated: - July 19, 2024, - no documented evidence Patient 18 was given a bath; - July 21, 2024, - no documented evidence Patient 18 was given a bath; - July 28, 2024, - no documented evidence Patient 18 was given a bath; and - August 4, 2024, - no documented evidence oral care was provided. An interview was conducted on September 19, 2024, at 3:47 p.m., with the DNCS. The DNCS stated the nursing staff should be providing a bath daily. DNCS stated the patient can refuse the bath, and if the bath is refused the nursing staff should go back and check with the patient and then document the refusal in the patient’s chart. On September 19, 2024, at 3:39 p.m., the survey team identified significant concerns in the facility’s Medical Surgical Telemetry (MSTU) and Intensive Care Unit (ICU). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the hospital’s Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director of Quality (RDQ), Director for Nursing Clinical Services (DNCS), and Director Quality Management (DQM). The facility’s CEO, COO, DNCS, RDQ and DQM were verbally notified regarding the concerns of the facility’s failure to ensure patients receive care in a safe setting. On September 20, 2024, at 9:39 a.m. the COO provided a Corrective Action Plan (CAP). On September 23, 2024, at 2:42 p.m. the COO provided a revised CAP. The CAP indicated the following: 1.The Nursing Leadership team reviewed the following policies on September 19, 2024, an no modifications were recommended. a. H-PC 04-015 Oral Hygiene for Airway Assisted Patients b. H-PC 04-009 Routine Bathing c. H-PC 05-006 Administration of Enteral Nutrition d. H-PC 05-010 Mid line Catheter Site Placement, Maintenance and Dressing Change. e. H-PC 03-007 Sepsis: Early Recognition and Management f. H-PC 02-001 Interdisciplinary Assessment and Re-Assessment g. H-IM 01-001 General Documentation Guidelines. 2. All patients were assessed by nursing for the need of oral care, peri care and bathing needs. Care was provided to patients identified as needing oral care, peri care . or bathing. Medical records were reviewed by clinical leadership to verify that the current worklist includes oral care, peri care and bathing. Any missing elements were added onto the worklist within the electronic medical record for nurses, CNA and/or RT. Bathing and/or peri care to occur daily (by CNA, LVN, RN) and as needed for patients who are soiled, incontinent or upon patient request. For patients who are hemodynamically unstable based on RN assessment, bathing may be paused until hemodynamic status improves. Oral care to occur daily (by CNA, LVN, RN, RT) and as needed or upon patient request. For patients with artificial airway or patients receiving continuous BiPAP therapy by mask, oral care will occur at 6-hour intervals (by Nursing, Respiratory Therapy). 3. All patient records with current physician orders for lactate lab specimen collection associated with a positive Sepsis protocol meeting SIRS criteria were verified and placed on the worklist for collection every 6 hours. Additionally, a sepsis screening was completed on each patient to ensure that any early signs of sepsis were identified and sepsis protocol activated, including lab orders, as appropriate. 4. All patients with midlines were reviewed for date of insertion. The physician was contacted for an order to replace midline with an insertion date greater than 30 days. All patients with line dressing were assessed for intact dressings as well as labeled with date and time. The dressings were changed as appropriate. 5. Education began with nursing (RN, LVN, CNAs, RTs) that were on duty. The remaining staff will be trained within 30 days of acceptance of plan. Any required staff that have not completed the training within the 30 days will not work until training has been completed. Education included: a. Interdisciplinary assessment and reassessment policy (H-PC-02-001) b. Change of condition to include notification of provider and instructions for completing documentation in Protouch (electronic medical record). c. A change of condition is anything that is not anticipated or is an unexpected change from previous status. A change of condition includes changes in status, such as a transfer to a higher or lower level of care, change in GI status, early signs and symptoms of Sepsis and abnormal vital signs. d. Vital sign requirements for ICU level patients. e. Proper assessment of GI status includes abdominal assessment and PEG/ G tube assessment every shift. On September 23, 2024, at 2:51 p.m., the CAP for the immediate jeopardy was reviewed and accepted. On September 24, 2024, at 9:30 a.m., the CAP was verified while onsite, through observations, interviews, and record review to have been fully implemented. On September 24 , 2024, at 10:25a.m., the IJ was removed in the presence of DNCS and DQM.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, facility failed to ensure the facility’s policy and procedure (P&P) was implemented, for one of 31 sample patients (Patient 8), when soft wrist restraints (a device designed to limit the movement of wrists) were initiated on Patient 8 without a physician’s order. This failure had the potential for patient harm and injury for Patient 8. Findings: A tour of the Intensive Care Unit (ICU, unit for critically ill patients) was conducted with the Director for Nursing Clinical Services (DNCS) on September 16, 2024, at 8:47 a.m. An observation was conducted with the DNCS and Registered Nurse (RN) 8 at the ICU on September 16, 2024, at 9:17 a.m. Patient 8 was observed to have soft wrist restraints on both wrists. During a concurrent interview at the time of the observation, RN 8 stated the soft wrist restraints were placed on Patient 8’s wrists because the patient was pulling his nasogastric tube (NGT, a feeding tube). An observation and interview were conducted on September 18, 2024, at 9:17 a.m. with the DNCS and RN 16. Observed patient on bilateral wrist restraints. RN 16 stated Patient 8 was on bilateral wrist restraints because he removed his NGT twice yesterday. An observation was conducted on September 20, 2024, at 6:38 a.m. with the DNCS and Patient 8 was observed to still be in bilateral soft wrist restraints. A review of Patient 8’s record was conducted on September 20, 2024, at 9:23 a.m., with the Rancho Quality Director (RQD). A facility document titled, “History and Physical” dated September 14, 2024, was reviewed. The document indicated, “... DATE OF ADMISSION: September 14, 2024... IMPRESSION...Chronic hypoxic respiratory failure (condition where there is not enough oxygen in the blood)...Acute pulmonary (lungs) embolism (blood clot)...” An observation and interview were conducted on September 22, 2024, at 6:01 a.m., with RN 21. Patient 8 was observed to have soft wrist restraints on both wrists. RN 21 stated Patient 8 has pulled his NGT several times. An observation was conducted on September 23, 2024, at 4:05 p.m., at the ICU with RN 61. Patient 8 was observed to be more awake and alert, and had soft wrist restraints on both wrists. RN 61 stated Patient 8 was still on restraints for pulling on his NGT. A concurrent interview and review of Patient 8’s record were conducted on September 24, 2024, at 11:10 a.m., with the Education Manager (EM). There was no documented evidence a physician’s order was obtained for the use of soft wrist restraints on Patient 8 from September 16 to 18, 2024. The EM stated there was no documentation an order for the restraints was given by the physician for the use of soft wrist restraints on Patient 8 from September 16 to 18, 2024. The EM also stated a physician’s order is needed for restraints per facility policy. An interview was conducted on September 24, 2024, at 11:20 a.m., with RN 62. RN 62 stated a physician’s order is needed when restraints are placed on patients. An interview was conducted on September 24, 2024, at 1:08 p.m., with the Chief Operating Officer (COO). The COO stated based on his record review, there was no documentation a physician’s order was obtained for Patient 8’s restraints from September 16 to 18, 2024. A review of the facility’s policy and procedure (P & P) titled, “CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion,” dated June 2023, was conducted. The P&P indicated, “...For current inpatient initial restraint order from the attending physician or other licensed practitioner (LP) is required immediately or within a few minutes from initiating restraints...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 45431 Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) for restraints when an ongoing assessment for a patient on restraints (devices or methods that restrict a patient’s movement without their consent) was not conducted, for one of 31 sample patients (Patient 10). This failure had the potential to cause harm, injury, and/or death to Patient 10. Findings: A tour of the Medical Surgical Telemetry Unit (MSTU) was conducted on September 16, 2023, at 9:55 a.m., with the Director for Nursing Clinical Services (DNCS) and Director of Quality Management (DQM). An observation was conducted with the DNCS on September 16, 2024, at 10:36 a.m., in Patient 10’s room. Patient 10 was observed lying in bed with eyes closed and did not move nor open his eyes when the surveyor and facility staff introduced themselves while they were entering the room. Patient 10 was observed to have soft wrist restraints (restraint designed to limit the movement of both wrists) on both wrists. Patient 10 continued to have his eyes closed when observation was being done on the percutaneous endoscopic gastrostomy (PEG, a feeding tube) tube attached to him. An observation was conducted on September 19, 2024, at 10 a.m., in Patient 10’s room. Patient 10 was observed to be still with his eyes closed and was observed to have wrist restraints on both wrists. Patient 10 was observed to not move nor wake up when his name was called and his shoulder was tapped. An observation was conducted on September 20, 2024, at 7:29 a.m., in Patient 10’s room. Registered Nurses (RN) 43 and 48 were observed attempting to stimulate Patient 10 to elicit a response or to wake him up. Patient 10 was observed to not be responding after the RNs called the patient’s name and tapped his shoulders. Patient 10 was observed to have a soft wrist restraint on the left wrist. An interview was conducted with Respiratory Therapist (RT) 2 on September 20, 2024, at 7:31 a.m., at Patient 10’s bedside. RT 2 stated she has not seen Patient 10 awake nor moving while she provided care for him. RT 2 stated Patient 10 had a soft wrist restraint on his left wrist but not on the right wrist. An interview was conducted with Certified Nurse Assistant (CNA) 1 on September 22, 2024, at 7:07 a.m. CNA 1 stated the restraints were placed on Patient 10 because the patient was picking on his colostomy (an opening into the colon, a part of the intestine, from the outside of the body) bag and was attempting to remove his tracheostomy (an opening through the neck for breathing) tube. CNA 1 stated she observed Patient 10 was not moving and was sleeping more this week . A concurrent interview and review of Patient 10’s record was conducted with the Education Manager (EM) on September 24, 2024, at 10:30 a.m. A facility document titled, “Restraint Care Plan (Non-Violent, Non -Self Destructive Behavior),” from September 9, 2024, to September 20, 2024, was reviewed. There was no documented response provided for the section which asked, “...Is the need for restraint resolved?...” The EM stated there was no documented response to the question, “Is the need for restraints resolved?” on the dates of September 15, 16, 17, 18, and 20, 2024. A review of the facility’s P&P titled, “CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion,” dated June 2023, was conducted. The P&P indicated, “...Ongoing Assessment (at least daily) by an RN of the patient’s behavior, whether the unsafe situation is resolved and whether the criteria for discontinuing the restraints are met...””

“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: 47071 Based on interview and record review, the facility failed to ensure qualified and competent Registered Nurses (RN’s) were assigned to provide care for patients in the Medical/Surgical/ Telemetry Unit (MSTU), and Intensive Care Units (ICU, a unit for critically ill patients), requiring cardiac monitoring (continuous or intermittent monitoring of the heart’s activity to assess a patient’s condition) when: 1. 62 of 66 RNs (RNs 1 to 9, 11 to 14, 16, 18, and 20 to 66) did not complete a cardiac arrhythmia (irregular heart rate and rhythm) interpretation course for the certification required to care for patients needing cardiac monitoring, and who were providing care for patients on the cardiac monitor (a device which shows the heart rate and rhythm on a monitor with a capability of printing them on strips); 2. 44 of 66 RNs (RNs 2 to 9, 11 to 13, 20, 21, 25 to 41, 46, 50, 53, 55 to 59, and 61 to 66) did not complete the cardiac rhythm interpretation test required to care for patients needing cardiac monitoring, and who were providing care for patients on the cardiac monitor; 3. Two RNs (RNs 2 and 50), who were providing care to patients in the ICU, had no ICU competency validation and unit orientation completed; 4. Six of eight Nursing and House supervisors (NSRN 58, 59, 60, 61, and 62) who are responsible to oversee all the units in the facility during a shift and who take over the care of patients in the ICU when the ICU RN responds to emergency situations, had no ICU nursing orientation or competency; and 5. The Director of Nursing Clinical Services (DNCS) did not meet the qualification for the position based on the DNCS job description. These failures had the potential to delay patient care, cause harm or injury, and /or death to patients. Findings: 1. On September 16, 2024, at 8:47 a.m. a tour was conducted in the ICU with the DNCS. Six patients were observed to have electrocardiogram leads (EKG, a procedure to obtain a graphical description of the electrical activity of the heart) on their chests with the cables connected to a cardiac monitor at bedside. An interview was conducted the Monitor Technician (MT) 1 in the ICU on September 16, 2024, at 8:50 a.m. MT 1 stated there were six ICU patients and 14 Medical/Surgical Telemetry patients with cardiac monitoring. MT 1 stated part of her responsibility is to print and interpret the rhythm strips (thin strips of paper where the heart rate and rhythm are documented by the cardiac monitor machine), then the RNs are responsible for verifying the interpretation and signing the rhythm strips. MT1 also stated printing and rhythm interpretation is done once a shift. A concurrent interview and review of rhythm strips interpretation were conducted with RN 1 and RN 2 on September 16, 2024, at 10:30 a.m. RN’s 1 and 2 were unable to interpret the heart rhythm on the rhythm strip. RN’s 1 and 2 both stated they have not received training on cardiac monitoring. An interview was conducted with the Education Manager (EM) on September 16, 2024, at 2:02 p.m. The EM stated, to his knowledge, it is not a requirement for RN’s hired to work in MSTU to complete a cardiac rhythm interpretation course. The EM also stated he is not qualified to teach a cardiac rhythm interpretation course. A record review was conducted with the Director Nursing Clinical Services (DNCS) on September 16, 2024, 2:37 p.m. A facility document titled, “MED-SURG-TELEMETRY [Medical-Surgical unit, unit where nurses provide care for patients with a wide range of medical and surgical problems and conditions who are needing less than critical care; Tele, unit where patients’ heart rates and rhythms are remotely monitored continuously] DAILY ASSIGNMENT SHEET,” dated September 16, 2024, was reviewed. The document indicated the following: - RN 1 was assigned three patients on cardiac monitoring; - RN 2 was assigned five patients on cardiac monitoring; - RN 3 was assigned five patients on cardiac monitoring; and - RN 4 was assigned five patients on cardiac monitoring. A review of the facility document titled, “ICU STAFFING ASSIGNMENT SHEET,” dated September 16, 2024, was conducted on September 16, 2024, at 2:40 p.m. The document indicated RN 5 was assigned two patients on cardiac monitoring. A review of employee files was conducted with the EM on September 17, 2024, at 9:16 a.m. The employee education files of five RN’s (RN’s 1, 2, 3, 4, and 5) were reviewed for valid completion of cardiac rhythm interpretation course. There was no documented evidence RN’s 1, 2, 3, 4, and 5 had completed the cardiac rhythm interpretation course in accordance with the facility’s policy. A review of cardiac rhythm interpretation course certification was conducted with the DNCS and Rancho Quality Director (RQD) on September 18, 2024, at 9:27 a.m. The cardiac rhythm interpretation course certificates of RN’s 1 through 66 were reviewed. Only four of the 66 RN’s reviewed (RN’s 10, 15, 17, and 19) had completed the cardiac rhythm interpretation course certification. There was no documented evidence 62 of 66 RNs who provided care to patients on cardiac monitoring had completed the cardiac rhythm interpretation course. 2. An interview was conducted with the EM on September 16, 2024, at 2:10 p.m. The EM stated passing the cardiac rhythm interpretation test is a requirement for RN’s working in the MSTU. An interview and review of the employee education files of five RN’s (RN’s 1, 2, 3, 4, and 5) for valid completion of cardiac rhythm interpretation test were conducted with the EM on September 17, 2024, at 9:20 a.m. There was no documented evidence RN’s 2, 3, 4, and 5 had completed the facility cardiac rhythm interpretation test in accordance with the facility policy. A review the facility’s cardiac rhythm interpretation test completion was conducted with the DNCS and RQD on September 18, 2024, at 9:27 a.m. The cardiac rhythm interpretation test of RN’s 1 through 66 was reviewed. Only 22 of the 66 RN’s (RN’s 1, 10, 14, 15, 16, 17, 18, 19, 22, 23, 24, 42, 43, 44, 45, 47, 48, 49, 51, 52, 54, and 60) reviewed had completed and passed the facility’s cardiac rhythm interpretation test. There was no documented evidence 44 of 66 RN’s had completed the facility’s cardiac rhythm interpretation test. The facility policy and procedure (P&P) titled, “Continuous Cardiac Monitoring,” dated June 2023, was reviewed with the DNCS and the Chief Operating Officer (COO) on September 18, 2024, at 9:35 a.m. The policy indicated, “...Staff Orientation, Competency, Requirements, and Competency Validation a. In addition to general and nursing department orientation, the following are requirements concerning care for telemetry patients...Cardiac rhythm interpretation qualification...The hospital maintains sufficient number of registered nurses with competency in cardiac rhythm interpretation...A valid certificate of satisfactory completion of a cardiac rhythm interpretation course from another institution is acceptable evidence of course completion, but the staff member must also pass [Facility Name] cardiac rhythm interpretation test...” During a concurrent interview, the DNCS stated the facility only needs to have a sufficient number of nurses competent in cardiac rhythm interpretation. The DNCS was unable to define what a sufficient number of nurses is. A review of the American Heart Association (AHA, a nationally recognized organization) Scientific Statement titled, “Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings. A Scientific Statement from the American Heart Association,” dated November 7, 2017, was reviewed. The document indicated, “...Endorsed by the American College of Cardiology, American Association of Critical Care Nurses and Pediatric Congenital Electrophysiology Society... BACKGROUND AND PURPOSE: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electrocardiographic monitoring of hospitalized patients...Education of Staff: Education is a critical aspect of the process in electrocardiographic monitoring. Adequate education is crucial for correct interpretation of electrocardiographic waveforms and data and proper care of patients undergoing continuous electrocardiographic monitoring. Incorrect interpretation can result in unnecessary diagnostic or surgical interventions...Education about electrocardiographic monitoring should be included in orientation and on an ongoing basis, with both didactic content and clinically based hands-on practice...” On September 18, 2024, at 1:12 p.m., the survey team identified significant concerns in the facility’s Medical Surgical Telemetry (MSTU) and Intensive Care Unit (ICU). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation which had the potential to cause harm to the health and safety of the patients) was called in the presence of the facility’s Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director for Quality (RDQ), Director for Nursing Clinical Services (DNCS), Director for Quality (DQ), and Clinical Analyst (CA). The facility’s CEO, COO, DNCS, RDQ, and QD were verbally notified regarding the concerns of the facility’s failure to ensure qualified and competent RN’s, for 62 of 66 RNs, were assigned to provide care to patients requiring cardiac monitoring. On September 20, 2024, at 9:39 a.m., the COO provided a Corrective Action Plan (CAP). The CAP was found to not be acceptable. On September 20,2024, at 3:28 p.m., the COO provided a revised CAP. The CAP indicated the following: 1. The Nursing Leadership team reviewed the facility policy and procedure titled, “Continuous Cardiac Monitoring H-PC 7-015,” and no modifications to policy were recommended; 2. All RN files were reviewed by the Nursing Leadership to develop a list of RN team members who have taken a course in cardiac interpretation and have passed the Kindred cardiac rhythm interpretation test; 3. All patients currently on continuous cardiac monitoring were assessed by a competent Registered Nurse with evidence of cardiac rhythm interpretation competency. Rhythm interpretation, vital signs and plan of care reviewed with bedside nurse. Documentation of rhythm interpretation, vital signs, and any interventions are to be documented in the change of condition and will continue to be charted under change of condition for a period of 30 days; 4. All Patients with continued cardiac monitoring will be assessed each shift by a competent Registered Nurse (RN) with evidence of cardiac rhythm interpretation competency by a) rhythm interpretation, vital signs and plan of care, b) review with bedside nurse and c) assessment and interventions as indicated until education can be completed to obtain the sufficient number of licensed nurses with competency in cardiac rhythm interpretation; 5. At least 2 RNs, with the support of a Nursing Supervisor who are competent in cardiac interpretation, will be assigned to continually monitor and provide interpretation of cardiac status of all patients requiring cardiac monitoring. This process will continue until a sufficient number of RNs, based on the number of patients with continuous cardiac monitoring, have completed the competency for cardiac rhythm interpretation; and 6. A Lippincott (a publisher of medical and nursing books) based education plan was identified. Initial implementation of education and testing began on to ensure qualified and competent licensed nurses are assigned to provide care to patients requiring cardiac monitoring; On September 20, 2024, at 4:10 p.m., the CAP for the IJ was reviewed and was found to be acceptable, and the DNCS and the Director of Quality Management (DQM) were notified. On September 23, 2024, at 11:40 a.m., through observations, interviews, and record review, the CAP was verified onsite to have been fully implemented. On September 23, 2024, at 1:10 p.m., the IJ was removed in the presence of the COO, the DNCS, and the DQ. 3a. A review of RN 2’s employee file was conducted with the EM on September 17, 2024, at 9:16 a.m. A facility document titled, “Clinical Skills Initial Core Competency Checklist RN Critical Care/High Observation,” dated January 15, 2024, indicated, “... areas of need...To learn more on charting drips [medications are administered through the veins over a given amount of time] on the paper...Orientation release date 01/23/2024 [January 23, 2024]...Release from Orientation - yes...” The document indicated it was signed by RN 2, RN 59, who was RN 2’s preceptor (an experienced licensed clinician who supervises nurses during their unit orientations), and the DNCS on January 23, 2024. A review of the facility document titled, “Clinical Skills Initial Core Competency Checklist RN Critical Care/High Observation,” dated January 15, 2024, was conducted with RN 59 on September 17, 2024, at 3:38 p.m. During a concurrent interview, RN 59 stated she was the ICU Preceptor when RN 2 was undergoing her orientation at the ICU. RN 59 stated she was instructed by the former DNCS to “just put a date and sign the competency checklist” of RN 2. A review of the facility document titled, “ICU staffing Assignment Sheet,” dated January 1, 2024, through January 23, 2024, was conducted with the EM on September 18, 2024, at 2:45 p.m. The documents indicated: - On January 1, 2024, day shift (7 a.m.- 7 p.m.), RN 2 was assigned one ICU patient; - On January 11, 2024, day shift, RN 2 was assigned two ICU patients; - On January 14, 2024, day shift, RN 2 was assigned two ICU patients; - On January 15, 2024, day shift, RN 2 was assigned two ICU patients; - On January 20,2024, day shift, RN 2 was assigned two ICU patients; and - On January 23, 2024, day shift, RN 2 was assigned one ICU patient. During a concurrent interview, the EM stated, if there was no “O [on orientation]” and the name of the Preceptor beside RN 2’s name in the ICU assignment sheet, then RN 2 was providing patient care on her own. The EM also stated the former DNCS allowed RN 2 to work in ICU, even while knowing RN 2 failed the cardiac rhythm interpretation test and the ICU critical care examination. A review of RN 2’s employee file was conducted with the EM and DNCS on September 19, 2024, at 11:15 a.m. A facility document titled, “Job Description,” dated May 17, 2023, indicated, “...Job Title: Registered Nurse...Experience: Minimum six months’ Medical/Surgical experience in acute care setting preferred...” An interview was conducted with the EM and DNCS on September 19, 2024, at 12:30 p.m. The EM stated it was the former DNCS who oversaw RN 2’s orientation. The EM stated he does not know the facility’s policy on the duration of the ICU unit orientation. The DNCS stated she does not know the orientation process at this facility. A review of the facility document titled, “HD Orientation/Annual Guidelines,” dated July 2018, was conducted with the EM, the DNCS, and the RDQ on September 19, 2024, at 1:10 p.m. The document indicated, “Orientation Guidelines...Following 8 [eight] hours of General Hospital Orientation, these are the recommendation for Department Orientation...discipline...New Graduate RN/LPN [Licensed Practical Nurse]...Recommendation...360 hours of unit orientation...” During a concurrent interview, the EM stated he was not aware of these guidelines. The RDQ stated this document is the official guidelines for all [Name of Facility] Hospitals. An interview was conducted with the EM on September 19, 2024, at 1:13 p.m. The EM stated there was no documentation RN 2 completed the ICU unit orientation prior to January 23, 2024. An interview was conducted with RN 2 on September 19, 2024, at 2:20 p.m. RN 2 stated she did not completed the 360 hours ICU unit orientation. b. An interview was conducted with RN 50 on September 22, 2024, at 5:55 a.m. RN 50 stated she started as a medical/surgical nurse at this facility in November 2023. RN 50 stated she did not have any ICU experience prior to working at the facility. RN 50 stated she has not completed any critical care course nor had 360 hours of ICU unit orientation. An observation was conducted on September 22, 2024, at 6:10 a.m. in Room A in the ICU. RN 50 was observed at the bedside providing care for Patient 12. A review of facility document titled, “ICU staffing Assignment Sheet,” dated September 21, 2024, was conducted on September 22, 2024, at 5:30 a.m. The document indicated, “...1900 [7 p.m.]- 0700 [7 am]...[Room B]...PATIENT [name of Patient 19]...STATUS...ICU...NURSE [name of RN50]...[Room C]...PATIENT [name of Patient12]...NURSE...[name of RN 50]...” A review of RN 50’s employee file was conducted with the EM on September 24, 2024, at 9:05 a.m. There was no documented evidence RN 50 completed a critical care course nor any ICU competencies and ICU unit orientation. An interview was conducted with the EM on September 24, 2024, at 9:15 a.m. The EM stated the former DNCS was in charge of the ICU training. 4. An interview was conducted with the EM on September 16, 2024, at 2:15 p.m. The EM stated, during a medical emergency or rapid response (a hospital code for a group of healthcare professionals who are called to a patient’s bedside to assess and treat a medical emergency), an ICU RN or the Nursing Supervisor (an RN who oversees all the units at the facility) would respond because they have certification for Advance Cardiac Life Support (ACLS, training of healthcare professionals on how to respond to life threatening emergencies and provide the appropriate electrical shock and emergency medication). The EM stated the Nursing Supervisors will take over the care of ICU patients assigned to an ICU RN who would respond to the emergency or rapid response. An interview was conducted with the DNCS on September 16, 2024, at 2:45 p.m. The DNCS stated the Nursing supervisors will respond to a code (code blue, a hospital code for a patient who requires immediate medical attention or needs to be revived) or rapid response (a team of providers who are called to a patient’s bedside to assess and treat a patient who is showing signs of clinical deterioration) because they are ACLS certified or covers ICU patients when ICU RN responds to the code. On September 16, 2024, at 2:47 p.m., a rapid response was observed to be called on Room D. ICU RN 8 and Nurse Supervisor (NSRN) 62 were observed to respond to the rapid response call. An interview was conducted with RN 8 on September 16, 2024, at 4 p.m. RN 8 stated NSRN 62 assumed the care for her patients when she (RN 8) responded to the rapid response at 2:47 p.m., on the same day. RN 8 stated she was then informed NSRN 62 responded also to the rapid response with her. RN 8 stated, “Then nobody was watching my patients.” A review was conducted with the EM on September 23, 2024, at 9:25 a.m. The following employee files of the House/Nursing Supervisors were reviewed for their critical care experience or current ICU competencies: - For NSRN 58, there was no documented evidence of critical care experience and current critical care competencies; - For NSRN 59, there was no documented evidence of critical care experience, initial ICU unit orientation when hired, and current ICU competencies; - For NSRN 60, there was no documented evidence of critical care experience, initial ICU unit orientation, and current ICU competencies; - For NSRN 61, there was no documented evidence of current ICU competencies; - For NSRN 62, there was no documented evidence of critical care experience, initial ICU unit orientation, and current ICU competencies; and - For NSRN 65, there was no documented evidence of critical care experience, initial ICU unit orientation, and current ICU competencies. An interview was conducted with the COO on September 23, 2024, at 11:18 a.m. The COO stated a Nursing Supervisor should have ICU competencies to care for ICU patients. A review of an undated facility document titled, “Job Description,” was conducted with the EM on September 23, 2024, at 11:25 p.m. The document indicated, “...Job Title: Registered Nurse...Experience: Minimum one year training and experience in Critical Care...” During a concurrent interview, the EM stated the document is the ICU RN job description. The EM stated the current Nursing Supervisors do not have a signed ICU job description and did not complete the initial ICU unit orientation. 5. A review of an undated facility document titled, “Job Description,” was conducted with the EM on September 24, 2024, at 3:33 p.m. The document indicated it was signed by the DCNS on August 4, 2024. The document indicated ACLS is required upon hire. An interview was conducted with the DNCS on September 24, 2024, at 3:40 p.m. The DNCS stated she is still on a 90- day probationary period and has until the end of the probationary period to obtain ACLS certification. An interview was conducted with the COO on September 24, 2024, at 3:45 p.m. The COO stated ACLS certification is a requirement for the DNCS position based on the qualification listed on the job description. An interview was conducted with the COO on September 24, 2024, at 4 p.m. The COO stated there is no documentation to support the claim of the DCNS that she can obtain her ACLS certification before the 90- day probation ends.”

“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: 42512 Based on interview and record review, the facility failed to follow their policies and procedures (P&P) for significant weight loss/gain and discarding sharps, for four of 31 patients (Patient 15, 21, 29, 30) when: 1. Patients 29 and 30, who were receiving enteral feeding (method of delivering nutrition to the body through the digestive system) were not re-weighed after a significant weight loss/gain; and 2. For Patients 20 and 28, sharps and needles were left on the patients over bed table and not discarded in the sharps container. This failure had the potential to delay patient care and cause patient harm. Findings: On September 23, 2024, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint. 1. a. A review of Patient 29’s medical record was conducted on September 23, 2024, at 1:07 p.m., with the Radiology Manager (RM). The undated facility document titled, “Patient Registration Data” indicated Patient 29 was admitted to the facility on September 4, 2024. The facility document titled, “History and Physical,” dated September 10, 2024, indicated, “...with muscular dystrophy [a hereditary condition marked by progressive weakening and wasting of the muscles]...past medical history of mitochondrial DNA depletion syndrome associated with mutation in TKA 2 Gene [genetic condition where mutations in the TK2 gene lead to a deficiency]...Neuromuscular scoliosis [ sideways curvature of the spine that’s caused by conditions that affect the muscles, nerves, or brain]...Ventilator dependence [a serious medical condition that occurs when a patient can’t breathe independently and requires a ventilator to help them breathe]...Starvation ketosis [a metabolic acidosis that occurs when the body breaks down fat and muscle for energy after prolonged fasting or starvation]...” The facility untitled document dated September 4, 2024, indicated, “...LVN [Licensed Vocational Nurse]/RN [ Registered Nurse] TO ENTER WT[weight]. IF > [more than] 5 LB [pounds] CHANGE RE-WEIGH & COMMENT “RE-WEIGH & [and] POSSIBLE CAUSES...IF >10% CHANGE, HOYER PT [patient]. RE-ZERO & RE-WEIGH. IF STILL >10% CHANGE, OPEN A COC [change of condition], NOTIFY MD [Medical Doctor]...” The facility document titled, “Weight,” dated September 5, 2024, through September 23, 2024, indicated the following weights in pounds: -September 5, 2024, (58.50) -September 9, 2024, (143) -September 16, 2024, (147) -September 23, 2024, (145) The facility document titled, “Nutrition progress note,” dated September 7, 2024, at 1:38 p.m., indicated, “...Per MD [medical doctor] notes, pt [patient] visited in room with father at bedside...father shared that pt wt [weight] hasn’t changed much...Diet order: Osmolite 1.5 at 30 mL/hr [milliliters an hour, unit of measurement]...Provides 720 mL, 1080 kcals, 45g [grams] protein, 823 mL TF [tube feeing] daily...Current weight: 26.5 kg [kilograms, unit of measurement] (58.5 lbs - bed scale)...Malnutrition status: Pt meets severe malnutrition criteria d/t [due to] severe muscle wasting and severe fat loss...Nutrition risk level...HIGH...” The facility document titled, “Nutrition progress note,” dated September 16, 2024, at 6:04 p.m. indicated, “...During last week’s ICT [inter care team] discussion, pt family states pt’s usual body weight is 80 lbs. Suspected weight inaccuracy. Please re-weigh patient using appropriate procedure in order to obtain accurate weight...Anthropometrics: NOTE SUSPECTED WEIGHT INACCURACY. PLEASE RE-WEIGH ACCORDING TO PROCEDURE...Per wt hx [history]...09/16/2024 [September 16, 2024]...66.6 kg/147 lbs. (bed scale)...09/09/2024 [September 9, 2024]...64.9 kg/143 (unspecified scale)...09/05/2024 [September 5, 2024]...26.5 kg/58.5 lbs (bed scale)*admission...UTA [unable to assess] wt status d/t [due to] limited assessment data and questionable wt accuracy...Intervention...Request re-weigh ASAP [ as soon as possible] d/t large weight discrepancy...” The facility document titled, “Nutrition progress note, “ dated September 18, 2024, at 1:09 p.m., indicated, “...In previous RD [Registered Dietician] assessment note 09/16 [September 16], there had been a request to obtain new patient weight as there is suspected weight inaccuracy. Recommendation for new weight not yet carried out. Patient does not appear to reflect 147 lb weight per EMR [electronic medical record]...Due to suspicion of inaccurate weight, it is not possible to calculate patient’s estimated needs...RECOMMENDATIONS WHILE PATIENT REMAINS IN HOSPITAL...Please re-weigh patient, noting scale modality, and noting that the bed was zero’d out and pt was weighed according to policy...Request daily weights...” An interview was conducted on September 23, 2024, at 1:48 p.m., with the RM. RM stated when Patient 29 was weighed and there was more than a five-pound difference, the nursing staff should have re-weighed the patient and added a note the patient was re-weighed. If the weight was still more than a five-pound difference, or more than a ten percent difference from the last weight, the nurse should have completed a change of condition, notified the physician, and notified the registered dietician. RM stated there was no documented evidence Patient 29 was re-weighed, a change of condition was completed, or the registered dietician was notified. 1 b. A review of Patient 30’s medical record was conducted on September 24, 2024, at 9 a.m., with the RM. The facility document titled, “History and Physical,” dated December 20, 2023, indicated Patient 30 was admitted to the facility on December 20, 2023, for altered level consciousness after being found to have fentanyl overdose. Patient 30 was intubated and on the vent. The facility document titled, “Nursing Admission,” dated December 20, 2023, indicated, Patient 30 weighted 220 lbs (pounds, unit of measurement)/ 100 kilograms (kilograms, unit of measurement) per bed scale. The facility document titled, “Vital signs/I&O/unit labs,” dated December 25, 2023, indicated “...weight 200.8, (91.27 kg) bed scale...LVN/RN TO ENTER WT. IF >5 LB CHANGE RE-WEIGH & COMMENT “RE-WEIGH & POSSIBLE CAUSES...IF >10% CHANGE, HOYER PT. RE-ZERO & RE-WEIGH. IF STILL >10% CHANGE, OPEN A COC, NOTIFY MD...” This was 19.2 lbs. less than what Patient 30 weighed on admission. The facility document titled, “Vital signs/I&O/unit labs,” dated December 29, 2023, indicated, “...Weight 193.4 lbs (87.91 kg) bed scale...” This was 26.6 lbs. less than what Patient 30 weighed on admission. The facility document titled, “Vital signs/I&O/unit labs,” dated December 30, 2023, indicated, “...Weight 189 lbs (85.91 kg) bed scale...” This was 31 lbs. less than what Patient 30 weighed on admission. The facility document titled, “Vital signs/I&O/unit labs,” dated January 03, 2024, indicated, “...Weight 186.5 lbs (84.77 kg) bed scale...” This was 33.5 lbs. less than what Patient 30 weighed on admission. The facility document titled, “Vital signs/I&O/unit labs,” dated January 07, 2024, indicated, “...Weight 179 lbs (81.36 kg) bed scale...” This was 41 lbs. less than what Patient 30 weighed on admission. The facility document titled, “Vital signs/I&O/unit labs,” dated January 08, 2024, indicated, “...Weight 176.9 lbs (80.41 kg) bed scale...” This was 43.1 lbs. less than what Patient 30 weighed on admission. The facility document titled, “Vital signs/I&O/unit labs,” dated January 22, 2024, indicated, “...Weight 180 lbs (81.82 kg) bed scale...” The facility document titled, “Vital signs/I&O/unit labs,” dated January 29, 2024, indicated, “...Weight 169 lbs (76.82 kg) bed scale...” There was no documented evidence Patient 30 was re-weighed when his weight changed 11 lbs. in one week. This was 51 lbs. less than when Patient 30 was admitted. There was no documented evidence a change of condition was completed by nursing staff for Patient 30’s continued loss of weight. An interview was conducted on September 24, 2024, at 10 a.m., with the RM. RM stated the expectation would have been to re-weigh Patient 30 due to his weight variance of 11 lbs. in one week. The RM stated due to the constant weight loss, the expectation would have been to place a change of condition and notify the physician. An interview was conducted on September 24, 2024, at 3 p.m., with the Registered Dietician (RD). The RD stated due to the significant loss of weight in a short period of time the expectation would have been to re-weigh Patient 30, if the weight remained low, greater than five pounds or more than ten percent, and nursing staff should have placed a change of condition. The RD further stated nursing staff should have also placed a dietician consult. A review of the facility policy titled, “CORE: Weight Measurement,” dated June 2021, indicated, “...The policy of [name of facility] is to ensure proper measurement of patient weights...Weight is determined by appropriate methods and measuring devices...Timing of weight assessments may be individualized based on a physician’s order, nutrition assessment or interdisciplinary team recommendations...Change in weight gain or loss are addressed in the nutrition assessment and the patient’s plan as applicable...If patient has a 5 pound or more difference from the most recent weight, the scale shall be re-balanced...and the weight taken again to confirm accuracy...” A review of the facility policy titled, “CORE: Interdisciplinary Assessment and Re-Assessment,” dated June 2023, indicated, “...All patients will have an initial assessment and appropriate follow up assessments upon identified patient-specific needs...The goal of the Assessment/Reassessment process is to provide an interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implanting patient specific interventions...Data analysis to develop a plan of care...Coordination of care by sharing patient information internally...patient information may include...care, treatment, medications, services, and any recent or anticipated changed to any of these...admitting RN will screen each patient during the initial assessment...Screening for specialized interventions and/or possible referral to other disciplines is completed...and includes...Nutritional status...licensed staff...may update the patient’s needs/problems and plan of care based on results of clinical findings...To respond to significant changes in status and /or diagnosis or condition...The registered dietitian identifies patients needing further monitoring...Examples of patients that may need further monitoring include...Receiving enteral or parenteral nutrition...Having significant unintentional weight change...Having non-severe or severe malnutrition...Reassess patient upon significant change of condition in nutritional status...weight change...Reporting/Notification of a Change in Condition...To achieve this goal, nurses as well as physicians must recognize a change in condition...Changes in condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition...When an Assessment Reveals a Change or Suspected Change in Condition...The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient’s primary physician...Document change of condition, notification and interventions in the medical record...EMR facilities document under the “Change of Condition” Pathway...” 2. A tour of the Intensive Care Units (ICU) medication room was conducted on September 16, 2024, at 10 a.m., with the Director of Quality Management (DQM) and Director of Pharmacy (DOP). In the ICU medication room, a packaged needle was noted in the trash can. At this time the DOP stated the needle should have been placed in the sharp’s container not be in the trash can. During the tour, in Patient 21’s room, the over bed table was observed to have four intravenous angio catheter needle (type of needle used for Intravenous access) 22-gauge kits, and Vanish Point blood collection set (type of safety needle for blood collection) 23 gauge. At this time the DMQ stated the nursing staff should have disposed of the sharps in the sharp’s container and should not have left them on the over bed table. During the tour, in Patient 15’s room, the over bed table was observed to have two gray capped needles, and two needles in a white plastic container. At this time the DQM stated the needles should have been properly stored or in the sharp’s container and not left on Patient 15’s over bed table. A tour of Patient 15’s room was conducted on September 22, 2024, at 6:29 a.m., with the Environmental Services Marketing Director (ESMD) and Registered Nurse (RN) 56. Patient 15’s over bed table was observed to have an orange cap insulin syringe (type of syringe used for administering medication) in a container. At this time RN 56 stated the syringe should have been placed in the sharp’s container and not left on Patient 15’s over bed table. A review of the facility policy and procedure titled, “[Facility Name] Specific Addendum to Regulated Medical Waste Management,” dated July 2023, was conducted. The policy indicated, “...sharps waste shall be placed in a sharps container...””

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 47071 Based on interview and record review the facility failed to follow their “Medical Staff Rules and Regulations,” policy and procedure (P&P), and ensure the patient’s history and physical (H&P) was completed within 24 hours of admission, for one of 31 patients (Patient 18). This failure had the potential to cause harm and a delay in patient care. Findings: A review of Patient 18’s medical record was conducted on September 19, 2024, at 10:40 a.m., with the Clinical Analyst (CA). The facility document titled, “History and Physical,” dated July 19, 2024, at 12:32 a.m., indicated Patient 18 was admitted to the facility on July 17, 2024, with a diagnosis of acute (less than 6 months) and chronic (greater than 6 months) respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood), inhalation injury (injury affecting the airway) sustained in a house fire. It further indicated, “...Date of admission...July 17, 2024...dictation date [DD] 07/19/2024 [July 19, 2024] at 00:13 [12:13 a.m.] Eastern Standard Time...” An interview was conducted on September 17, 2024, at 11:48 a.m., with the CA. The CA stated the H&P should have been completed within 24 hours of Patient 18’s admission. CA further stated the H&P was not completed according to the policy. An interview was conducted on September 23, 2024, at 2:12 p.m., with the Health Information Management Technician (HIM T). HIM T stated the H&P was completed on July 19, 2024, which was longer than 24 hours after Patient 18 was admitted to the facility and should have been completed within 24 hours of admission. A review of the facility’s policy and procedure titled, “Medical Staff Rules and Regulations,” dated 2022, was conducted. The policy indicated, “...Complete History and Physical...medical History and Physical examination completed and documented...24 hours after admission...The medical history and physical must be placed in the patient’s medical record within 24 hours after admission...””