Pam Health Rehabilitation Hospital of Westminster

“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: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services, was out of compliance. A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and documents reviewed, the facility failed to ensure vital signs were assessed in accordance with facility policy and providers’ orders in two of three records reviewed for patients diagnosed with critical illness myopathy (weakness involving the muscles of the arms and legs, and the muscles which help to breathe). (Patient #1 and #3)”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50313 Based on interviews and documents reviewed, the facility failed to ensure vital signs were assessed in accordance with facility policy and providers’ orders in two of three records reviewed for patients diagnosed with critical illness myopathy (weakness involving the muscles of the arms and legs, and the muscles which help to breathe). (Patient #1 and #3) Findings include: Facility policy: The Guidelines for Nursing Care policy read, to ensure quality patient care, certain standards of care must be upheld. The following outlines basic nursing tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. A specific physician order will supersede the minimum frequencies noted below. Vital signs (heart rate, blood pressure, respirations, temperature, oxygen saturation) assessed at a minimum frequency of every shift or doctor of medicine (MD) order. Reference: The Methadose (methadone hydrochloride) prescribing information read, serious, life-threatening, or fatal respiratory depression (slowed breathing) has been reported with the use of methadone, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest (absence of breathing) and death. Monitor for respiratory depression. The peak respiratory depressant effect of methadone occurs later, and persists longer than the peak pharmacologic effect (the point in time when a medication reaches its highest concentration in the bloodstream and produces its best result). Methadone may cause severe hypotension (low blood pressure) including orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position) and syncope (fainting) in ambulatory patients. 1. The facility failed to ensure vital signs were assessed in accordance with facility policy and providers’ orders. A. Document Review i. A review of Patient #3’s medical record revealed Patient #3 was admitted on 11/24/25 with a diagnosis of critical illness myopathy, acute hypoxic respiratory failure (the inability of the respiratory system to maintain adequate blood oxygen levels to preserve normal organ function), right-sided heart failure (the heart’s right ventricle is too weak to pump enough blood to the lungs), and chronic hypotension (low blood pressure). The provider’s note on 11/25/25 revealed Patient #3 had a history of polysubstance abuse, which included heroin (a highly addictive opioid drug) and fentanyl (an opioid pain medication) use, and had taken methadone (a medication used to help patients reduce or quit their use of opiates and to treat pain) intermittently in the past. The provider’s orders revealed methadone 15 mg was to be administered once daily for opioid use disorder. Staff were to assess Patient #3’s vital signs every shift. Additionally, staff were instructed to notify the provider if Patient #3’s systolic blood pressure (the top number in a blood pressure reading) was less than 90, and if the diastolic blood pressure (the bottom number in a blood pressure reading) was less than 50. On 11/27/25, at 7:41 a.m., the nursing shift assessment flowsheet revealed Patient #3 was alert and oriented, with clear speech, and had a Glasgow coma scale (GCS) (an assessment used to determine a patient’s level of consciousness or impairment in response to stimuli) score of 14 (normal is 15). The provider’s note on 11/27/25 at 9:06 a.m. revealed Patient #3 was found slumped over in bed, diaphoretic (sweating), and had difficulty maintaining alertness. The note revealed Patient #3 was found with an oxygen saturation of 75% while on oxygen at 1 liter(L) via nasal cannula (NC). Patient #3’s oxygen was increased to 2.5L/NC, and Patient #3’s oxygen level improved to 94%. At 9:13 a.m., the provider ordered Patient #3’s vital signs to be assessed every hour for four hours, and then every four hours until 11/28/25 at 6:00 a.m. At 9:40 a.m., the medication administration record revealed a licensed practical nurse (LPN) administered 15 mg of methadone to Patient #3. The vital signs flowsheet revealed staff assessed Patient #3’s vital signs at 11:30 a.m. Patient #3’s respiratory rate was 22 (normal is 12-20) and Patient #3’s oxygen saturation was 89% (normal is 95%-100%) on 3L/NC. Patient #3’s respiratory rate and oxygen saturation were not reassessed until 8:48 p.m., nine hours and 18 minutes later. This was in contrast with the provider’s order to assess vital signs every four hours. At 2:24 p.m., the vital signs flowsheet revealed Patient #3’s blood pressure was 80/46 (a normal blood pressure is 120/80). In addition to the lack of oxygen saturation and respiratory rate assessments, there was also no evidence Patient #3’s temperature had been assessed. Additionally, there was no evidence the provider was notified for Patient #3’s low blood pressure reading. This was in contrast with the provider’s order to notify the provider if Patient #3’s systolic blood pressure was less than 90 and if the diastolic blood pressure was less than 50. Review of the nursing shift assessment flowsheet revealed, at 7:02 p.m., Patient #3 was disoriented and lethargic (sluggish), with slurred speech and a GCS of 9 (impaired level of consciousness). Review of the vital signs flowsheet revealed Patient #3’s vital signs were next assessed at 8:48 p.m., four hours and 57 minutes after the previous assessment, and one hour and 46 minutes after Patient #3’s mental status had worsened. At 8:48 p.m., Patient #3’s blood pressure was 87/52, heart rate was 78, respiratory rate was 16, and their oxygen saturation was 90%. The vital signs flowsheet further revealed the next assessment of Patient #3’s blood pressure and heart rate was on 11/28/25 at 5:22 a.m., 8 hours and 34 minutes later. The vital signs flowsheet failed to reveal assessment of Patient #3’s respiratory rate, oxygen saturation, and temperature at that time. These gaps in vital signs assessments were in contrast with the provider’s order for Patient #3’s vital signs to be assessed every four hours. These gaps were also in contrast with the Guidelines for Nursing Care policy which read, to ensure quality patient care, certain standards of care were to be upheld. Vital signs included heart rate, blood pressure, respirations, temperature, and oxygen saturation, and should have been assessed according to the MD’s order. Additionally, the gaps in monitoring were in contrast with the Methadose prescribing information which read, serious, life-threatening, or fatal respiratory depression had been reported with the use of methadone, even when used as recommended. Staff should have monitored for respiratory depression. ii. A review of Patient #1’s medical record revealed Patient #1 was admitted on 10/1/25 with diagnosis of critical illness myopathy, Methicillin-resistant Staphylococcus aureus (MRSA) (a bacterial infection resistant to several antibiotics), alcohol abuse, pancreatitis (swelling or inflammation of the pancreas), and chronic anemia (not enough healthy red blood cells to carry oxygen to the body’s tissues). The provider’s orders revealed Patient #1’s vital signs were to be assessed every shift. The vital signs flowsheet revealed Patient #1’s vital signs were assessed on 10/9/25 at 9:27 p.m., and the next vital signs assessment occurred on 10/10/25 at 9:57 p.m., 24 hours and 30 minutes later. There was no evidence staff assessed Patient #1’s vital signs during the day shift from 7:00 a.m. to 7:00 p.m. on 10/10/25. This was in contrast with the provider’s order which read, Patient #1’s vital signs were to be assessed every shift. This was also in contrast with the Guidelines for Nursing Care policy which read, vital signs should have been assessed according to the MD’s order. B. Interviews i. An interview was conducted on 3/18/26 at 8:35 a.m. with registered nurse (RN) #2. RN #2 stated vital signs were assessed to determine if a patient’s clinical condition had changed. RN #2 stated staff should have assessed a complete set of vital signs at least once a shift on day shift and on night shift. RN #2 stated providers sometimes changed an order to assess vital signs more frequently if the provider was concerned about a patient’s change in condition. RN #2 stated a GCS score indicated if a patient was alert, oriented, and if they were responsive. RN #2 stated a change in GCS from a 14 to a 9 was concerning, and indicated a patient may not be as responsive to stimuli. RN #2 also stated it was important to monitor for side effects, such as respiratory depression or changes in mental status, after methadone was administered. RN #2 stated it was important to monitor a patient’s respiratory status if they had a history of hypoxia. RN #2 stated there was a risk to the patient’s life if a patient’s oxygen status was not monitored. This interview was in contrast with the medical record reviews, which revealed staff did not assess Patient #3 or Patient #1’s vital signs according to providers’ orders. Additionally, this interview was in contrast with Patient #3’s medical record review, which revealed Patient #3 had a diagnosis of acute hypoxic respiratory failure, was administered methadone, and staff did not monitor Patient #3’s oxygen saturation or respiratory status according to facility policy or providers’ orders. ii. An interview was conducted on 3/18/26 at 11:37 a.m. with provider (Provider) #1. Provider #1 stated they used vital signs to help determine if a patient was clinically stable. Provider #1 stated they expected staff to obtain vital signs according to the provider’s order, and to communicate trends in abnormal vital signs to providers. Provider #1 stated they ordered vital signs to be assessed every four hours for patients they were concerned for and when they wanted more frequent monitoring. Provider #1 stated it was concerning if a patient’s GCS declined from a 14 to a 9 over the course of a day. Provider #1 stated if a patient’s GCS was a 9, staff should have monitored the patient’s vital signs frequently. Provider #1 stated there was a risk of not identifying a deterioration in patient condition if vital signs were not assessed.”